Although deficiency syndromes like Qi or Blood/
Yin deficiency can also be implicated in Blood stasis, Blood stasis always involves an excess syn-drome. The tongue body is a reliable indicator and should always be considered (see colour plate section).
A purple-bluish discolouration of the tongue body immediately alerts one to Blood stasis, but what exactly is the meaning of ‘purple-bluish’?
For the diagnostician who has not yet had the opportunity to observe thousands of tongue images it is not always easy to recognize this typical colouration. It should be made clear that this colouration, which can be found in both skin and tongue, is the result of poor blood circulation, resulting in a tendency for cyanosis. Chinese studies have shown that increased blood viscosity can lead to the development of this colouration, because the smaller blood vessels transport blood cells that are less oxygenated and thus more red-appearing. This increased blood viscosity has also been artificially recreated using injections of high molecular dextran solutions (molecular weight of 100 000–400 000 daltons.) It has also been shown that elevated blood lipids and a high proportion of immunoglobulins can slow down blood flow, which becomes particularly evident in the tongue capillaries due to lowered oxygenation saturation.
Furthermore, chronic Blood stasis has also been linked with a reduction in capillaries.
To the expert eye, then, the difference is as strik-ing as the difference between a piece of raw meat and a piece of raw liver displayed side by side on the meat counter. However, there is no substitute for experience when it comes to comparing tongue slides; the same goes for taking the pulse.
Dark blue or purple dots on the tongue with a purple shading of the tongue body generally indi-cates Blood stasis. The location of Blood stasis in the body can be determined from the region of the tongue affected, as taught in Chinese tongue diagnosis.
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If dots or lines appear on one or both sides of the anterior tongue, then the Heart and Lung regions are affected, which hints at chest pain or chest Bi syndrome. Further back is the Liver and Gallbladder region, which can hint at syndromes such as Liver-Qi stagnation and other similar syn-dromes. If the spots are distributed on one side only instead of symmetrically, then only one side of the body is affected.
The different regions of the tongue are described in every good book on TCM.
The following section discusses the inspection of the bottom of the tongue in detail, as this is particularly relevant for the diagnosis of Blood stasis.
As well as their colour being an indication, sub-lingual veins that become engorged and crooked (sublingual varicosis) are unmistakable signs in tongue diagnosis: if they are dark blue or deep purple, or crooked and look ‘angry’ (as the Chinese say), then in most cases Blood stasis is present. These prominent veins then form a tortu-ous ‘nest’ on the bottom of the tongue. Small venules emerging from the ends of the veins are usually also a sign of Blood stasis. The number of stasis spots or dots, and the length and colour of the sublingual veins determine the degree of Blood stasis (see Figure 5.1).
As we can see in this figure, the bottom of the tongue can be divided into nine zones. Firstly, it is divided horizontally: above the upper end of the frenulum of the tongue (frenulum linguae) is the upper third, and below the frenulum linguae are the middle and lower thirds. Vertically there are three semicircle-like zones. The inner zone, which is well-defined anatomically, lies within the whitish margins (skin folds) that are present to the left and right of the sublingual veins.
This marks off the first segment. The middle and outer zones are both located outside this area and extend to the edge of the tongue. An imagi-nary dividing line halfway through this area sep-arates the middle from the outer segment.
New vessel formations or enlargement of venules are assessed according to which segment they extend into. Whenever the sublingual veins pass over the midline at the end of the frenulum, this is regarded as sign for Blood stasis (see Figure 5.2).
Bottom of the tongue Stage I
Bottom of the tongue Stage II
Bottom of the tongue Stage III
Figure 5.1 Zones of the tongue showing stages of Bood stasis.
This imaginary division line marks off the middle from the outer segment
This visible fold divides the middle and inner segment
The sublingual veins The frenulum linguae
Veins that reach beyond the end of the frenulum are regarded as pathological signs
Figure 5.2 Sign of Blood stasis: sublingual veins passing over the midline at the end of the frenulum.
THEORY AND BACKGROUND KNOWLEDGE 40
The inspection of the bottom of the tongue is an indispensable tool in recognizing Blood stasis. I have often seen patients with a normal tongue surface but obvious stasis spots or other pointers on the bottom of the tongue; therefore all patients should have this examination.
It should be said that mixed tongue pictures occur quite frequently. In these cases, one must differentiate between Blood stasis and other path-ogenic conditions. For example, in Blood stasis due to Cold, the purple-bluish tongue colour of the body is often covered by a thick white coating, so that only the colour on the sides of the tongue can be seen clearly.
Box 5.1 summarizes tongue diagnosis and includes a detailed differentiation of the sublin-gual veins as practised in many clinics in China today. This Box is based on the standard ques-tionnaire of the Institute for Medical Research and Technology of the University for Traditional Chinese Medicine, Tianjin.
CONDITIONS FOR SUBLINGUAL DIAGNOSIS
Prior to sublingual diagnosis, the patient should not consume any food or drink and should avoid speaking (so this is best done before the oral history is taken). As in diagnosing the surface of the tongue, the face should be turned towards the brightest natural source of light. The angle of light should be chosen so that the floor of the tongue can be clearly seen. Unreflected daylight of at least 10 000 lux is suitable, or (for photographic record-ings) a standard white light lamp of 4200° Kelvin and 10 000 lux or a D65 standard light source of 6500° Kelvin (in Europe). It is also possible to use a flash from a camera with white balance.
The patient should extend the tongue as far as possible towards the middle of the hard palate, keeping it relaxed to avoid a discolouration (a purple shading) resulting from backing up of blood. For the same reason, the inspection should
Box 5.1 Check-up list of tongue diagnosis
Tongue surface
■ General appearance: normal; thick; stiff; teeth marks; cracks (shallow, medium, deep); tremor;
deviated
■ Tongue body colour: pale white; slightly pale;
pale red; dark red; deep red; pale purple; purple;
dark purple; deep purple; cyanotic; sides red; tip red
■ Tongue body stasis spots: sides; middle; tip;
sublingual;, dispersed
■ Tongue coating appearance: thin; thin-sticky;
sticky; thick-sticky; slippery; dry; like tofu; mirror tongue; geographical tongue; partially no coating; no coating
■ Tongue coating colour: white; grey-white; white-yellow; white-yellow; dark white-yellow; yellow-brown; brown-grey; grey-black; black; burnt; discoloured other.
Bottom of tongue/sublingual veins
■ Appearance at stem: no branching, double branched; multiple-branched; large area;
crooked; enlarged; interrupted
■ Length: passing over the tip of the frenulum yes/no?
■ Shape: indistinct; enlarged at floor of the tongue – small towards the tip; enlarged and slightly crooked; evidently enlarged and crooked
■ Colour: pale blue; pale red; red-purple; cyanotic-purple; black-purple.
Length of arteries and signs (degrees) of stasis
■ 0: no veins, no elongated veins; no stasis dots or spots
■ I: small veins reaching into outer zone; less than three stasis dots
■ II: small veins enlarged and crooked, reaching into outer zone; less than 10 stasis dots/some stasis spots
■ III: small veins evidently enlarged, crooked, rope-like, reaching into outer zone; dense
accumulation of stasis dots/many stasis spots.
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not exceed 3–5 seconds. A few seconds should pass before the tongue is shown for a second time, otherwise it may acquire a darker shading and the sublingual veins may protrude more visibly. It is best practice to demonstrate this procedure to the patient at the first consultation. It should be noted that some patients with very short frenulae can turn the tongue only slightly upwards.2
DETAILS OF SUBLINGUAL DIAGNOSIS
During sublingual diagnosis we need to evaluate:
■ Colour and moisture of the tongue body
■ Length and thickness, as well as shape of sub-lingual veins
■ Length, distribution, location and colour of small venules and
■ Size, colour and location of haemorrhagic signs of stasis (dots, spots, areas).
Colour
A purple colour on the bottom of the tongue differs from that of the surface of the tongue most clearly in cases of Blood stasis with Kidney-Qi and Heart-Qi deficiency. These two syndromes also generate most of the Blood stasis spots.
Moisture
Under normal conditions the bottom of the tongue is moister and paler than the surface (60% differ-ence), but in older patients it becomes darker and less moist, and the mucous membrane becomes rougher.
During middle age, a relatively dry tongue sig-nifies Body Fluid deficiency, caused for example by Yin deficiency, whereas, a tongue that is too moist on the bottom with a lot of saliva – espe-cially if the mucous membrane is also thicker and the sublingual veins are obscured as if covered by fog – signifies Kidney- and Spleen-Yang deficiency with Dampness or water retention.
Sublingual veins
About three fifths of the length of the tongue and a thickness of approximately 2.5 mm are regarded as normal. The more the sublingual veins elongate towards the tip of the tongue, the more this points towards pathological changes. Such changes indi-cate the presence of Heat and infections.
Flaccid sublingual veins due to decreased vessel elasticity develop largely from chronic hyperviscosity of blood, caused for example by elevated blood lipids or a slow exsiccosis. The result is a widening of the vessel walls with the veins being distended, which causes them to visibly protrude. This sign suggests pain, tumour formation, dysmenorrhoea and amenorrhoea with Qi stagnation and Blood stasis. On the other hand, a flaccid widening of the veins, which makes them appear enlarged but indistinct from each other, suggests Blood stasis and Phlegm, as in arte-riosclerosis.
Clear, pale blue, short and thin veins without any stasis dots point towards Qi deficiency or
2 For photographic recording and storage, digital cameras with white balance (e.g. Nikon Coolpix 990) should be used to avoid film- and processing-induced shading.
Printing images of the tongue (slides, pictures) in books is restricted to the colours of a subtractive colour model (CYMK), whereas an additive colour model is available on the computer screen (RGB). This rather limits paper printing and makes it harder to display the different shadings of the tongue, and this can be observed in all printed samples. Finding the right setting of the colour mixture when processing pictures is also problematic, which is why digital cameras are preferred to normal mechanical ones: additive colour mixture as used on computer screens yields more exact picture quality, as pictures can be transmitted directly from the digital camera without undergoing any modifications during processing in a laboratory.
First, the computer screen settings need to be standardized: it is recommended that the
brightness/contrast balance is adjusted to 2.2 gamma in PCs and 1.57 gamma in Apple Macintosh, according to IEC standard 61966 (Comission International de l’Eclairage). To my knowledge, currently the best available colour balance system for computer screens takes a picture of the colour spectrum and displays this on the screen (for example ‘Monaco Sensor Colorimeter and Software Monaco EZ Color Profiling Software incl.
IT-8 Template’, ‘Heidelberg View-Open ICC 2.0’ or ‘X-Rite Color DTP92 and Color Monitor Optimizer’).
Afterwards, using a screen scanner, the image on the template and screen is scanned and the colour temperature of the screen is adjusted so both original and photographed image match.
THEORY AND BACKGROUND KNOWLEDGE 42
Blood deficiency. Veins that are visibly filled up on one side only can occur congenitally. However, if they appear later on in life they can suggest aneurysms or circulatory problems of the carotid arteries. Black, dark veins point towards Cold or pain. Red veins indicate Heat, fever and infections.
Small vessels
Normally, the venules and branches of the main sublingual veins cannot be seen. However, the more they elongate, the more pronounced the Blood stasis. Elongated venules are classified into four degrees (0–III). (see Box 5.1).
Further signs are described in Table 5.1.
Stasis dots
There are three degrees of stasis dots: the smaller dots; stasis spots of the size of rice corns, which can be flat or raised; and converging stasis areas.
Flat spots suggest Qi deficiency. The appearance of haemorrhagic stasis signs is classified into three degrees. Less than three dots indicates the first degree, less than ten indicates the second, and converging or more than ten dots indicates the third.
Although a few stasis dots, especially on the bottom of the tongue, are normal in elderly patients, in younger patients their appearance suggests digestive disorders, for example stomach ulcers due to the ‘Liver attacks Spleen and Stomach syndrome’. In this case, the spots are visibly demarcated and mostly raised.
Dark red or dark purple stasis spots, particu-larly if they are raised and cannot be made to fade by pressing them with a cotton bud, suggest Blood stasis in high blood pressure, CHD, liver cirrhosis and asthma. Dark red or dark purple stasis areas, some of the size of a bean, that are clearly demar-cated or hard suggest myocardial infarction or tumour formation due to loss of Zheng-Qi with Blood stasis. Typical diseases that become partic-ularly visible in sublingual diagnosis are coronary heart diseases, high blood pressure, lung emphy-sema, cor pulmonale, chronic hepatitis and tumour formations.
The highest degree (III) of sublingual veins can be found mostly in CHD, and the lowest degree (I–II) in hepatitis. High blood pressure is charac-terized predominantly by the appearance of finely distributed vessels and several spots. In heart disease, the latter occur especially at the tip of the bottom of the tongue. In cor pulmonale the sub-lingual veins are heavily engorged due to the pres-sure in the pulmonary artery, and there are hard stasis spots that do not fade when pressed. Many tumours feature even larger hard stasis spots at the lower end of the bottom of the tongue.
However, in hepatitis the venules become more evident and elongated and appear small and reddish, with spots on the sides only occurring occasionally.
The last part of traditional diagnosis is palpa-tion. Also important at this stage is to palpate for painful, hard or palpable abdominal masses (resistances).3 Local and persisting resistances, Table 5.1 Signs and their causes
Sign Cause
Diversified, red Heat, high blood pressure, infections
Pale, purple, engorged Yin deficiency with empty Heat or Blood-Heat, in headaches, migraine and late stages of Wen Bing diseases
Pale, clear Qi deficiency and Blood stasis
Engorged like a hose, elongated and reaching Severe Blood stasis, for example in apoplexies, angina pectoris, up to the tip, dark red or pale purple chronic asthma
3 See Glossary.
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and those that change location and are not always palpable, are differentiated. The former indicate Blood stasis, the latter Qi stagnation. Pulse diag-nosis also belongs to this category.