Tongue Diagnosis in. Traditional Chinese Medicine. Tony Reid

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1 A traditional Chinese medical (TCM) diagnosis has two essential aspects. Firstly, a description of the patient s main complaint expressed in terms of the disease process (including the etiology and pathogenesis), and secondly an assessment of the state of health of the person as a whole. This is done by collecting clinical data in a systematic and objective manner, using the four diagnostic methods, followed by analysis in terms of TCM physiology and pathology. The essential steps involved in diagnosis include: INTRODUCTION Examination of the body as a whole Consideration of the relationship between the patient and his environment, including dietary and lifestyle factors Comprehensive analysis of the data gained by all the diagnostic methods Syndrome-pattern differentiation There are four categories of traditional diagnostic methods: inspection; inquiry (= case history taking); auscultation and olfaction; palpation. 18 THE NATURAL THERAPIST Volume 28 No.3

2 16,17 Relief and management of chronic constipation Examined and tested since 1917, MUTAFLOR Australia s only AUST R registered probiotic Strain specific modes of action - in vivo and in vitro Antagonistic activity against other microorganisms 1,2,3 Anti-invasive effect at the gut epithelium 4 Anti-inflammatory and Immunomodulatory effects, - inhibition of IL-5, IL-6, IFN-y, TNFα stimulation of IL-8 synthesis, enhanced IL-10 levels 5,6,7,8 Synthesis of endogenous antimicrobial peptides-defensins 9,10 Mucosal integrity - enhanced epithelial barrier function 11,12,13,14 Stimulation of colonic mucosa 15 Distributed by Ph: M.P Leatham et al., Infection & Immunity 77: (2009) 2. R.Reissbrodt et al., FEMS microbiology letters 2009;290: J.Henker et al., Eur. J. Pediatrics 166(4): (2007) 4. Altenhoefer A, et al.,,fems Immunol Med Microbiol 2004;40: B.Arribes et al., British Journal of Pharmacology 157: (2009) 6. U.Helwig et al., World J Gastroenterology 12: (2006) 7. Kamada et al., Infection & Immunity 76: (2008) 8. J.M.Otte et al., Nutrition & Cancer 61: (2009) 9. J.Wehkamp et al., Infection and Immunity 72: (2004) 10. M.Schlee et al., Infection and Immunity 75: (2007) 11. J.Miyoshi & Y.Takau(2005). Adv Drug Delivery Rev 57: J-M Otte et al.,(2004) Am.J.Physiol.Gastrointest.Liver Physiol. 8694):G613-G A.A. Zyrek et al., Cellular Microbiology 9: (2007) 14. S.N. Ukena et al., (2007) PLoS ONE, 2(12): e1308w 15. Bar, F., et al.-neurogastroenterol Motil. 2009;21(5): M. Möllenbrink & E. Bruckschen (1994). Med. Klin. 89: E. Bruckschen & H. Horosiewicz (1994). MMW 1994; 16:241-5 Homeopathic Lab Dispensing quality homeopathic remedies Web: Phone: / Freecall: Address: PO Box 2007, South Melbourne, VIC 3205 Staffed by qualified homeopaths Orders individually prepared using traditional methods Personalised service Over 2,500 individual remedies Remedy Starter Kits First Aid Kits Custom-made Kits THE NATURAL THERAPIST Volume 28 No.3 19

3 Inspection, or visual examination, consists of observing the patient s vitality and overall appearance, complexion, physical condition, behavior, tongue, bodily secretions and excretions. Examination of the tongue is a major component of this method and, in conjunction with data gathered from the other methods it provides confirmation and clarification of the diagnosis. Inspection of the tongue allows a practitioner to: Assess the state of the Qi (normal or deficient) Assess the state of the Blood (normal, deficient or stagnant) Determine the location of a disease Differentiate the nature of pathogenic factors (e.g. Hot, Cold, Damp, etc.) Infer the development of a disease (progression or regression) Estimate the prognosis of a disease In 80-90% of cases the tongue provides important clinical information. However, in some situations a serious illness may be present without showing any pathological changes in the tongue. Alternatively, a normal healthy individual may have a tongue that displays various abnormalities. Therefore the information gained from observing the tongue must always be considered along with the presenting signs and symptoms, the pulse and the patient s history. TOPOGRAPHY OF THE TONGUE The topography of the tongue is associated with the condition of the Zang-Fu organs. Although there are minor disagreements amongst various schools of TCM, the following is generally accepted: The anterior third relates to the Heart and Lung (organs of the upper Jiao) The middle third relates to the Spleen and Stomach (organs of the middle Jiao) The posterior third relates to the Kidney (organs of the lower Jiao) The edges relate to the Liver and Gallbladder The tongue should be inspected in good light, either in natural light close to a large window, or under full-spectrum incandescent light. The patient should be relaxed and comfortable and should be asked to protrude the tongue without strain for short periods of time only. Several viewings may therefore be necessary. The coat should be inspected first, then the tongue body. All parts of the tongue should be observed, including the undersurface. THE TONGUE COAT A normal tongue coat is thin and white with a moderate degree of moisture and does not cover the whole of the tongue surface. Changes or deviations from normal in both the color and the quality of the tongue coat should be noted. The tongue coat color may be white, yellow, grey and black. The coat quality may be thin, thick, slippery, greasy, moist, dry, rough, curd-like or peeled. a) Quality of the Coat This refers to the substance of the tongue coat, which may be: Thin Thick Moist or Slippery Dry or Rough Greasy Curd-like Peeled (exfoliated) Thin Coat or Thick Coat The thickness of the coat is judged by whether or not the tongue body can be seen underneath the coat. If the tongue body can be seen through the coat, it is regarded as thin, if not, it is considered to be thick. By observing the thickness of the coat one may determine the location of the disease and the progress or decline of the pathogens. A thin coat gives information about the pathogens or the state of the health Qi. It should also be noted that a thin coat is present on a normal tongue. In regard to pathogens, a thin tongue coat may indicate an Exterior condition, or a mild Interior condition. It reflects the fact that the disease is not very serious since the pathogens are only in the Exterior or relatively mild if on the Interior; the health Qi has not been impaired and the pathogens are not very strong. A thin or scanty coat on a pale tongue indicates deficiency of the Qi or deficiency of the Blood. A thin or scanty coat on a red tongue indicates Yin deficiency. A thin coat on a pale tongue that is also swollen and either moist or slippery indicates deficiency of the Yang Qi (either Spleen Yang or Kidney Yang deficiency) with retention of Damp 1, Fluid or Water. A thick tongue coat indicates more severe pathogens and an Interior location of the disease. It may be due to the retention of Phlegm, Damp or food stagnation, causing the Stomach Qi together with the pathogens to rise upward and accumulate on the surface of the tongue. If a thin coat becomes thicker, it suggests that the disease is becoming more severe. If a thick coat becomes thinner, it shows that the health Qi is overcoming the pathogens. Moist Coat or Slippery Coat It is considered normal for the tongue to be somewhat moist, but neither slippery nor rough. A normal amount of moisture in the tongue coat indicates that the patient s body Fluids have not been depleted, though he may be ill. If the coat appears excessively wet with a copious amount of saliva adhering to it, then it is referred to as slippery (or glossy). This indicates a Cold or Damp condition, caused by invasion of Cold-Damp into the Interior, or retention of stagnant Fluids such as Damp, Phlegm, Edema, etc. due to insufficiency of the Yang Qi (e.g. Spleen Yang deficiency or Kidney Yang deficiency). Dry Coat or Rough Coat A coat with a lack of moisture is referred to as dry. A coat that is dry and lacks the normal smoothness is termed rough. Both the dry and rough coats are due to depletion of the body Fluids, indicating a Dry condition. They occur in cases with deficiency of Yin (with Yang hyperactivity or deficiency Heat) and excess Heat conditions. They may also arise due to obstruction of the Yang Qi by retained Damp or Phlegm. In this case the Spleen and the Kidney are unable to generate sufficient normal physiological Fluids, leading to Interior Dryness, together with the accumulation of pathological Fluids (i.e. Damp or Phlegm). A dry coat with fissures is hard, tough and chapped in appearance. This is caused by Heat or Fire, which damages the body Fluids. Greasy Coat A coat that appears slimy, compact and grainy, and looks as if it is tightly adhering to the surface of the tongue is termed a greasy. Such a coat is difficult to scrape off. In general, a greasy coat indicates internal Phlegm, Damp or food stagnation. A white and greasy coat indicates internal retention of Damp or Phlegm-Damp. A yellow and greasy coat indicates internal retention of Damp-Heat, Phlegm-Heat, or excess Heat in the Stomach and Intestines due to food stagnation. This is also referred to as a slimy coat, sticky coat or a sticky-slimy coat. 20 THE NATURAL THERAPIST Volume 28 No.3

4 Curd-like Coat A curd-like coat is thick with coarse granules like mashed bean curd (or cottage cheese). It may easily be scraped off. This type of coat occurs due to excess Heat. It is present in cases of food stagnation in the Stomach and Intestines, retention of Phlegm-Heat in the Interior, internal abscess, or aphthous stomatitis due to Damp-Heat. Peeled Coat A peeled, or exfoliated coat, is one that appears to have completely or partially peeled off, revealing a smooth shiny surface beneath. This is a sign of depletion of the Yin. It occurs as a result of impairment of the Stomach Yin and Qi, injury to the Qi and body Fluids by a febrile illness, deficiency of Yin with depletion of the body Fluids, deficiency of both the Qi and Blood, or it may be seen in patients with an allergic constitution. In general a small degree of exfoliation of the coat indicates a mild deficiency condition, and a completely peeled coat, referred to as a mirror-like tongue (jing mian she) is due to a much more severe condition. The disappearance and re-appearance of the coat can show both the condition of the Stomach Qi and the struggle between pathogens and the health Qi. For example, the gradual disappearance of the tongue coat indicates deficiency of the Stomach Qi and Stomach Yin, with a gradual decline of the health Qi. On the other hand the reappearance of a thin and white coat after exfoliation denotes a domination of the health Qi over the pathogens and recovery of the Stomach Qi. It is better for the tongue coat to appear or disappear gradually than abruptly. When the tongue coat disappears rapidly or suddenly reappears, this usually reflects a sudden worsening of the disease. b) Color of the Coat Changes in the color of the tongue coat reveal the nature of an illness, e.g. Heat or Cold, excess or deficiency and may also show the development of a disease. The tongue coat color may be: White Yellow Grey Black Mixed colors White Coat The normal coat is thin white and moist, with a fine grainy appearance, and is evenly distributed. In an Exterior condition or a mild Interior condition the coat will be unchanged (i.e. normal appearance). On the other hand a thick coat indicates an Interior syndrome with excess pathogens. Generally a white coat indicates Cold and related pathogens (retention of Damp or Phlegm due to Qi or Yang deficiency). However, under certain circumstances it may also indicate Heat. A thin white coat (i.e. normal coat) may occur in Exterior syndromes. A thin white and wet coat indicates Cold or Cold-Damp. A thick, white and slippery or greasy coat indicates Phlegm, Cold-Damp, Phegm-Fluid or food stagnation. A thick, white, and dry coat indicates retained Phlegm or tubid Damp that has transformed into Heat and injured the body Fluids. A powdery white coat that covers the whole tongue surface, with a red tongue body indicates Interior Damp- Heat, exogenous turbid Damp (e.g. food poisoning), or Interior Heat-toxin (e.g. internal abscess) A thick, white and curd-like coat indicates an Interior syndrome of Damp-Heat, Phlegm-Heat or Heat Toxin and may also be seen in cases with Heat in the Stomach due to food stagnation. A thick white coat that is dry and has fissures may be seen in an exogenous Warm disease that has been inappropriately treated with warming and tonifying herbal medicines. The exogenous pathogens have damaged the body Fluids and the incorrect treatment has caused retention of endogenous pathogens (e.g. Damp). Yellow Coat A yellow coat may be yellow or yellowbrown ( burnt-yellow ) and indicates a syndrome of Interior Heat. In general, the deeper the yellow, the more severe the pathogenic Heat. Because Heat tends to damage the body Fluids, it is also necessary to assess whether the coat is moist or dry as this reflects the state of the body Fluids. The color of the tongue body is generally red or crimson, showing Interior Heat. A thin, yellow and moist or slippery coat shows that the Interior Heat is of recent onset and that the body Fluids have not yet been impaired by the Heat. A thin, yellow and dry coat shows Heat excess with depletion of the body Fluids. A thin slippery and yellow coat on a pale and swollen tongue indicates retention of pathogenic fluids (e.g. Damp, Water, retained Fluid, etc.) due to Yang deficiency. A yellow, greasy and moist coat shows Heat and Dampor Heat and Phlegm in the Interior. A thick yellow and dry coat shows depletion of the body Fluids by Heat (e.g. when there is a high fever). A burnt-yellow and dry coat with fissures shows severe internal Heat and depletion of the body Fluids. A thick yellow and slippery coat on a pale and swollen tongue indicates retention of pathogenic fluids due to Spleen and Stomach deficiency. Grey Coat A grey or pale-black coat usually develops from a white coat, or occurs together with a yellow coat. It indicates either Interior Heat, Cold-Damp or Phlegm-Damp. Generally a grey coat is found in serious diseases, e.g. prolonged illness of the digestive tract, dehydration and acidosis. A grey and dry coat is often due to depletion of the body Fluids by excess Heat in a febrile disease, or by flourishing Fire due to Yin deficiency. A grey and moist, slippery or greasy coat may be due to either retention of Phlegm in the Interior or retention of Cold-Damp in the Interior. Black Coat A black coat is either brown-black or black and usually arises as a further development of the pathological conditions that caused a yellow or a grey coat. It is often found in the critical stage of a disease, indicating an Interior syndrome, which may be either excess Heat or excess Cold. In general, if the coat is also dry, this indicates Heat; if also moist or slippery, this indicates Cold. It should be noted that the tongue coat may also be stained by smoking, drinking black coffee etc. and give the false appearance of a black coat. Both the grey and the black coats indicate serious conditions of internal Heat or internal Cold. In general, the deeper the color of the coat, the more serious the disease. However, occasionally a black coat may occur in a patient with a mild disease and with no obvious symptoms. THE NATURAL THERAPIST Volume 28 No.3 21

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7 A dry black coat is caused by excess Heat or Fire that depletes the Yin and body Fluids. A dry black coat with fissures or prominent prickles reflects an extreme condition of internal Heat excess, indicating the impending exhaustion of the Kidney Yin and is a sign of critical illness. A black coat that is also moist or slippery shows Yang deficiency and excess Cold. A black and greasy coat indicates Phlegm and excess Heat in the Interior. A black coat on the tongue-tip indicates Heart Fire. A black and dry coat in the middle part of the tongue shows excess Heat in the middle Jiao, e.g. retention of Phlegm-Heat in the Stomach. It may also indicate constipation due to Heat with retention of dry stools or impending exhaustion of the Stomach Qi 2. A black coat on the root of the tongue indicates excess Heat in the lower-jiao. Mixed Colors Frequently the tongue coat presents with two or more colors together. This generally indicates the presence of more than one pathogen. In general, mixed colors indicate the presence of pathogens and pathological processes that relate to each color. The commonly occurring mixed colors of the tongue coat are: white and yellow; turbid; white and black; white, yellow and black; white and grey; white grey and black; yellow and grey; black and grey. White and yellow: Both colors are present on the tongue coat. In an Exterior syndrome, this indicates that the Cold pathogen has begun to enter the Interior and transform into Heat, while the Exterior Wind-Cold still remains unresolved. In the absence of an Exterior syndrome, this indicates Interior Damp-Heat. Turbid: The coat appears like a mixture of off-white and off-yellow; i.e. a dirty white and a dull yellowish-cream. This indicates the accumulation or retention of turbid Phlegm or turbid Damp in the Interior. White with black: White coat with black spots or lines that is slippery or greasy indicates Damp obstructing the Spleen. White, yellow and black: The coat was originally white and changes to yellow and then to black, with some areas of white and yellow remaining. The coat is dry and there may also be prickles and fissures. This indicates an exogenous Cold pathogen that has entered the Interior, transforming into Heat and the virulent Heat damages the Yin. White and grey: A white coat with grey areas that is also slippery indicates Interior Cold-Damp. A white coat with grey and slippery areas on the sides indicates a Cold pathogen that is half-exterior and half-interior (Lesser Yang syndrome). White grey and black: A white coat with areas of grey and black, which is also greasy or slippery indicates Damp obstructing the Spleen Yellow and grey: A greasy or slippery yellow coat with some black areas indicates Interior Damp-Heat. If the coat is yellow on the sides with a dry brownblack area in the centre, on a red tongue with prickles, this indicates a Bright Yang Fu organ syndrome. A dry, brown-black coat with dry and dull yellow areas on a red tongue with prickles indicates severe Interior Heat. Black and grey: A black coat with grey areas may indicate food stagnation. THE TONGUE BODY Inspection of the tongue body may reveal changes in the color, surface condition, shape and state. a) The Color of the Tongue The tongue body under normal conditions is pink. Pathological colors are as follows: Pale Red Crimson Purple or Cyanotic Blue Tongue with macules, tongue with speckles Tongue with red spots Pale Tongue A tongue that is much paler than the normal healthy pink indicates deficiency of the Qi and Blood where the Blood fails to nourish the tongue, or the Yang Qi is too weak to transport the Blood upward, thus causing the tongue to turn pale. Thus a pale tongue indicates a deficiency syndrome or a Cold syndrome. A pale tongue that is normal sized or thin or small is a manifestation of deficiency of both the Blood and the Qi, while a pale tongue that is swollen indicates deficiency of the Yang Qi, with subsequent retention of pathological fluids e.g. Damp or Phlegm. Red Tongue A tongue that is a deeper red than normal indicates a Heat syndrome. Heat causes the Blood to circulate more rapidly and dilates the vessels, hence the red appearance on the tongue. In general, the deeper the red color, the more severe the pathogenic Heat. Deep red tongue with absent coat Light red and swollen tongue with a greasy coat Light red tongue with a thick white and greasy coat Light red tongue with a thin white coat Light red tongue with some cracks, a dark tip, and a thin white coat Light red with tooth marks and a thin white and moist coat 24 THE NATURAL THERAPIST Volume 28 No.3

8 Pale swollen tongue body with a slippery coat Pale tongue Pale tongue with a white & yellow coat, thick at rear Red tongue with cracks Red tongue with purple spots and a greasy coat A light red tongue (also referred to as pale red tongue ) may indicate either the early stages of an Interior Heat syndrome or a combined deficiency of the Qi and Yin. A tender and red tongue has a light, fresh, red color with a smooth and shiny surface. This may indicate either Qi deficiency with an early stage Heat syndrome, or Yin deficiency. A rough and red tongue (that may also have prickles), is due to internal Heat that has injured the body Fluids. A rough red tongue with a thick, yellow coat is due to excess Heat. A tender and red tongue with little or no coat, or with fissures, is due to deficiency Heat (i.e. Heat due to Yin deficiency). A red tongue tip is due to Heart Fire. Red sides of the tongue are due to excess Heat or Fire of the Liver and Gallbladder. Red in the middle part of the tongue is due to excess Heat of the middle Jiao (Stomach and Spleen). A deep red tongue with a scanty coat indicates interior Heat that has damaged the Yin and body Fluids. Crimson Tongue A crimson tongue is a much deeper red than a red tongue. It often occurs due to the further pathological development of the processes that initially caused a red tongue. Therefore the red and crimson tongue bodies are usually classified together. The causes for the development of a crimson tongue are the same as those of the red tongue. A crimson tongue indicates extreme Heat, which therefore indicates a more serious illness. In cases with invasion by an exogenous pathogen, a crimson tongue indicates: Invasion of the Nutrient and/or Blood aspects by Heat Accumulation of latent Heat in the Heart and Stomach Transmission of Warm-Heat pathogens directly to the Pericardium In cases of an internal disease, a crimson tongue with a dry coat, absent coat, or peeled coat, indicates flourishing Fire due to Yin deficiency, or exhaustion of the Fluids of the Stomach and Kidney. A crimson tongue with a scanty and moist coat shows Blood Stasis in the Interior. Both the red tongue and crimson tongue indicate Heat syndromes: the deeper the color, the more severe the Heat pathogen. If the tongue body changes from pale to red and then to crimson, it indicates that the pathogenic Heat is becoming more intense and the disease more serious. On the other hand, if the tongue changes from crimson to red, then to light red, it indicates subsidence of pathogenic Heat and that the patient is recovering from the illness. Purple Tongue, Cyanotic Tongue A tongue that is a bluish-purple color is referred to as a purple or cyanotic tongue. This usually denotes stagnation of the Qi and Blood, caused by either Cold, Heat, deficiency of the Qi and Yang, food stagnation, internal retention of Phlegm, internal retention of Damp- Heat, or by alcoholism. The Blood is unable to circulate to the tongue, which becomes purple or blue-purple as a result, just as the lips become cyanosed due to hypoxia. If the Qi and Blood stagnation is due to excess Heat, there will generally also be consumption of the body Fluids. In such cases the tongue will also become dry, rough, or in protracted conditions small and thin. In cases of Blood stagnation due to Cold, the tongue is a light shade of purple (or blue-purple) and is generally also moist with a moist, slippery or greasy coat. Tongue with Macules, Tongue with Speckles Macules or speckles on the tongue are areas of purple or blue-purple discoloration that may vary in size. The larger patches are referred to as macules (or stasis macules ), while the smaller dot size discolorations are referred to as speckles (or stasis speckles ). Both indicate Blood stasis. They are often quite subtle and may easily be missed. They may appear at first sight to be nothing more than shaded areas due to irregularities of the tongue surface. However, on closer examination of the tongue, also taking into account the direction of the light source, it will be seen that they are not shadows but, in fact, real discolorations. As with the purple or cyanotic tongue body, Blood stasis may be due to various factors, which may also be revealed in the tongue. In cases with Blood stasis due to deficiency of the Qi or Yang the tongue will be pale and moist with a thin coat. In cases with Blood stasis due to excess conditions, such as internal retention of Phlegm-Damp, there will be a thick coat on the tongue that may also be greasy. THE NATURAL THERAPIST Volume 28 No.3 25

9 Blue tongue, blue-green tongue A blue tongue is the color of blue veins exposed on the skin. It arises due to a Coldexcess congealing in the Interior causing stagnation of the Yang and Blood. Thus, a blue tongue indicates stagnation of the Yang caused by the accumulation of Cold, or accumulation of Cold caused by Yang deficiency, or Blood stagnation in the Interior. Generally speaking, a wholly blue tongue indicates a Cold syndrome, while blue sides of the tongue indicate Blood stagnation in the Interior. Tongue with red spots A tongue with red spots has small flat dots on the surface, which are red in color. They generally indicate a condition of Heat. This may be excess Heat or deficiency Heat. Red spots on a tongue, which is pale with a thin or scanty coat, indicate deficiency of the Qi and Yin with deficiency Heat. Red spots on a red tongue with a substantial coat indicate excess Heat. The location of the spots may give an indication of the organs most affected. Red spots on the tip of the tongue indicate Heat or Fire in the Heart. Red spots on the edges indicate Heat or Fire in the Liver and Gall Bladder. Red spots scattered over the tongue surface may also indicate infestation by parasites. b) The Shape and Surface of the Tongue The pathological shapes and surface features of the tongue are: Enlarged Thin Prickled Cracked Indented Rough Tender Enlarged Tongue An enlarged tongue refers to one that appears larger than normal. It is usually, but not always, indented by the teeth. Enlargement of the tongue is caused by stagnation of the body Fluids, which are unable to circulate in the normal way and hence accumulate in the tissues of the tongue. There are several different ways in which this may occur. Deficiency of the Spleen Qi, Lung Qi, Spleen Yang or Kidney Yang may each lead to impaired fluid transformation with subsequent retention of pathogenic Fluid or Water. Prolonged disorders of fluid transformation will lead to the formation of Damp and Phlegm, which cause further stagnation of the fluid pathways. In addition, any pathological process that causes stagnation of the Qi and Blood in the upper part of the Body may cause the tongue to become enlarged (e.g. Blood-Heat, Heat Toxin, Blood stasis, alcoholism). An enlarged tongue that is also pale and tender indicates a Cold and deficiency syndrome. In this case the swelling of the tongue is due to retained Fluid caused by Yang deficiency of the Spleen or Kidney. An enlarged tongue that is also pale with a slippery or greasy coat is due to Spleen Qi deficiency with retention of Damp or Phlegm-Damp. An enlarged tongue that is also red with a yellow and greasy coat indicates a Heat excess syndrome. This is may be due to Phlegm-Heat or Damp-Heat, usually accompanied by Spleen Qi deficiency, which is the underlying cause. An enlarged tongue with a red tip is due to excess Heat in the Heart together with Spleen Qi deficiency, generally also with retention of Damp or Phlegm. An enlarged tongue that is also purple or blue is due to stasis in the upper part of the body caused by alcoholism, or Blood stasis due to Heat Toxin. A swollen tongue is an abnormally enlarged tongue that is usually red. This is generally due to excessive Fire in the Heart and Spleen or Damp-Heat. Thin Tongue A tongue that is thinner and smaller than normal is referred to as a thin tongue. This is caused by malnutrition of the tongue body due to either deficiency of the Qi and Blood involving the Heart and Spleen, or deficiency of the Yin and body Fluids. Thus, a thin tongue may indicate deficiency of the Qi, Blood, body Fluids, or flourishing Fire due to Yin deficiency. A pale and thin tongue indicates either deficiency of the Qi and Blood or deficiency of the Qi and body Fluids (if it is also dry and with a scanty coat). A red and thin tongue indicates either depletion of the Yin and body Fluids by excess Heat, or flourishing Fire due to deficiency of the Yin. Prickled Tongue A tongue with prickles has raised spots on the surface that look like tiny strawberries. Prickles are mostly red, although they may occasionally be black. Prickles indicate severe conditions of internal Heat, e.g. Heat Toxin, accumulation of Damp-Heat, or Heat in the Blood aspect. Prickles may appear on the borders of the tongue, or may be scattered over the entire tongue. When confined to certain areas they give an indication of the organs most affected by Heat, e.g. red prickles on the tongue tip indicate Heart Fire or Heat attacking the Pericardium. Red prickles on a crimson or deep red tongue with a dry and scanty coat indicate severe Interior Heat damaging the Yin. Cracked tongue A cracked tongue has obvious cracks on the surface, which are not covered by the tongue coat. Cracks may be seen on the whole tongue or only on some parts. They may have various shapes and sizes and may be shallow or deep the long and deep ones being referred to as fissures. Cracks are caused by deficiency of one or more of the Kidney Essence, the Blood, the Yin and the body Fluids. This leads to malnutrition of the tongue body and atrophy of the tongue surface. It should be noted that a congenital cracked tongue occurs in approximately 0.05% of healthy people. A cracked tongue generally indicates a deficiency syndrome, especially Blood deficiency or Yin deficiency. However, it may also indicate an excess Heat syndrome, where the Heat has depleted the Yin and body Fluids. A pale or light red tongue with cracks indicates Blood deficiency. A red or deep red tongue with cracks shows depletion of the body Fluids by excess Heat, or deficiency of the Yin and body Fluids. A fissure along the midline of the tongue may indicate a tendency to Heart disorders and mental-emotional problems Indented Tongue An indented tongue has imprints of the teeth on the edges; thus it is also commonly referred to as a tongue with tooth marks. This is generally caused by hypofunction of the Spleen (i.e. Spleen 26 THE NATURAL THERAPIST Volume 28 No.3

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11 Qi deficiency or Spleen Yang Deficiency), which leads to retention of pathogenic fluids (such as Water, Damp, Phlegm or retained Fluid) in the Interior. These pathogenic fluids also accumulate in the tongue, so that the tongue becomes swollen and consequently compressed by the teeth. Thus tooth-marks often appear on a pale, swollen and tender tongue, indicating deficiency of the Spleen together with internal retention of Damp. A pale and moist tongue with tooth marks is due to excess Cold-Damp in the Interior or edema caused by Yang deficiency. A pale or light red tongue with toothmarks is due to deficiency of the Spleen or deficiency of the Qi. A pale tongue with tooth marks and a white greasy coat is due to Spleen Qi deficiency with internal retention of Cold- Damp or Phlegm-Damp. A red and swollen tongue with toothmarks, with a greasy coat may be due to Damp-Heat or Phlegm that has developed from Damp-Heat. Rough Tongue A rough tongue has a dry and rough surface or coat. This comes about due to the effect of severe or prolonged Heat, which has damaged the body Fluids. This creates a deficiency of the body Fluids, which are unable to moisten the tissues of the tongue. The tongue surface becomes excessively dry and rough as a result of the combined effects of the Heat and lack of body Fluids. The tongue body is generally red or crimson, indicating pathogenic Heat. A rough and red tongue with a greasy coat at the root (i.e. the back of the tongue), indicates a chronic condition of Damp or Phlegm-Damp that has transformed into Heat. A rough red tongue with a thick yellow and dry coat indicates severe internal excess Heat. A rough crimson tongue with a black coat indicates severe internal Heat Toxin. Tender Tongue A tongue with a fresh looking, smooth and shiny surface is referred to as a tender tongue. The surface of the tongue has undergone mild atrophic changes leading to a loss of definition of the papillae. This is due to an insufficient supply of Qi and body Fluids to the tongue. Thus, a tender tongue generally indicates a deficiency condition. A tender and pale tongue indicates Qi deficiency. A tender and red tongue may indicate Yin deficiency, Qi and Yin deficiency or Qi deficiency in an early stage Heat syndrome. c) The State of the Tongue The pathological states of the tongue are: Shortened Flaccid Stiff Trembling Deviated Shortened Tongue A shortened tongue is shorter than normal and appears to be contracted and unable to protrude out of the mouth. If a patient s tongue is shortened during an illness, this is an indication of a critical condition. In this case a shortened, pale and moist tongue is due to Cold causing stagnation in the muscles and spasmodic contraction of the tongue. A red, dry and shortened tongue is due to Heat that has damaged the Yin and body Fluids. If the tongue is swollen with a greasy coat, this indicates retention of Damp-Phlegm or Phlegm-Fluid, which obstructs the Qi, Blood and body Fluids. If the patient loses consciousness or becomes delirious and has a shortened and stiff tongue, or if he has a Phlegm syndrome and becomes comatose, with the tongue retracted, this is critical condition with a poor prognosis. Flaccid Tongue A flaccid tongue is one that is weak and unable to protrude and curl up. There is atrophy of the tongue muscle. It is due to extreme deficiency of the Qi and Blood, exhaustion of the Yin and body Fluids and the consequent malnutrition of the tongue muscles, which causes the tongue to become flaccid. There are two types: a flaccid tongue seen in an acute disease, and a flaccid tongue seen in a protracted disease. In an acute or recent illness, a flaccid tongue that is red and dry indicates pathogenic Heat that has impaired the Yin and the Blood. In a protracted disease, a flaccid tongue that is pale indicates extreme deficiency of the Qi and Blood. In a protracted illness, a red or crimson, dry and flaccid tongue shows exhaustion of the Yin of the Liver and the Kidney and extreme deficiency of the Yin. Stiff Tongue A stiff tongue is unable to move freely, resulting in impairment of speech. This may result from invasion of the Pericardium by Heat in an exogenous febrile disease, which disturbs the Spirit, impairing consciousness with subsequent loss of motor control of the tongue. It may also arise due to severe damage to the Yin by high fever and the consequent malnutrition of the muscles. A stiff tongue may also occur as a result of Phlegm obstructing the mind and senses (e.g. psychosis), or as a result of blockage of the tongue channels by Phlegm that is carried upwards by Liver-Wind, which is seen in cases of Wind-stroke (i.e. apoplexy). Trembling Tongue A trembling tongue is one that trembles uncontrollably. This may be due to either a deficiency or an excess condition. The former type includes deficiency of the Qi and Blood, depletion of the body Fluids or severe Yang deficiency, resulting in failure to moisten the muscles and provide them with warmth and nutrition. On the other hand, a trembling tongue may be caused by Dry-Heat in the Blood which consumes the body Fluids and generates Internal Wind, or by extreme Heat generating Internal Wind and causing convulsions. In a prolonged illness a pale or light red tongue that trembles slightly is due to either depletion of the body Fluids, depletion of the Yang, or deficiency of the Qi and Blood. In an exogenous febrile disease, a red and dry tongue that trembles shows consumption of the body Fluids and interior Wind that has been generated by the Heat. A deep red tongue that trembles severely is due to extreme Heat or Yang hyperactivity (due to Yin deficiency) that generates interior Wind. 28 THE NATURAL THERAPIST Volume 28 No.3

12 Deviated Tongue CONCLUDING REMARKS Begin by observing the tongue in terms of: A deviatedor wry tongue deviates to one side while protruding. This mostly occurs together with facial hemiparalysis or hemiplegia in cases with Wind-Stroke (i.e. apoplexy). This is due to either an attack on the Channels by pathogenic Wind, obstruction of the Channels by Wind- Phlegm, or pathogenic Wind attacking the Zang. When the channels and collaterals on one side of the body are obstructed, the muscles on the same side of the body will become relaxed and unable to contract, so the tongue deviates to the opposite healthy side. Thus a deviated tongue indicates an actual or impending Wind-Stroke. Inspection of the sublingual veins Inspection of the tongue generally concludes with examination of the sublingual veins. From this observation one may assess the movement and circulation of the Blood. By this stage, the condition of the tongue body and coat, together with the case history and pulse examination will have revealed the main pathological processes. The sublingual veins may therefore show to what extent the movement of the Blood has become impaired by these processes. If the veins are distended, this indicates Blood stasis. If they are also cyanotic (purple or greenblue) and the small branches are distinctly visible this indicates a severe condition of Qi stagnation and Blood stasis. Proficiency in examination of the tongue requires a great deal of regular practice. It will be seen that there is much variation in what may be considered normal, and one must be prepared to ignore some seemingly pathological features on the tongue if they are not supported by the rest of the patient s case history and examination. In other situations there may be minimal or absent signs of pathological processes that have been confirmed by other diagnostic methods. Thus, the examination and evaluation of the tongue must always take place within the context of a full case history and clinical examination. Like anything else, your ability will improve with practice and experience. It is useful to examine your own tongue regularly and note any changes when you experience an illness. You should also keep a regular check on the tongues of friends and family and particularly note any signs that occur with changes in their state of health. This is also a good opportunity to practice and refine your TCM case history taking technique. Overall size and shape, also noting any abnormal movements Color of tongue body, also noting any discolorations (e.g. macules, speckles, spots, prickles etc.) Extent, nature and color of the tongue coat In the beginning simply look for basic abnormalities such a pale or red tongue body; thin coat or thick coat; yellow coat or white coat, and see how these findings correlate with the rest of the patient s case history. Like any art it takes a considerable amount of practice and experience to integrate even a small amount of theory. As the ancient Chinese wisdom states: The journey of a thousand miles begins with the first few steps. Notes: 1. Note that the Stomach and Intestines are often considered together as a single unit. 2. In general, a swollen tongue with a moist or slippery coat indicates retention of stagnant Fluids, i.e. retained Water (Edema), retained Fluid, Damp or Phlegm (usually Cold-Phlegm). THE NATURAL THERAPIST Volume 28 No.3 29

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