Tongue Macicioca

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JOURNAL OF CHINESE MEDICINE NUMBER 48 MAY 1995

CLINICAL

ASPECTS OFTONGUE DIAGNOSIS

One of the most useful aspects of tongue diagnosisis that the tongue body colour nearly alwaysshows the true character of the disharmony. This

is especially helpful in complex and contradictory condi-tions, some examples of which will be described below. Ourdiscussion 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 SHOWSTHE TRUE CONDITION

The colour of the tongue body is the most important andreliable aspect of tongue diagnosis because it always showsthe true condition. This is especially useful in those situa-tions where there are confusing manifestations of heat andcold, and of deficiency and excess. Some examples willclarify the importance of this aspect of tongue diagnosis.

Kidney yin and Kidney yang deficiencyWhen there is deficiency of both Kidney yin and yang(which is relatively common, especially in women) theclinical manifestations may be contradictory. For example,a woman may suffer from backache, frequent and paleurination, cold feet, slight oedema of the ankles (all signsand symptoms of Kidney yang deficiency), as well as nightsweats (a symptom of Kidney yin deficiency). On the otherhand, another woman may suffer both from night sweats,hot flushes, dry throat and eyes (all symptoms of Kidneyyin deficiency), and from cold feet and pale urine (symp-toms of Kidney yang deficiency). Both of these conditionsare more likely to appear in women over forty. Unless thepulse is clearly floating and empty, signifying Kidney yindeficiency, or very deep and slow, denoting Kidney yangdeficiency, it may not be of much help in differentiating between the two conditions. In fact, in both Kidney yin andKidney yang deficiency the pulse may simply be weak at both proximal positions.

Thus, in such contradictory conditions, the colour of thetongue body is vital in determining the true character of the

disorder. If the tongue body colour is pale, Kidney yangdeficiency predominates, and if it is red, Kidney yin defi-ciency predominates. In the former case one should tonifyand warm the Kidney yang, and in the latter nourish theKidney yin. The importance and significance of the tongue body colour is such that one can safely choose the treatmentstrategy based upon it.

The following brief case history serves to highlight thisprinciple. A woman of 45 had been suffering from nightsweats and severe hot flushes for several weeks. Whilethese two symptoms pointed to yin deficiency, she also feltcold in general, her feet were cold, urination was frequentand pale, and, most of all, the body of her tongue was verypale. 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 princi-ple of tonifying and warming the Kidney yang and useddirect moxibustion with seven moxa cones on GuanyuanREN-4. Although this technique would appear to have beencontraindicated by her hot flushes, the results were excel-lent: the hot flushes which she had suffered for six weekswere stopped with just one treatment.

Emotional ProblemsWhere there are emotional disorders the tongue is a veryreliable indicator of the true origin of the problem. Gener-ally speaking, for long-standing emotional disorders eitherthe whole tongue or only the tip becomes red. This is due tothe 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 Hearthouses the spirit, which is affected by all types of emotions,Heart heat or Heart fire will develop. And because thetongue is the offshoot of the Heart, and its tip specificallycorresponds to the Heart, either the whole tongue or only itstip will become red. It is for this reason that a red tip to thetongue is such a common finding in long-standing emo-tional disorders.

However, although emotional problems are by far themost common cause of a red tip to the tongue, they are notthe only cause. In a few cases the tip of the tongue may

by Giovanni Maciocia


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become red due to overwork. Barring this reason, which isfairly rare, a red tip to the tongue is therefore a very reliableindicator that the basis of disharmony is emotional innature. Thus, in the course of examining a patient, it isessential 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 integrationwith the pulse, always provides reliable information aboutthe origin of a disharmony. For example, a person may bevery depressed, tired, move very slowly and speak in adecidedly low voice, all of which would suggest a conditionof deficiency and the presence of such emotions as sadnessor grief. However, if the tongue is dark red with reddersides and tip, this definitely indicates that anger rather thansadness is the cause of the depression. On the other hand,although a person may look restless and anxious, if thetongue is not red, or only slightly red on the tip, sadness orgrief may be the real cause of the disharmony.

Let us take an example of a different situation: a personmay look very anxious and be restless, but if the tongue ispale this indicates that the spirit is restless from a generaldeficiency of qi and blood, which in this case affects thespirit and causes an emotional disturbance, rather than theother way round.

The Heart crack (see illustration 1) is another reliableindicator in emotional problems. If a person is subject toconsiderable emotional stress with severe anxiety and men-tal restlessness and has a red tongue, the presence of a Heartcrack (in the midline extending to just behind the tip)indicates that the patient has a constitutional tendency to aHeart pattern, and that the problem will therefore be moredifficult to treat. If, however, the same manifestations ap-pear with no Heart crack, the condition is not so deeplyrooted and should be easier to treat.

Spleen yin and Stomach yin deficiencySometimes the tongue may show a certain condition veryclearly even though other signs and symptoms are absent.In these cases the tongue signs are such clear evidence thatthey may be relied upon and the patient may be givenpreventive treatment. Two cases in point are Spleen yin orStomach yin deficiency.

With Spleen yin deficiency the tongue has very distinctsmall transverse cracks on the sides (see illustration 2) andis generally dry. This indicates long-standing deficiency of

Spleen yin, the manifestations of which generally includethose of Spleen qi deficiency plus a dry mouth, dry lips anddry stools. If the deficiency of Spleen yin is severe there mayalso be some symptoms of heat from deficiency, such as afeeling of heat in the face.

With Stomach yin deficiency the tongue also presents veryclear and reliable signs: either a wide crack in the midline inthe centre of the tongue (see illustration 3) or small scatteredcracks (see illustration 4). Occasionally the tongue mayshow such cracks even though there are no Stomach symp-toms. In my experience such cracks are always diagnostic of a Stomach pattern which can be treated preventively beforethe appearance of symptoms.

THE TONGUE DOES NOT NECESSARILY SHOWTHE WHOLE CONDITION

Although the tongue body colour shows the true conditionof the patient, it should be remembered that it does notnecessarily show the whole condition. It needs to be inte-grated with other aspects of the disharmony, chiefly thepulse, complexion and symptoms. A patients disharmonyis a complex of various patterns, each of them manifestingmore fully in a particular sphere of clinical manifestations.We therefore need to use tongue diagnosis dynamically in

Illustration 1

Illustration 3

Illustration 4

Illustration 2


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conjunction with other manifestations and not merely toconfirm the diagnosis. A few examples will clarify thisconcept.

A woman may suffer from Liver blood deficiency leadingto Liver yang rising, which causes headaches. Her tongue

may be pale, reflecting the blood deficiency, and her pulsewiry, reflecting the rising of Liver yang. If she has othersymptoms of Liver yang rising, such as a slightly redcomplexion and a dry throat, when we integrate thesesymptoms with the wiry pulse we may be baffled by thepale colour of the tongue. ln fact, most books will say thatwith Liver yang rising, the tongue (or its sides) will be red.However, if we understand the principle that the tonguemay show only a part of the configuration of patterns, werealise that the tongue is reflecting the deficiency of Liver blood, and the pulse and symptoms the rising of Liver yang.

Liver Blood deficiency Liver yang rising(Pale tongue) (Wiry pulse, red face etc.)

The example of a tongue when there is a deficiency of bothKidney yin and Kidney yang has already been discussedabove. In that case the tongue reflects only part of theconfiguration of patterns, i.e., the predominant deficiency:

Kidney yang deficiency and Kidney yin deficiency(Pale tongue, feeling cold) (Night sweats etc.)

Another striking example of how the tongue may reflectonly part of a condition occurs in skin diseases. In manycases of chronic skin disease there is wind-heat, damp-heator heat in the blood (or a combination thereof) which causesthe skin lesions to become very red, itchy and hot to thetouch. With such striking manifestations of heat in the skinone would expect the tongue to be red. However, becausethere is often a background of blood deficiency in chronicskin diseases, the tongue is often pale. If we disregarded theprinciple that the tongue may show only one aspect of aconfiguration of patterns, we would again be baffled.

Blood deficient and dry Heat in the blood(Pale tongue) (Red-hot-itchy kin lesions)

Another very common case in which the tongue reflectsonly one aspect of a disorder is that of Spleen qi deficiencyleading to dampness or phlegm. In women, Spleen qideficiency also frequently leads to blood deficiency anddryness. While one would therefore expect the tongue to bethin and dry, in fact it is nearly always found to be pale,swollen and with a sticky coating. This occurs because thetongue is reflecting the Spleen qi deficiency and dampness/phlegm, but not the blood deficiency.

Yet another case in which the tongue does not show thewhole condition is when a certain pattern is incorporatedwithin another. For example, Liver blood deficiency mayevolve into Liver yin and/or Kidney yin deficiency after

some years. The tongue would have been pale initially, and become red and peeled with the onset of Liver yin defi-ciency. Liver yin deficiency will, of course, manifest with itsown characteristic signs and symptoms, but some of thoseassociated with Liver blood deficiency may remain. In this

case the tongue is unable to show both conditions becauseit obviously cannot be both pale (Liver blood deficiency)and red (Liver yin deficiency) at the same time. Here we saythat Liver blood deficiency has been incorporated withinLiver yin deficiency. We must therefore pay attention to thesymptoms and nourish Liver blood as well as Liver yin.

WHEN THE TONGUE TAKES PRECEDENCE OVERTHE PULSE AND SYMPTOMS

In many instances the treatment strategy should be basedon the appearance of the tongue rather than the symptoms.Some examples will clarify this concept. Many patients willpresent with localised heat signs even though the underly-ing condition is characterised by yang deficiency or cold.Although it is imperative that the heat signs be treated, theunderlying condition, as evidenced by the appearance of the tongue, must be the primary focus of treatment. Con-sider the following case history A 35-year-old woman had been suffering from inflammation and swelling of the lefteye; the sclera was red and the eye always felt irritated. Allof these symptoms clearly pointed to heat affecting the eye.Her tongue, however, was very pale and she had othersigns and symptoms of Spleen yang deficiency. In modernChina the tendency in such cases is to completely ignore thetongue and follow the symptoms. As a matter of fact, thispatient (a practitioner of acupuncture) had been treatedwith Chinese herbs while studying in China. But not onlyhad this failed entirely to help the eye, it had also made herworse in other ways, causing diarrhoea and abdominalpain. I examined one of the packets of herbs which she had brought back and noticed that the ingredients were all cold- bitter herbs to drain fire from the eyes. In treating thispatient I followed the principle of giving precedence to theappearance of the tongue and treated the patient accord-ingly. I therefore prescribed a formula to tonify Spleen qi,

adapted with the addition of a few herbs which gently clearheat from the eyes. This not only produced an improvementin her general condition, but also helped the eye.

An example of a contradiction between the tongue andsymptoms has already been described above, in which thesymptoms showed heat in the blood and the tongue showed blood deficiency and dryness. Although in such cases it isimportant to address the condition of heat in the blood,nourishing and moistening of the blood should not beoverlooked.

Patients suffering from carcinoma of the lung may de-velop a fever followed by symptoms of dryness, such as adry throat. Very often, however, the tongue is pale, tooth-marked and has a sticky coating, which are indications of Spleen qi deficiency and dampness. In this case one shouldnot nourish the yin (in accordance with the symptoms) but


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tonify the Spleen qi and resolve dampness (in accordancewith the appearance of the tongue).

WHEN NOT TO FOLLOW THE TONGUEThere are cases when one needs to base the treatment

strategy on the symptoms rather than the tongue, at leastinitially. Heat and cold can coexist and there are cases whenthe symptoms show heat but the tongue shows cold. Inmost cases it is better to deal with the heat first and the coldlater. This is especially desirable when heat and cold coexistin the same system, e.g., Bladder and Kidneys. A verycommon example would be that of a patient suffering fromurinary problems from damp-heat in the Bladder, but withan underlying deficiency of Kidney yang. The former pat-tern would cause signs and symptoms of heat, such as burning on urination and dark urine, while the latter pat-tern will present with such symptoms as backache andfeeling cold. This situation is common in women withurinary symptoms or men with prostate problems. In suchcases, initially at least it is necessary to ignore the tongueand clear the damp-heat from the lower burner.Another example is that of cases when all the signs andsymptoms except the tongue point to a certain condition. Itmay be that the patient has reached a period of life, usuallyin the mid-forties, when the tongue is about to changecolour. For example, a woman of 44 may suffer from fre-quent and pale urination, oedema of the ankles, a feeling of cold, diarrhoea, backache, dizziness and tiredness, and herpulse may be very weak at both proximal positions: all of these signs and symptoms point clearly to Kidney yangdeficiency, and the tongue should accordingly be very pale.If it is not, we are probably seeing the patient at that momentin time when the condition is just about to change from yangto yin deficiency. This example, taken from an actual case,illustrates the principle in diagnosis of looking not only atthe horizon, but also over the horizon, i.e., not regardingthe clinical manifestations as static at a given point in time, but being aware of the time scale and how the condition ischanging over time.

This article is extracted from Chapter 8 of the forthcoming revisededition of Tongue Diagnosis in Chinese Medicine by Giovanni Maciocia, published by Eastland Press. This new edition, containgmuch new material, will be available from early June. Giovanni Maciocia, Eastland Press.

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