9.26.15 Gmaciocia Tonguedx LN

 

TCM Tongue Diagnosis By

Giovanni Maciocia, OMD, LAc

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TONGUE DIAGNOSIS IN CHINESE MEDICINE TABLE OF CONTENTS

TCM TONGUE DIAGNOSIS Limitations of tongue diagnosis Items of observations of the Tongue Aspects of tongue diagnosis  Normal Tongue Tongue Topography of tongue Tongue areas Chest/ breast area Swollen on the sides: differentiation between Liver Spleen and chest

Part 1

Giovanni Maciocia

Red tip Red sides/ red front Red centre The tongue body colour in exterior conditions Differentiation between Heat and Fire Red points and red spots Red points tip Red points/ spots sides and root Red points Lung/ breast area White vesicles Shen disturbances and tip of to tongue ngue Yin Xu and Empty Heat on tongue tongue Degrees of Yin Deficiency Degrees of Empty Heat Purple Tongue Differentiation between reddish-purple and bluish-purpl bluish-purplee Areas of Blood stasis Blood stasis in women Purple Chest/ Breast Area Purple Chest Area-Breast area in women Sublingual veins Sublingual veins in relation to modern diseases Observation of tongue body shape

Stomach-Yin deficiency Yin deficiency of Stomach and Intestines Spleen-Yin deficiency Kidney-Yin deficiency Sudden appearance or disappearance of partial coating Root of coating Coating without root Filiform papillae Thickness of Coating Colour of Coating Coating distribution Sticky/ Slippery/ Mouldy coating Tongue diagnosis and herbal therapy Differentiation between deficiency of Qi or Yin of Stomach and Spleen Differentiation between Heat at the Qi or Ying/ Blood level and that Correlation between Types of Tongue and Endoscopy Results in Patients with Chronic Illnesses of the Stomach and Duodenum Correlation between Types of Tongue and Endoscopy Results continued  GastroscopyResults and Tongue Coating Correlation between Gastric Acidity and the Tongue Types of Tongue in Cases of Perforated Ulcer 

© Giovan Giovanni ni Maciocia & Lotus Institute Institute of Integrative Integrative Medicine, Medicine, PO B Box ox 924 92493, 93, City of IIndustry, ndustry, CA 9 91715 1715 Tel: 626-780 626-780-7182 -7182 • Fa Fax: x: 626-609 626-609-292 -2929 9 • Webs ebsite: ite:

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Spleen Sides, area onUterus sides Spleen-Yin deficiency cracks Thick coating on root Circumvallate papillae Pale tongue Red tongues Red tongue areas

Thin tongue Swollen tongue Partial swelling of the tongue Swelling of tip Swelling of side area between centre and tip Swelling of the side area between centre and tip photos Swelling of front third of tongue Swelling of sides, central section Swelling of sides Liver area Teethmarks Cracks Heart crack  Stiff tongue Quivering and moving tongue Deviated tongue Preventing value of tongue diagnosis in the elderly Tongue coating Differentiation between thick coating and coating without root Aspects of tongue coating Coating/absence of coating Degrees of Yin deficiency Areas of Yin deficiency Lung-Yin Deficiency

Body Shape and Sublingual Veins Tongue in Stomach Cancer-Body Colour  Tongue and ColonoscopyColonoscopy- Body Colour  Correlation between Atrophic-Necrotic Atrophic-Necrotic Epithelial Cells of the Tongue and Y Yin-Xu in-Xu Epigastric Pain Correlation between Atrophic-Necrotic Atrophic-Necrotic Epithelial Cells of the Tongue and Y Yin-Xu in-Xu Epigastric Pain Epithelial Cells of the Tongue in Three Groups Wen Bing and tongue diagnosis

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Strength of Tongue Diagnosis

Limitations of Tongue Diagnosis

The tongue gives the true picture roughly 98% of the time e.g. Yin/ Yang Xu, Hot/ Cold.

The tongue does not always reflect all aspects of a condition e.g. in Liver-Blood deficiency with Liver-Qi stagnation, the tongue will often reflect the former but not the latter.

The progress, or lack of progress, of disease can be monitored e.g.: Do not expect the tongue to reflect all the aspects of a pathology.

• A purple body colour is expected to become less purple. • A tongue without coating is expected to develop a coating. • Thick coating is expected to become thinner.

It is easier than pulse diagnosis! Also more objective

Order of observation of the tongue

There is a lack of detail e.g. a thick-sticky, yellow coating on the root shows Damp-Heat in the Lower Burner but not its exact location. Pulse diagnosis can clarify the exact location of Damp-Heat (e.g. Damp-Heat in the Bladder presents with a Wiry pulse in the left Chi  position, in Damp-Heat Damp-Heat in the IIntestines ntestines the pulse is Wiry on both both Chi positions.)

1.

Body Colour: It is important to analyze the tongue systematically, in a certain order. One should not let one’s attention be drawn to details of the tongue first. One must look at the tongue systematically and this is the order I recommend:

•

Heat or Cold 

•

Yin or Yang deficiency

•

Xu

•

Shi

•

Fu (Stomach)

•

Hot/ Cold 

•

Xu/ Shi

2.

1) Body colou colour  r  Body Shape:

2) Body sha shape pe 3) Coati Coating ng 4) Moist Moisture ure 3.

5)Shen The importance of looking at a tongue systematically cannot be overemphasized.

Aspects of Tongue Diagnosis

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Coating:

1

2

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Topography of Tongue

Normal Tongue

1. Bod Body y col colour our



2. Bod Body y sha shape pe



Pale-red Lower Burner 

 Not thin, not swollen swollen Middle Burner 

 Not stiff, not flabby flabby Without cracks  

3 . Co Coaa ttin ing g



4. Mo Mois istu ture re 5. Shen



 



Upper Burner 

Thin – white white

HE Heat

Slightly moist “With shen”, fresh, radiant, brilliant

Please note that the Lung area encompasses the Heart area

LU Heat

Differentiation between Liver and Spleen swelling Tongue areas

Heart / tip

Liver / sides

Liver and Heart / sides and tip

Stomach / centre

Stomach and Spleen / sides in central section

Lungs / front third 

Liver swelling

Spleen swelling

Chest/breast area

Spleen swelling

Spleen swelling

Differentiation between Liver, Stomach/Spleen and chest areas

The “chest” area is on the sides of the tongue, between between the centre part and the tip. The chest area reflects a pathology of three organs: heart, lungs or  breast in women.

Changes in this area to look for are: 1) Changes in colour (us (usually ually purple or red) 2) Changes in body shape (usually swollen or with teeth marks)

Thin, long band = Liver 

Broad band, middle section = ST/ SP

Chest/breast

Chest/breast

3) Red points 4) Coating (absence of coating)

lung/heart  breast

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3

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The chest area reflects pathologies of the lungs, heart or breast but in a Western medical sense. A change in the the chest area may involve a change in colour or body shape. How to differentiate when a change in the chest area indicates a  problem of the lungs or heart or of the breasts in women? A change in the chest area indicates a pathology of the breast in women rather that of lungs/heart:

Examples of lung pathology manifesting in the chest area are chronic asthma or chronic emphysema (in which case the chest area would be swollen and possibly purple). An example of heart pathology is chronic coronary heart disease (in which case the chest area would be purple). As the area on the sides between between the centre and the tip reflects the condition of heart/ lungs/ breast, I call this the “chest area”.

1) Especially In the absence of it anisobvious lungs/heart pathology 2) when unilateral

Swollen chest area

Apart from a purple colour and a swelling, other possible changes in the breast area are teeth marks that are confined only to the  breast area, red points points or the absence of coating of the breast area.

•Teeth marks only in the breast area indicate usually a problem in the breast in women (possible carcinoma) occurring against a  background of severe Qi deficiency •Red points in the breast area indicate Toxic Heat in the Lungs or  breast •The absence of coating in the breast area indicates a possible  problem in the breasts breasts in women occurring agai against nst a background of Yin deficiency.

Teeth marks  breast area on left

Teeth marks  breast area on right

Red points breast area on right

The area on the sides in the middle section of the tongue (around the centre) reflects conditions of the Stomach and Spleen. If it is red, it denotes Heat of the Stomach and Spleen. If it is swollen, it denotes Spleen deficiency with Dampness.

Red o on n th the sides around tth he centre: ST/SP Heat

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The same area on the sides that reflects the Liver, in women also reflects the Uterus (especially when it is purple) The sides indicate the state of the Liver but when they are Purple, in women, they may indicate Blood stasis in the Uterus

 No coating breast area left side

Area on sides around centre

Red centre: ST ST Heat

Purple chest area

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Root of tongue

Thick-sticky-yellow coating with red spots on the root = Damp-Heat in Thick-sticky-yellow the Bladder, Intestines, Kidneys, prostate or uterus

4

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Circumvallate papillae

Normal tongue

It is important to note that, in Chinese tongue diagnosis, we do not look at the two large papillae (circumvallate (circumvallate papillae) that are right at the back of the root of the tongue. They have no clinical significance. If we see those two papillae, we are looking too far back.

The normal tongue is pale-red. It is pale because the Stomach fluids flowing up to the tongue make it  pale. It is red for for two reasons:

a) Because Heart-Blood makes it red (the tongue is an offshoot of the Heart)  b) Because the Minister Fire flows up to the tongue making making it red.

Therefore, the influence of Stomach fluids, Heart-Blood and Minister Fire give the tongue a normal pale-red colour. It follows, therefore, that a normal, pale-red tongue indicates a good state of the Stomach, Heart-Blood and Minister Fire (and therefore KidneyYang).

Circumvallate papillae

Pale (too pale) Normal tongue

•

ST-Fluids

Tongue Pale

•

HE-Blood

Tongue Red  

Minister Fire

KI

HE

By “Pale” is meant a tongue that is too pale, not a norm normal al pale-red tongue. The tongue may be pale either because not enough Blood reaches it (Blood deficiency) or because a deficient Yang fails to Pale-Red (Normal)

Tongue

Normal Red

carry Blood to it (Yang deficiency). A deficiency of Kidney-Yang also makes the tongue pale because not enough heat from the Minister Fire reaches it. Therefore, a pale tongue indicates either Blood deficiency or Yang deficiency. The Blood deficiency may involve the Spleen, Liver or Heart or a combination of these organs. If there is Liver-Blood deficiency, only the sides of the tongue may  be pale. Other than that, one cannot pinpoint pinpoint from the to tongue ngue only which organ is primarily affected by Blood deficiency.

This tongue is almost normal in terms of body colour and shape and coating. The only abnormality is a slight swelling

Minister Fire

Pale, dry

Pale, dry

Red Tongue

Blood Xu

Yang Xu

• Sligh Slightly tly dry

• Slightly Slightly wet

• Slightly Slightly thin

• Slightly swollen

• Wo Women men

• Men and women

Frequently  pale on sides in LIV-Blood  Xu

Occasionally orangey in Severe LIVBlood Xu

By “Red” is meant a tongue that is too red, not a norm normal, al, pale-red tongue. Obviously, Obviously, “red” refers to the colour of the body and not to that of the coating. A red tongue indicates pathological pathological Heat. The first question weneed to ask ourselves when confronted with a red tongue is: does it have a coating or not? For a red tongue with coating indicates Full Heat while a red tongue without coating indicates Empty Heat. It is important to understand that both Full Heat and Empty Heat are indeed Heat and they therefore each make the tongue too red. It is the lack of coating that indicates Yin deficiency deficiency and, for this reason, if a tongue is too red and lacks a coating, coating, it indicates Empty Heat deriving from Yin deficiency.

The tongue is never pale only on the tip Red with coating = Full Heat

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 Normal colour, without coating = Yin deficiency

Red without Empty Heat coating =

5

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YIN XU VS EMPTY HEAT

= Yin = Empty Heat

RED (Too red)

Normal Pale-Red

Coating with root Red = Heat

T on on gu gu e w wit ith h ou ou t c o oaa ttin ing g

= Full Heat

 No coating or coating without root

Time

Dark red

= Empty Heat

Re Red d tto on ng gu uee wit with ho ou u t co co ati atin ng

T oo oo th th in in

Wi th th ou ou t r oo oo t

Red with normal coating

Full Heat

P ar ar titi aalll y wi th th ou ou t coating

Totally no coating

Red without coating = Empty Heat

If the whole tongue is red, it indicates Heat or Empty Heat, depending on whether it has a coating or not. When the whole tongue is equally red, we cannot actually pinpoint the location of the Heat. Often however, the tongue is either red only in a specific area or, although it is all red, it is redder in a specific area. The five areas where the tongue is commonly either red (on a normal tongue) or redder (on a red tongue) are: • The ce centre ntre • The sides ((Liver Liver area) • The sides around the centr centree (Stomach/Spleen area) • The tip (H (Heart eart area) • The front third (L (Lung ung area)

RED TIP

Redder tip on red tongue without coating = Heart Empty Heat

Redder tip on red tongue with coating = Heart Full Heat

RED SIDES (LIVER)

Centre (ST)

Sides (LIV)

Sides (ST/SP)

Tip (HE)

Front third (LU)

Redder sides on red tongue with coating = Liver Full Heat

RED SIDES (ST/SP)

Redder sides on red tongue without coating = Liver Empty Heat

RED CENTRE Red sides around centre (more on right) on tongue without coating= ST/SP Empty Heat

Red sides around centre on tongue with coating= ST/SP Full Heat

Red centre on tongue with coating = Stomach-Heat

RED FRONT (LUNG)

Redder front (LU area) on red tongue with coating = Lung Full Heat

Redder front (LU area) on red tongue without coating = Lung Empty Heat

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Statistic on body colour based on database of 2500 patients (UK)

Red centre on tongue without coating = Stomach Empty Heat

6

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The tongue body colour colour in exterior conditions

Differentiation between Heat and Fire

In exterior conditions with invasion of external Wind, the tongue may not change much if the pathogenic pathogenic factor is light. In some cases, the tongue coating may change (see below). If the exterior Wind is accompanied by Heat (i.e. Wind-Heat), the tongue body colour may  become red on the sides towards the the front (i.e. ssame ame area as the “chest area” defined above).

Heat (re) and Fire (huo) are not the same. Although they both share share similar characteristics as they both pertain to Heat (in a general sense), they are not quite the same. The distinction between H Heat eat and Fire is  particularly important important in herbal therapy therapy as they call for for different treatment methods.

This change is more likely to occur in children. Thus, in the beginning stages of invasion of Wind-Heat, the chest area may become slightly red: indeed this change is likely to occur in children even before symptoms

Chinese books do not always always use the terms “Heat” and “Fire” consistently. The confusion arises arises also because the term “Heat” has two different meanings. In a broad sense, it indicates any syndrome

appear. When the redness spreads towards towards the centre, it means that the  pathogenic factor has become interior interior..

characterized by Heat, including Fire; thus, for example, Liver-Fire is a “Heat” pattern.

In a narrow sense, “Heat” is used as opposed opposed to “Fire”. This distinction between Heat and Fire stems from the Yang Ming patterns of the 6 Stages in the Shang Han Lun.

Exterior Wind-Heat

When centre becomes red, pathogenic factor has moved to Interior 

HEAT

FIRE

Within the Yang Ming stage of the 6 Stages, there are two patterns: Channel Syndrome and Fu Syndrome. Syndrom Channel is characterized by Stomach-Heat withe.theThe “four bigs”, Syndrome i.e. big sweating,  big fever, big thirst, big pulse.

The Fu Syndrome is characterized by Stomach-Fire and its main manifestations are abdominal pain and constipation. These two symptoms indicate that the Heat has penetrated deeper and has affected the Fu organs by drying up the fluids: it is now called “Fire”.

Red body, thin yellow coating: Heat

Redder body, thick, dry, dark yellow/ brown/  black coating: Fire

6 STAGES

YANG MING CHANNEL

4 LEVELS

Thus, within the Qi Level, there are two energetic levels, that of Heat and that of Fire, the former being more superficial.

Heat can be cleared with pungent-cold pungent-cold herbs (such as Bai Hu Tang White Tiger Decoction) which expel Heat outwards.

STOMACH-HEAT QI LEVEL

YANG MING FU

STOMACH-INTESTINES-DRYHEAT

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Fire can only be drained downwards with bitter-cold herbs as it is energetically too deep to be expelled outwards. Tiao Wei Cheng Qi Tang Regulating the Stomach Stomach Cond Conducting ucting Qi Decocti Decoction on or Cheng Qi Tang Conducting Qi Decoction are the representative formulae to drain Fire at the Qi Level.

7

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The 4 Levels

Expelled outwards towards the surface with pungentcold herbs herbs (Bai Hu Tang) Tang)

WEI LEVEL

HEAT FIRE

QI LEVEL YING LEVEL

Drained downwards through the Intestines with bitter-cold herbs (Cheng Qi Tang)

BLOOD LEVEL

The Channel Syndrome with Stomach-Heat is treated by  pungent-cold herbs (such as Shi Gao) which clear Heat because the Heat is still superficial enough to  be expelled outwards outwards towards the surface with pungent herbs. The Fu Syndrome with Stomach-Fire is treated by  bitter-cold herbs which drain Fire by moving downwards and stimulating the bowel movement. In the case of Fire, this is too deep in the Interior to be expelled by  pungent herbs.

Common manifestations: feeling of heat, thirst, red face, dark urine, Rapid pulse and Red tongue with yellow coating HEAT

FIRE

• More intense: pronounced feeling of heat, intense thirst • More drying: dark urine, dry stools, dry tongue tongue

Red points and red spots

Red points (called dian in Chinese) or red spots (called ban in Chinese) indicate Heat. Red points are small and pointed and they indicates Heat; red spots are larger and flatter and they indicate Heat with some Blood stasis. The latter are more commonly seen on the root of the tongue.

• Affects Shen more: agitation agitation,, mental res restlessness, tlessness, insomnia • May cause bleeding: epistaxis, coughing coughing up blood, vomiting blood, blood in urine or stools Tongue signs: Red tongue with thick, dry, yellow/ brown or black coating

Tongue signs: Red tongue with yellow coating Treatment principle: Clear Heat with pungent-cold herbs to push Heat outwards 泄热

Red points front

Three large red spots right side

Treatment principle: Drain Fire with bitter-cold herbs which move downwards 泻 火

Red points and red spots

Red points and spots are a pathological change of the normal red  “grains”.

The ancient Chinese called the fungiform fungiform papillae “red grains”. grains”. “Red grains” are a normal, physiological structure structure of the tongue body. body. They are the individual papillae which form the body of the tongue. “Red” in “red grains” refers to a physiological red. Also, the red grains are flush with the tongue surface and do not stick out.

The physiological red grains are a manifestation of the physiological Minister Fire of the Kidneys. Therefore, red grains indicate a  physiological condition condition of normal normal heat deriving from the Minister Fire.

DIAN 点 and BAN

RED POINTS AND SPOTS

Physiological Minister Fire

Pathological

Tongue

Red points (Dian)

“Red grains” grains” Normal (fungiform (fungifor m papillae)

Red grains  become:

Points = Dian 点 Spots = Ban 斑

When this becomes excessive, it flares upwards and makes the red  grains redder and causes them to stick out of the tongue’s surface. When this happens, happens, “red grains” are called “red points”or “red spots”.

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Spots indicate Heat with some Blood stasis (more common on root)

- Redder  Redder  - protrudi protruding ng

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Red points tip

Red points/spots sides and root

Red points sides

Red points/spots sides and root

Red points front, chest/breast area and on Stomach/Spleen area, worse on right

Red spots on root

White vesicles

Similarly to red points and spots, white vesicles are also pathological fungiformpapillae. These protrude from from the tongue surface but th they ey are white rather than red. White vesicles indicate Dampness.

Red spots root

Red points Lung/ breast area

Red points breast area left side (also some on the side, on the right)

Red points Lung area (and also SP area right side)

Shen disturbances and tip of the to tongue ngue

Generally speaking, the progression of severity of emotional stress according to the tip of the tongue is as follows: • Red tip, normal body colour  • Red body colour colour,, redder tip • Red body colour, redd redder er tip with red points • Red body colour, redd redder er and swollen tip • Red body colour, redder and swollen tip with red points • Red body colour, redder tip with red points, Heart crack  • Red body colour, redder and swollen tip with red points, deep Heart crack 

Of course, this is only a guideline and actual situations in practice may deviate from this outline. White vesicles (Dampness)

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Yin Xu and Empty Heat on ton tongue gue

The tongue shows conditions of Yin deficiency deficiency and Empty Heat clearly. It is important to understand that, although Empty Heat derives from Yin deficiency, it takes time for it to develop.

Therefore, a patient may display all the signs of Yin deficiency on the tongue for several years without developing Empty Heat and the tongue shows this clearly by being of a normal colour and lacking a coating.

In fact, Yin deficiency manifests on the tongue with a lack of coating; therefore, a tongue without coating but of a normal body colour indicates Yin deficiency without Empty Heat.

As Yin deficiency aggravates with time, Empty Heat may develop and this turns the tongue red: therefore Empty Heat on the tongue is manifested by a red body colour together with the absence of coating.

One often hears that “in Yin deficiency the tongue is red ” (a statement that is tempting to make since “in Yang deficiency the tongue is pale”). This is not not so:

A tongue without coating indicates Yin deficiency first and foremost of the Stomach: in addition, it may also indicate Yin deficiency of the Kidneys, Liver or Heart.

- In Yin deficiency, the tongue tongue lacks a coating (and has a normal colour) - In Empty Heat, the tongue tongue lacks a coating and its body is red.

Yin Xu and Empty Heat on tongue

That Yin deficiency can occur without Empty Heat is demonstratedby tongue diagnosis as many patients have a tongue that lacks a coating (indicating Yin deficiency) but is not red. YIN

EMPTY HEAT

T ong ongue ue w iith thou outt coa coatin ting g

This tongue partially lacks a coating and the other coating is rootless (Yin deficiency) and has a normal colour (= no Empty Heat)

T ong ongue ue re red dw with ithou outt coa coati ting ng

Yin Xu and Empty Heat on tongue

This tongue lacks a coating (Yin deficiency) and is slightly red in the centre (beginning of Stomach Empty Heat)

Yin Xu and Empty Heat on tongue

Yin deficiency and Empty Heat are not formed in a short space of time: it takes years from them to develop. The tongue shows clearly not only the present condition but also the stage it is at: it therefore also shows where it is developing from and what it may lead to. The three stages of the formation of Yin deficiency are:

YIN XU

NO COATING

This tongue lacks a coating (Yin deficiency) and has a normal colour (no Empty Heat)

1) Rootless coating (this is the mildest form of Yin deficiency) 2) Coating partially peeled 3) Coating missing completely Empty Heat may develop at any of these stages but it is more likely to develop at the third.

YIN XU WITH EMPTY HEAT

NO COATING RED BODY

WITH COATING

FULL HEAT

RED

WITHOUT COATING

EMPTY HEAT

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Degrees of Yin Deficiency

Degrees of Yin Deficiency

Yin deficiency is a gradual process which develops over years. The absence of coating in a tongue with a normal body colour indicates fairly advanced Yin deficiency but without Empty Heat. The following slides are illustrations of varying degrees of Yin deficiency. 1

3

4

2

Coating missing entirely, colour normal: Stomach-Yin Xu, no Empty Heat. Note that the tongue is also swollen and therefore there is Phlegm.

Coating entirely missing, slightly red body: Deficiency of Yin of Stomach and possibly Kidneys with some Empty Heat. The widespread presence of cracks indicates a deeper stage of Yin deficiency

Coating entirely missing, red body: Yin deficiency of Stomach and  possibly Kidneys with Empty Heat. Heat. The presence of a Heart crack also leads us to deduce that there is possibly also Heart-Yin Xu.

Entirely without coating everywhere: deficiency of Yin of Stomach and Kidneys. As the tongue is also deep red, there is intense Empty Heat. This is very severe Yin Xuand this patient had liver cancer.

Purple Tongue

Purple is one of the pathological colours of the tongue body. Chinese  books regularly regularly say that in Qi stagnation the tongue tongue is purple. I do not agree with this statement because the tongue body colour reflects the condition of Blood rather than of Qi. Therefore, a purple body colour, in my opinion always indicates Blood stasis. In general, it takes a relatively long time for a tongue to become purple and therefore, a purple tongue usually indicates a chronic condition. The only two exceptions to this are trauma and surgery, after which the tongue becomes purple in a matter of days or hours.

As indicated earlier tongue diagnosis allows us not only to diagnose the pathology but also to assess the degree of the severity of such  pathology. In In the case of a purp purple le tongue, it allows allows us not onlyto diagnose Blood stasis but also to ascertain its degree of severity. For example, a tongue may be only slightly purple which means that the Blood stasis is mild. By contrast, if a tongue is deeply purple it indicates that the Blood stasis is severe.

It is important to remember that the purple colour is not always obvious as it is often quite subtle. As a rule of thumb, I would say that if a tongue is not of a normal colour, not pale nor red, the chances are that it might be subtly purple. It is important to be able to recognise a purple colour because it is clinically very significant. A purple colour always indicates Blood stasis which potentially causes serious diseases, e.g. coronary heart disease, cancer, and stroke. Severely purple, more on the right side

Very slightly purple, more on the left side

Purple Tongue

There are two pathological purple colours: bluish-purple and reddish purple, the former former indicating B Blood lood stasis associate associated d with Cold an and/or d/or Yang deficiency, and the latter associated with Heat. Therefore,the  bluish-purple  bluish-purp le tongue develops from a pale tongue, tongue, while the reddishreddish purple tongue tongue develops from a red tongue.

YANG DEFICIENCY COLD (Pale tongue)

HEAT (Red tongue)

Cold congeals Blood 

Heat condenses Blood 

BLOOD STASIS

BLUISHPURPLE

Bluish-purple

Reddish-purple

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REDDISHPURPLE

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Areas of Blood stasis (Partially Purple tongue)

Just as in the case of the pale and red tongues, a tongue may also be  partially purple in in a specific area. The The three areas that are commonly  partially purple are: are: the sides, the chest area and the centre. Purple sides indicate Blood stasis in the Liver or, in women, in the uterus. A purple colour in the chest area indicates Blood stasis in the heart or lungs (in the sense of Western pathology) or in the breast in women. A purple colour in the centre indicates Blood stasis in the Stomach. Purple chest/breast area (Blood stasis in chest/breast –  LU, HE, breast)

Purple sides (Blood stasis in Liver/Uterus)

Purple centre (Blood-stasis in the Stomach)

Blood stasis in women (purple sides)

In women, purple sides (Liver area) may indicate Blood stasis in the uterus. As Blood stasis in the uterus is very common, purple sides in women usually indicate Blood stasis in the gynaecological systemrather than in the Liver itself.

Bluish-Purple

Bluish-Purple

It is important to remember, however, that the tongue may NOT be purple in women if the Blood stasis is relatively mild. In other words, a woman may display all the symptoms of Blood stasis in the uterus (painful  periods with dark menstru menstrual al blood and dark clots) without the tongue  being purple. Moreover, the degree of severity of the purple colour of the tongue in women is directly correlated to the severity of Blood stasis. We can identify four stages of Blood stasis according to the tongue: 1. Normal body colour 2. Purple veins underneath the tongue 3. Purple sides 4. Whole tongue purple

Reddish-Purple

Bluish-Purple

Blood stasis in women

Four degrees of severity of Blood stasis

Purple chest/ breast area

As explained earlier the chest area on the tongue reflects Western  pathology of the heart or lungs or of the breast in women. When the chest area reflects pathologies of the heart heart or lungs these will be very obvious from the symptoms (e.g. coronary heart disease, chronic obstructive pulmonary disease). In women, the chest area may reflect a pathology of the breast especially when the purple colour is unilateral.

1. Normal body colour 

3. Purple sides

2. Purple veins underneath

4. Whole body Purple

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Sublingual Veins

Purple chest/breast area in women

In women, a purple colour in the breast area often appears in breast cancer as this usually occurs against a background of Blood stasis. There is a correlation between the purple colour of the breast area and the prognosis: the darker this area, the worse the prognosis. If the breast area on the tongue tongue is purple in women who have not been diagnosed with breast cancer, this sign may indicate a tendency towards the disease before any symptoms manifest; for this reason, observation of the chest area in women is particularly relevant.

Observation of the tongue should always include observation of the veins under the tongue. Under normal circumstances circumstances the veins are not distended, not dark, and one can barely see their outline.

Although a purple colour of the veins under the tongue is clinically very significant, other abnormalities abnormalities may also be observed, such as, for example, the veins being distended and shiny.

When the veins under the tongue are purple it indicates the early stages of Blood stasis. The sublingual veins, therefore, become purple before the rest of the tongue. A purple colour of the veins under the tongue gives an early indication of Blood stasis particularly in the upper and middle burners. Bluish-Purple chest/breast area

Purple, peeled chest/breast area

Reddish-Purple chest/breast area

In modern China, doctors also correlate the appearance of the sublingual veins with modern diseases such as hypertension and arteriosclerosis.

Distended = Qi Xu Distended and dark = Blood Stasis Early indication of Blood stasis in upper burner, Lungs, Heart, but also in the Liver

• Too thin = Yin Xu • Swollen, white-sticky = Dampness and Stasis of Blood (Bi syndrome) • Reddish, shiny = Damp-Heat • Yellowish = Turbid Dampness steaming upwards Cold-Dampness ess • White-slippery = Cold-Dampn • Dark-dry veins: severe Yin Xuwith Empty Heat

 Normal sublingual sublingual veins

Yellowish shiny sublingual veins: Damp Heat

Dark subling sublingual ual veins

Very slightly purple sublingual veins on the right side

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Sublingual veins slightly dark 

Sublingual veins very dark on the left side

Sublingual veins dark and distended 

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Sublingual veins in relation to modern diseases

• Dark-Purple veins: Blood stasis in heart and/ or lungs; in some cases it can indicate hardening of arteries in the brain.

TCM TONGUE DIAGNOSIS

• Distended-dark and crooked veins : hardening of the arteries, high  blood pressure. pressure. If veins also also stick out a lot an and d look like earthworms, the disease is severe. • Dark nodules on veins: small nodules like rice or wheat grains indicate hardening of arteries and heart disease. Part 2

Tongue-body shape

Observation of the tongue-body shape should come immediately after that of the t ongue-body colour colour.. The normal tongue-body shape is neither too thin nor too swollen, not cracked and neither too stiff nor too flabby. The tongue-body shape gives us an indication of the Full or Empty character of the condition while the tongue-body colour gives us an indication of Yin and Yang and Heat and Cold. The information gleaned from the observation of the tongue-body shape and the tongue-body colour therefore complement each other.

XU TONGUE-BODY COLOUR = YIN/YANG, HEAT/COLD SHI

TONGUE-BODY SHAPE = FULL/EMPTY

As we shall see, in general the clinical significance of a particular tongue-body shape depends on the tongue-body colour. For example, a thin tongue indicates Blood deficiency if it is pale, and Yin deficiency if it lacks a coating. The tongue-body shape reflects the Full or Empty character of the condition and it also gives an indication of its severity. For example, if a tongue is pale and dry it indicates Blood deficiency, but if in addition it is also thin, it indicates that the Blood deficiency is severe.

TONGUE-BODY COLOUR = YIN/YANG, HEAT/COLD Pale = Blood Xu THIN Tongue Without coating = Yin Xu

Red = Heat

Pale = Yang Xu, Cold 

TONGUE-BODY SHAPE = XU/SHI

Thin-Pale = Blood Xu This tongue is Thin (from Blood Xu),

This tongue is red,  but also swollen

compare with Pale tongue above

(Phlegm)

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Thin without coating = Yin deficiency

Statistic from practice = 1.9% of tongues are Thin

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Although the tongue is often described as being “Thin” in Blood deficiency, the Thin tongue is actually relatively rare. This is not  because Blood deficiency deficiency is rare (it is in fact very common common especially in women) but because the tongue is very frequently Swollen from Dampness or Phlegm. Obviously, the tongue cannot be Thin and Swollen at the same time and the swelling predominates.

SP-Qi Xu

Blood Xu

Dampness/ Phlegm

Thin (Pale)

Swollen

Therefore it is important to realise that, especially in women, if the tongue is Swollen it does not mean that there is no Blood deficiency. The tongue on the left is a good example of the co-existence of Blood deficiency and Dampness in women. In fact, it is Pale and Thin which indicates Blood deficiency but it is Swollen on the sides which indicates Spleen deficiency and Dampness.

In fact in women Blood deficiency and Dampness or Phlegm often coexist.

This happens because when the Spleen is deficient it may lead to Dampness or Phlegm which make the tongue Swollen. On the other hand, a deficient Spleen fails to make Blood and this leads to Blood deficiency: this would make the tongue Thin but it does not because the tongue is Swollen from Dampness or Phlegm.

Swollen sides

Swollen sides

Thin

Swollen Tongue

In my database of over 2500 patients, only 1.9% have a Thin tongue. As we have seen this does not mean that Blood deficiency is uncommon; on the contrary, it is common especially in women.

The term “Swollen” refers to a tongue with a body larger than normal. Although the tongue maybe partially Swollen in places, the term “Swollen” indicates a tongue that is completely swollen in every part.

The tongue is often Swollen from Dampness or Phlegm (which are very common pathogenic factors): if, in addition, there is also Blood deficiency this cannot make the tongue Thin because it is Swollen from Dampness or Phlegm.

In fact, in the same database of over 2500 patients, 38% have a Swollen tongue.

Just as when the tongue is smaller than than normal it indicates that there is a lack of some substance (Blood or Yin), when it is larger than normal, it obviously indicates that there is a pathogenic factor (Dampness or Phlegm). One often hears that “a Swollen tongue indicates Qi deficiency”: this cannot be because the very swelling in indicates dicates the  presence of an excess excess of a substance that that should not be be there (in this case Dampness or Phlegm). Of course it is true to say that Dampness and Phlegm themselves derive from Qi deficiency, but the swelling itself indicates Dampness or Phlegm and not Qi deficiency. In my database of 2500 patients 38% have a Swollen tongue.

 Normal-sized tongue tongue

Swollen Tongue

Partial swelling of the Tongue

When the tongue is completely Swollen it indicates the presence of Dampness or Phlegm but especially the latter (Dampness is indicated more by the stickiness of the coating). Note how the tongue changes shape when it is swollen, it becomes more round. Whole tongue swollen = Dampness and/ or Phlegm (especially Phlegm)

A partial Swelling of the tongue indicates either the location of Phlegm in a particular part of the body or, in some cases, Heat (in which case that particular area would also be red). Partial swelling due to Phlegm (Lungs)

Partial swelling due to Heat (Liver)

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Swollen tongues

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When the tongue is partially Swollen it indicates either the localised  presence of Phlegm in a specific part of the body or, if the tongue is Red, Heat. The tongue may be partially Swollen in the following areas: • Ti Tip p • Front Front third  • Sides between the cen centre tre and the tip • Sides (central section) • Sides (the w whole hole side)

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Swelling of Tip

Partial swelling of the tongue

A swelling in the tip indicates emotional stress affecting the Shen. It usually appears in conjunction with a redness of the tip.

Swollen front third 

Swollen chest/breast area

Swollen tip

Sides (central section, ST-SP)

Sides (the whole side, LIV)

Swelling of chest/breast area (heart/ lungs/breast)

As indicated earlier, changes changes in the area between the centre and the tip

A swelling in the chest area indicates retention of Phlegm in the Lungs or, in women, in the breast. Especially when the swelling is unilateral, it is more likely to indicate Phlegm in the breast.

reflect a pathology of the heart, lungs or breast in a Western medical sense. A change in the chest area may involve a chang changee in colour or  body shape. How to differentiate differentiate when a ch change ange in the chest ar area ea indicates a problem of the lungs or heart or of the breasts in women? A change in the chest area indicates a pathology of the breast in women rather that of lungs/heart: 1) In the absence of an obvious lungs/heart pathology 2) Especially when it is unilateral Examples of lung pathology manifesting in the chest area are chronic asthma or chronic emphysema (in which case the chest area would be swollen and possibly purple). An example of heart pathology is chronic coronary heart disease (in which case the chest area would be  purple). As the area on the sides between the centre and the tip reflects reflects the condition of heart/ lungs/ breast, I shall call this the “chest area”.

Swelling of front third of t ongue

A swelling in the front third of the tongue indicates retention of Phlegm in the Lungs. Lungs. This is often a residual pathogen pathogenic ic factor from  previous invasions invasions of Wind.

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Swelling of sides, central section

A swelling in the central section on the sides indicates retention of Dampness with Spleen deficiency

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Swelling of sides (Liver area)

Teethmarks

A swelling in the Liver area indicates Liver-Heat or Liver-Fire.

Teeth marks indicate Spleen-Qi deficiency. Please note that the  presence of teeth marks marks does not necessarily indicate indicate that the tongue is Swollen as t eeth marks appear also on normally-shaped tongues.

Teeth marks in breast area = possible breast cancer (the cancer is located on the same side as the teeth marks).

Cracks

In general cracks indicate Yin deficiency

In general cracks indicate Yin deficiency. There are many different types of cracks according to their location on the tongue: •

Heart crack 

• •

Single Stomach crack  Scattered Stomach cracks

•

Spleen cracks

•

Central Lung crack 

•

Bilateral Lung cracks

•

Stomach-Lung cracks

•

Ice-floe cracks

•

Kidney cracks

The location of the cracks therefore, allows us to identify which organ is affected by Yin deficiency very clearly. Please note that not all cracks always indicate Yin deficiency. For example a shallow Heart crack indicates a constitutional tendency to mental-emotional stress. Bilateral Lung cracks indicate a past disease of the Lungs usually dating back to childhood. Cracks can become shallower with treatment.

Heart crack 

Stomach crack 

Stomach cracks

Stomach/Heart crack 

In general cracks indicate Yin deficiency

Heart crack

The Heart crack is a long, midline crack that starts near the root of the tongue and extends all the way to the edge of the tip; occasionally, it may extend to the very tip of the tongue.

Lung c rack

Lung c racks

Lung/Stomach crack  

The clinical significance of the Heart crack depends on its depth and on the colour of the tongue. If the Heart crack is relatively shallow and the tongue-body colour normal, normal, this indicates not an actual Heart pattern  but simply the constitutional ten tendency dency to mental-emotional mental-emotional stress. IIn n other words, when subject to the same stress, a person with a shallow Heart crack will suffer more emotional problems than one without.

Spleen cracks

Old age cracks

Kidney crack 

Heart cracks

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Scattered Stomach cracks

Stomach crack

The Stomach crack is a midline crack that is in the centre of the tongue (Middle Burner area).

Scattered Stomach cracks may be all over the tongue. tongue. They are either small horizontal cracks or irregular cracks that in Chinese books are

The clinical significance of the Stomach crack is either a Stomach-Yin deficiency or a constitutional tendency to Stomach patterns. The Stomach crack differs from the Heart crack in two respects: 1) It is only in the centre; 2) It is wider than the Heart crack.

described as being the shape of the ren character The clinical significance of the scattered Stomach cracks is either a Stomach-Yin deficiency or a constitutional tendency to Stomach  patterns.

Ren-12, ST-36, SP-6 or even  just Ren-12

Lung crack

The Lung crack is a central crack in the front third of the tongue. It indicates a constitutional tendency to Lung patterns and Lung-Yin Lung-Yin deficiency. LU-9 and Ren-12 Ren-12..

Lung-Stomach crack

A Lung-Stomach crack is a combined Stomach crack (that is in the middle section of the tongue) and a Lung crack (because it extends to the Lung area, front third of the tongue)

Lung crack 

Diagonal Lung cracks

Lung/Stomach crack 

Diagonal Lung cracks indicate a past lung disease such as whooping cough in childhood.

Lung cracks

Spleen cracks

Spleen cracks are small transversal cracks on the edges of the tongue: they indicate Spleen-Yin deficiency.

Old age cracks

Old-age cracks are are also called “ice-floe”cracks. They are not common and they simply indicate Kidney deficiency from old age.

Old age cracks Spleen cracks

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Kidney crack

The Kidney crack is longer than the Heart crack, extending towards the root. It is also deep and it has small cracks radiating outwards from the central crack. It indicates severe Kidney deficiency (usually Yin), Yin), from overwork.

Stiff 

The Stiff tongue indicates a tongue tongue that is stiff and hard. The Stiff tongue has three possible clinical meanings: 1. Internal Wind  2. Blood sta stasis sis 3. Yin deficie deficiency ncy As indicated above, a change in body shape indicates a more severe condition (compared to one in which there is a change only in the  body colour. For instance, a Purple tongue indicates indicates Blood stasis

Kidney crack 

and if it is also Stiff, it indicates that the Blood stasis is severe. Internal Wind

STIFF (Hard)

Blood stasis

Yin Xu

Quivering

The Quivering tongue trembles rapidly and with small amplitude. The Quivering tongue generally indicates Spleen deficiency; occasionally, in the elderly it may indicate Internal Wind.

Deviated

The Deviated tongue deviates deviates off centre as the patient sticks it out. It always indicates Internal Wind. Occasionally, in young people a deficiency of the Heart and Pericardium may cause the tongue to be Deviated but this is relatively rare.

Moving

The Moving tongue moves slowly from side to side as the patient sticks it out. This movement is involuntary and the patient is not aware of it.

Q UI UI VE RI RI NG NG = S SP P --Q QiXu

R ap ap iid d , t re re m mb b llii n ng gw wii th th a ssm m al al l a mp mp llii tu tu d dee

MOV MOV IIN N G = IIn n ter tern n al al Wi Wi nd nd

S lo lo w, w, ssii d dee tto o ssii d dee m mo ov vem emen entt w wii th th a l aarr g gee amplitude

Deviated

DEVIATED = Internal Wind (except occasionally in young people = Heart and Pericardium Xu)

Internal Wind with a Deviated tongue is seen in the elderly after a stroke or when suffering from a neurological disease such as Parkinson’s disease.

In those without symptoms a Deviated tongue always indicates Internal Wind and is a sign that the practitioner should take active steps to prevent the onset of an Internal Wind type disease.

Preventative value of tongue diagnosis diagnosis in the elderly

Tongue diagnosis plays a very important role in the prevention of disease especially in the elderly. Middle-aged and elderly patients often show abnormal signs on the tongue in the absence of any obvious disease. Elderly people often suffer from Internal Wind, Blood stasis, Phlegm, Heat or Yin deficiency or a combination of these. For example, it is common to have Blood stasis with Phlegm; or Phlegm with Yin deficiency; or Internal Wind with Phlegm; or a combination of the above. In the elderly, Blood stasis and Phlegm are so common that there is a saying in Chinese medicine which states  In  “In the elderly, when in doubt, invigorate Blood and resolve Phlegm ”. In such cases, the tongue often shows clear signs of these pathogenic factors and it therefore allows us to treat them before they give rise to disease. In particular, stroke in the elderly usually derives from a complex pathology involving Internal Wind, Yin deficiency with Empty Heat, Phlegm, and Blood stasis.  In the elderly, when when in doubt, invigorate invigorate Blood a and nd resolve Phlegm

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Tongue Coating

Preventative value of tongue diagnosis diagnosis in the elderly

The tongue coating is a by-product of the Stomach’s physiological activity of digestion. The normal coating should be thin and white. “Thin” means that the coating should be thin enough so that the tongue  body below is visible.

1) DEVIATED, MOVING

Internal Wind 

2) RED, WITHOUT COATING

Sever Severee Yin Xu – Empty Heat Heat Phlegm

3) SWOLLEN BODY, STICKY COATING

Wind Stroke

Blood Stasis

4) PURPLE, STIFF

Thus, in Chinese medicine a coating with root indicates that StomachQi is intact even if the coating is pathological in colour and/ or thickness. For example, a thick yellow coating usually indicates Stomach-Heat but, if it has a root, it means that Stomach-Qi is intact. By contrast, if the tongue lacks a coating it indicates a deficiency of Stomach-Qi and/or Stomach-Yin. In order to understand this, we should remember that a Full condition (such as Stomach Heat) is characterised by the presence of a  pathogenic factor, but also by th thee fact that the patient’ patient’ss Qi is relatively strong and it is reacting against the pathogenic factor; therefore the treatment is relatively easy and the prognosis good. By contrast, if Stomach-Qi is deficient the treatment will take longer.

1) Reddi Reddish-P sh-Purpl urplee = Blood stasis stasis 2) Devia Deviated ted and Stiff Stiff = internal internal Win Wind  d  3) Swoll Swollen en (slightly (slightly)) = Phlegm 4) Coating m missing issing in patches = Yin def deficiency iciency

Poll no. 2

Poll no. 1

Of these two tongues which is worse?

Of these two tongues which is worse?

a

b

The three tongues illustrated here are a good example of this principle. The tongue on the left has a thick, dry, black coating; however if we look at the other tongue signs carefully, we can see that the coating has root, the body has shen, it is only slightly red and it has no cracks. In this case the black, dry coating indicates indicates severe Heat in the Stomach and Large Intestine, but the other tongue signs indicate that the  patient’s Qi is strong. strong. Although the thick, black coating may look like an alarming sign, in this case, it simply indicates severe Stomach Heat which is usually relatively easy to treat. By contrast, the two tongues on the right have a thin, white coating without root; this indicates Stomach-Qi deficiency. Although these tongues may look less alarming than the one on the left, this condition will actually be more difficult and take longer to treat.

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a

 b

We have to grasp the concept that the Stomach could have a pathology such as Heat, Damp-Heat or Phlegm-Heat and yet its Qi “being intact”.

In fact, a Shi condition is characterized precisely by the presence of a  pathogenic factor but Zheng Qi is strong (and therefore fighting fighting the  pathogenic factor). factor).

A Xu condition is characterized by the weakness of ZhengQi.

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Coating/absence of Coating

 Normal

ST By-product of Stomach activity of digestion

Thin-white coating

When evaluating the tongue coating we should look at the following six aspects:

The first aspect we need to consider is whether the tongue has a coating or not. The presence of a coating (with root) indicates that Stomach-Qi is intact while the absence of it indicates a deficiency of Stomach-Qi and/or Stomach-Yin. Please note that this is irrespective of the colour or the thickness of the coating. For example, a thick, sticky coating is pathological  but, if it has a root, Stomach-Qi Stomach-Qi is intact. Please note also that the absence of coating denotes a Stomach-Yin deficiency irrespective of the body colour: if the body colour is normal, there is only Yin deficiency whereas, if the body colour is red, there is Yin deficiency and Empty Heat.

1) Coating or no co coating ating 2) With or with without out root 3) Thick Thickness ness 4) Colou Colour  r  5) Consistency (e.g (e.g.. sticky)

 Normal, thin-white coating coating

Thick, yellow coating

 No coating

6) Distribution

Yin deficiency is a pathological process that takes a long time to develop and it may therefore manifest in many different degrees of severity.

The photos below show different degrees of Yin deficiency by itself and with Empty Heat in i ncreasing order of severity.

The tongue gives an accurate indication of the degree of Yin deficiency and of the Empty Heat resulting from it.

YIN XU EMPTY HEAT

The tongue shows clearly not only the present condition but also the stage it is at: it therefore also shows where it is developing from and what it may lead to. The three stages of the formation of Yin deficiency are: 1) Rootless coating (this is the mildest form of Yin deficiency) 2) Coating partially missing 3) Coating missing completely

Rootless coating: mild ST-Qi Xu

Coating  partially missing: ST-Yin Xu

Coating missing entirely: ST-Yin Xu

Coating missing  partially, body Red: ST-Yin Xu with Empty Heat

Coating missing entirely, body Red: ST-and KIYin Xu with Empty-Heat

Empty Heat may develop at any of these stages but it is more likely to develop at the third stage.

Degrees of Yin Deficiency and Empty Heat

Yin deficiency is a gradual process which develops over years. The absence of coating in a tongue with a normal body colour indicates fairly advanced Yin deficiency but without Empty Heat. The following slides are illustrations of varying degrees of Yin deficiency. 1

3

4

2

Coating missing entirely, colour normal: Stomach-Yin Xu, no Empty Heat. Note that the tongue is also swollen and therefore there is Phlegm.

Coating entirely missing, red body: deficiency of Yin of Stomach and  possibly Kidneys with some some Empty Heat. The widespread presence of cracks indicates a deeper stage of Yin deficiency

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Coating entirely missing, red body: Yin deficiency of Stomach and  possibly Kidneys with Empty Heat. Heat. The presence of a Heart crack also leads us to deduce that there is  possibly also Heart-Yin Xu. Xu.

Entirely without coating everywhere: deficiency of Yin of Stomach and Kidneys. As the tongue is also deep red, there is intense Empty Heat

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When the tongue is partially without coating, it gives a clear indication of the organ affected by Yin deficiency.

Lung-Yin Deficiency (no coating in front third)

When the coating is partially missing the most common areas where it is so are:

Front third  Sides

Without coating in front third: Lung-Yin Xu, also Empty-Heat as it is red 

Centre

Without coating in front third: Lung-Yin Xu

Scattered small areas Root

Deficiency of Stomach-Yin (no coating in centre)

Without coating in centre: Stomach-Yin Xu

Without coating in centre and front third: Lung-and StomachYin Xu (and Empty Heat)

DEFICIENCY OF YIN OF STOMACH AND INTESTINES

Deficiency of Yin of Stomach and Intestines (coating partially missing in patches)

Without coating in patches on the root: deficiency of Yin of Stomach and Intestines

Coating missing on root, left side: deficiency of Yin of Stomach and Intestines

Deficiency of Spleen-Yin (coating missing on the sides)

Yang Ming = Stomach and Large Intestine. A Yin deficiency of the Stomach often affects the Large Intestine too, although we do not have a syndrome called “Yin deficiency of Stomach and Large Intestine”.

YANG MING

ST

SP

Earth

L.I.

Coating missing on left side in central section: Spleen-Yin deficiency (not Liver  because it is mostly in the middle section and not all along the sides)

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Deficiency of Kidney-Yin

Partially without coating

Although there is no specific sign or area on the tongue that points to Kidney-Yin deficiency when the coating is missing, when Yin deficiency is advanced, we can usually deduce that the Kidneys are involved. Therefore Therefore if a tongue lacks coating in its entirety and it is red from Empty Heat, we can deduce that, in addition to Stomach-Yin Xu, there’s also Kidney-Yin Xu. Stomach-Yin Xu (possibly antibiotics)

Coating missing in the centre: Stomach-Yin deficiency

Coating completely missing, very red: deficiency of Stomach-Yin and of Kidney-Yin with  pronounced Empty Heat

Sudden appearance or disappearance disappearance of partial coating

If a tongue has no coating it is always a good sign if the coating returns gradually over a period of months. Conversely, if a tongue has a thick coating it is a good sign if this coating recedes gradually. It is never a good sign if a partial coating appears appears suddenly on a  previously peeled tongue; conversely, conversely, it is also a bad sign if the coating disappears partially and suddenly on a tongue with a thick coating. The area where the coating appears or disappears suddenly gives an indication of the problem location. For example, if we are treating a patient whose tongue is normally without coating and a patch of coating appears suddenly on the edge of the tongue in the Liver area, this indicates an aggravation of the condition with the location of the problem in the Liver; similarly, if a patch of coating appeared suddenly in the chest area it may indicate the location of the problem in the lungs, heart or  breast.

Root of coating

The normal coating should grow out of the body of the tongue like  blades of grass grass grow out o off the soil: when this this happens, the ccoating oating is said to have a “root”. Also from the western anatomical point of view, the filiformpapillae (the “coating” in Chinese medicine) gro grow w out of the body of the tongue like blades of grass.

Stomach- and Liv Liver-Yin er-Yin Xu

Stomach-Yin Xu

Kidney-Yin Xu Xu

Stomach- and Lu Lung-Yin ng-Yin Xu

Yin Xu Xu of of St Stomach and Intestines

Sudden appearance or disappearance of partial coating

The clinical significance would be exactly the same if a patch of coating disappeared suddenly in a specific area on a tongue with thick coating. In cancer patients, such sudden appearance or disappearance of a patch of coating may indicate an aggravation of the condition or a metastasis to an organ corresponding to that area of the tongue. Two key factors make the appearance or disappearance of a  patch of coating pathological: first first,, the fact that the coating appears or disappears on a specific area; second, the fact that the coating appears or disappears suddenly.

The coating without root looks like it has been added onto the tongue rather than growing out of it. One can imagine a bare patch of soil with  blades of grass grass scattered on it.

Coating with root indicates a intact state of Stomach-Qi even if the coating is pathological in other respects, e.g. thickness or colour. For example, a coating may be thick and yellow indicating Stomach Heat but, if it has a root, Stomach-Qi is intact (even though there is Heat). By contrast, if a coating lacks root it indicates that Stomach-Qi is weak. In general, it is better to have a pathological coating with root than a coating without root. It is important not to confuse the root (or lack of it) of a coating with its thickness. In other words, a coating without root is not necessarily always thin. A thin coating without root simply indicates deficient Stomach-Qi, while a thick coating without root indicates that Stomach-Qi is deficient and that there is a pathogenic factor.

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With root

Without root

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Thickness of Coating

The normal coating should be thin and white; it is thin enough for us to be able to see the tongue body through it. A thick coating always reflects the presence of a pathogenic factor which may be Cold, Heat, Dampness, Phlegm or external Wind. The thicker the coating, the stronger the pathogenic factor.

Thick coating with root

 Note that a thick coating coating may also lack a root: I call this the the “worst of both both worlds” because it indicates that, on the one hand, the pathogenic factor is strong and, on the other hand, the body’s Qi has been weakened. In acute conditions, the tongue coating can appear quickly. Therefore, if we see a new patient with a thick coating, we have to keep in mind the  possibility that that it reflects an acute, passing passing problem.

Thick coating without root

Although the clinical significance of the coating is somewhat less important than that of the tongue-body colour and shape, it is clinically important to differentiate Full from Empty conditions. If the tongue has a thick coating with root, the condition is Full; the condition is Empty if the tongue coating is missing or if it is thin. Moreover, in mixed Xu-Shi conditions, the thickness of the tongue coating is important in choosing the appropriate treatment principle. If the tongue coating is thick, I would start the treatment with a formula that eliminates pathogenic factors; if the tongue coating is thin, I would start with a formula that tonifies the body’s Qi. For example, in chronic fatigue syndrome there is practically always a combination of an Empty condition (often Spleen-deficiency) with a Full condition (often Dampness). I consider the tongue coating an important factor in deciding whether to concentrate on eliminating  pathogenic factors factors (if the coating is thick) or to tonifing nifing the body’s Q Qii (if the coating is thin).  NOTE: although the thickness of the coating reflects the presence of a pathogenic factor, it is not the only sign that does so. Notably, the swelling of the tongue body also reflects the presence of a pathogenic factor. It follows therefore, that a thin coating does not necessarily always indicate the absence of a pathogenicfactor.

 Normal coating

Thick coating

Thickness of Coating

To summarise, we can identify four possible pathological conditions from the thickness of the tongue coating: 1) Thin, white coating with root = normal, Stomach-Q Stomach-Qii good  2) Thin, white coating without root = Stomach-Q Stomach-Qii weakened, Empty condition 3) Thick coating with root = pathogenic factor present, Stomach-Qi Stomach-Qi intact, Full condition 4) Thick coating without root = pathogenic factor present, present, Stomach-Qi weakened, Full-Empty condition. The “worst of both worlds”. It is better to have a thick coating with root (indicating a pathogenic factor) than a thin one without root (indicating weakened Stomach-Qi). Stomach-Qi). The former is easier to treat than the latter. I call the condition of a thick coating (indicating a pathogenic factor) without root (indicating Stomach-Qi deficiency), the “worst of both worlds”.

WITH ROOT = NORMAL THIN COATING

WITHOUT ROOT = STOMACH-QI XU 1) Thin; white; with root = Normal STQi good 

THICK COATING

2) Normal colour; coating without root; thin = ST-Qi Xu

WITH ROOT = PATHOGENIC FACTOR 

WITHOUT ROOT = PATHOGENIC FACTOR ON BACKGROUND OF ST XU = SHI/XU (“worst of both worlds”)

3) Thick coating with root = pathogenic factor but ST-Qi is still good 

4) Thick coating but without root = strong pathogenic factor and ST-Qi is weakened 

Out of these conditions number 3 is better than number 2, and number 4 is the “worst of both worlds”.

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Colour of Coating

The colour of the coating reflects conditions of Heat or Cold. A white coating indicates Cold, while a yellow or brown coating indicates Heat. A grey or black coating may indicate either Cold or Heat depending on whether it is wet or dry. As we have seen above the tongue body colour also reflects conditions of Cold or Heat, being Pale in Cold and Red in Heat. The colour of the coating is affected by shortterm influences and it is therefore somewhat less significant than the  body colour in in diagnosing Heat Heat or Cold.

The pathological coating colours are: -White = Cold  - Yellow (or brown) brown) = Heat - Gree Green n = Heat

As the tongue coating reflects in general the state of the Yang organs (Fu), changes in colour of the tongue coating reflect conditions of Heat or Cold mostly of the Yang organs. Examination of the coating colour is more important in acute conditions as it is more easily affected by short-term changes than the tongue-body colour.

White

Cold 

Yellow

Heat

Green

Heat

- Grey = Heat if dry, Cold Cold if wet

Grey

- Black = Heat if dry, Cold if wet wet

Black

Cold if wet Heat if dry Extreme Cold if wet Extreme Heat if dry

Coating Distribution Sticky ( Ni 腻)

Slippery ( Hua  )

•Thicker incentre •Slippery but rougherthan“slippery” •As if covered in oily fluid which adheres firmly •Papillae canbe seen •Cannot be scraped off 

GB

ST

GB

Mouldy •Thick and patchy •Crumbly like tofu •Without root •Can be scraped off 

GB

ST/ INT

Tongue Diagnosis and Herbal Therapy

 Nourish ST-Yin and resolve Dampness or Phlegm (because the lack of coating indicates Stomach-Yin deficiency and the swelling of the tongue body indicates Phlegm)

•Thicker incentre •Oily, smooth •As if covered in oily fluid which “slips” •Papillae seem tobe hidden •Cannot be scraped off 

Resolve Dampness or Phlegm (because of the swelling of the body)

 Nourish Yin, clear Empty Heat, resolve Dampness (because the lack of coating indicates Yin deficiency the redness of the body indicates Heat and the stickiness of the coating indicates  Dampness)

Clear Heat (because of the redness of the body and the  yellow coating with root)

TonifyQi and/or Blood (because the  pale and dry body indicates  Blood deficiency)

Resolve Phlegm, clear Heat, invigorate Blood (because the swelling of the body indicates Phlegm, the redness indicates Heat and the Purple colour indicates  Blood stasis)

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2) Differentiation between deficiency of Qi or Yin of the Stomach and Spleen SP-Qi Xu (Pale, swollen sides) LIU JUN ZI TANG (PROSPEROUS  EARTH )

ST-Qi Xu (rootless coating, ST crack) SHEN LING BAI ZHU SAN (CENTRAL MANSION )

ST-Yin Xu (No coating, ST crack) SHA SHEN MAI DONG TANG ( JADE SPRING)

ST- and SP-Yin Xu (lateral cracks and central crack) SHA SHEN MAI DONG TANG  JADE SPRING) ( JADE

3) Differentiation between Heat at the Qi or Ying/ Blood level and that between Heat and Fire.

Red body, thin coating = clear Heat Qi level

Red body, no coating = clear Empty Heat, nourish Yin, Ying-Blood level

Red body, thin coating = clear Heat Qi level

Red body, thick-dry-dark coating = drain Fire Qi level

Patient Statistics from Giovanni Giovanni Maciocia’s practice Total = 2220: Men 765 = 34% / Women 1455 = 66% • Pu Purple (Total)

363 =

16%

• Swollen

814 =

36%

• Bl Bluish-Purple

31=

8%

• Swo llll een n s iid d eess

52 =

2. 3 3% %

• Re Reddish-Purple

106 =

6.5%

• Thin

43 =

1.9%

• Purple sides

• Sticky coating

454 =

20% ST-crack

195 =

9%

• R eed d (including red points)

1012

45%

HE-crack

151 =

7 7% %

• Red Points

128 =

6%

ST-HE cra ck

• Red

884 =

4 0%

• Pale

706 =

32%

• Purple

363 =

16%

 Normal colour: colour: 6%

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34 =

36 = Only 6% were normal

1.5%

2%

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CorrelationBetweenTypes of Tongueand EndoscopyResults inPatientsWith ChronicIllnessesof the StomachandDuodenum CorrelationBetweenTypesof Tongueand EndoscopyResults continued

GastroscopyResultsand TongueCoating

Types of Tongue in255Casesof PerforatedUlcer

CorrelationBetweenGastricAcidityandthe Tongue

BodyShape

Sublingual Veins

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The Tonguein StomachCancer-BodyColour

The Tongue and Colonoscopy - Body Colour

CorrelationbetweenAtrophic-NecroticEpithelialCells ofthe TongueandYin-XuEpigastricPain

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Coating

Coating

CorrelationbetweenAtrophic-NecroticEpithelialCells ofthe TongueandYin-XuEpigastricPain

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Tel: 626-780 626-780-7182 -7182 • Fa Fax: x: 626-609 626-609-292 -2929 9 • Webs ebsite: ite:

www.eLo .eLotus.org tus.org•• Email: info@eLo eLotus.org tus.org

Shallll not be copied, duplicated, Sha duplicated, or distri distributed buted in any format or be used used for teaching without prior writ written ten consent ffrom rom Lotus Lotus Insti Institute tute of Integrative Integrative Medicine.  

Epithelial Cells of the Tongue in Three Groups

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More information on the classic single herbs mentioned in this seminar/webinar can be found in the Chinese Medical Herbology and Pharmacology

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More information on the classic formulas can be found in the Chinese Herbal Herbal Formulas and Appl ications

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Collection formulas can be found in the eLotus Clinical Manual of Oriental Medicine

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 All the above texts are available through www.elotus.org

This webinar is sponsored by :

Evergreen Herbs Herbs & Medical Supplies Toll-free Tel: 866-473-3697 Website: www.evherbs www.evherbs.com .com Email: [email protected] [email protected]

© Giovan Giovanni ni Maciocia & Lotus Institute Institute of Integrative Integrative Medicine, Medicine, PO B Box ox 924 92493, 93, City of IIndustry, ndustry, CA 9 91715 1715

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To read articles by today’s speaker, watch online videos, or to see his/her h is/her complete seminar/webinar schedule for this year, please visit www.elotus.org

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Herbs mentioned in this seminar/webinar, are available through our sponsor Evergreen Herbs & Medical Supplies. Please contact them for a catalog and see how they can help your practice.

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Tel: 626-780 626-780-7182 -7182 • Fa Fax: x: 626-609 626-609-292 -2929 9 • Webs ebsite: ite:

www.eLo .eLotus.org tus.org•• Email: info@eLo eLotus.org tus.org

Shallll not be copied, duplicated, Sha duplicated, or distri distributed buted in any format or be used used for teaching without prior writ written ten consent ffrom rom Lotus Lotus Insti Institute tute of Integrative Integrative Medicine.  

Evergreen Herbs is not just an Herbal company, company, we are an environmentally friendly, friendly, health conscious contributor to the healthcare community at large. Evergreen was founded by Dr Dr. John Chen and Tina Chen, siblings and coauthors of the Chinese Medical Herbology and Pharmacology Pharmacology,, and the Chinese Herbal Formulas and Applications books. Applications books. Evergreen is a family business that is run by professionals like you who care about Chinese medicine. And as a family family business, we have the well-being and satisfaction of our customers at the top of our list. We care about the quality of our herbs, because we care about our consumers, and have your best interest at heart. Our goal is to support you in improving your clinical skills, and enhancing the well-being of your patients. To learn more about Evergreen Herbs and our products, please

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