Chapter 3: Tongue Diagnosis and Inquiry

"The pulse diagnosis is entirely accurate. Now, proceed with the tongue diagnosis. Be careful not to look only at the tongue coating; you must also examine the tongue body, the tongue substance, and look for any sublingual stasis."

"Yes, understood." Zhang Jing nodded repeatedly, feeling quite invigorated.

He then asked the male patient to open his mouth wide. Observing carefully, he said in a low voice, "The tongue body is slightly plump with faint tooth marks on the edges; the coating is yellow, greasy, and moist."

"Please curl your tongue upward," Zhang Jing instructed.

As luck would have it, the patient was someone naturally unable to curl his tongue; he tried several times, only to fail. Zhang Jing had a sudden inspiration and asked the patient to extend his tongue as far as possible, while he himself squatted down to look upward from below. This allowed him to finally view the entire sublingual area.

"The tongue substance is red, and there is first-degree sublingual stasis," Zhang Jing reported.

Li Yu nodded slightly. "Now, tell me, what do these abnormal tongue signs represent?"

"A red tongue generally indicates a heat syndrome. If it is the onset of a febrile disease and the tongue substance is deep red, it suggests a latent pathogen febrile disease, caused by stagnant heat within."

"A plump tongue body with tooth marks, combined with a greasy and moist coating, suggests internal dampness-water. The yellow coating indicates that this is damp-heat, not cold-dampness."

"The first-degree sublingual stasis shows that the patient's blood circulation is slightly obstructed."

After listening to Zhang Jing's analysis, Li Yu nodded in approval. "Your fundamentals in tongue diagnosis are solid. The tongue is the sprout of the heart; examining it allows us to discern cold and heat, deficiency and excess, yin and yang, which is equally vital for the differentiation and treatment of traditional Chinese medicine."

He then suddenly changed the subject. "By the way, are you familiar with the theory of 'the lone manifestation hiding the truth' in diagnostic studies?"

Zhang Jing pondered for a moment and replied, "The theory of 'the lone manifestation hiding the truth' first appeared in the *Jingyue Quanshu*. It means that when we gather evidence from the four diagnostic methods, if most of the evidence is consistent but one or two points contradict the rest, we should not blindly follow the principle of 'the minority yields to the majority.' Often, the inconspicuous evidence is what truly reflects the facts."

"Exactly. However, this theory of Zhang Jingyue actually originates from a passage in the *Suwen: Treatise on the Three Categories and Nine Indicators*. The Emperor asked: 'How can one know where the disease lies?' Qibo replied: 'Observe the nine indicators. A single small one indicates disease; a single large one indicates disease; a single rapid one indicates disease; a single slow one indicates disease; a single hot one indicates disease; a single cold one indicates disease; a single sunken one indicates disease.'"

Li Yu added, "What the *Huangdi Neijing: Suwen* discusses is the application of this theory in pulse diagnosis. That is to say, when we take the pulse, we examine many areas across the three categories and nine indicators; when we find one spot that is particularly different, that is often where the problem lies. Zhang Jingyue merely popularized the theory and gave it that name."

Zhang Jing seemed to grasp the concept, saying slowly, "In other words, for general illnesses, the four diagnostic methods are mostly in agreement. But when dealing with difficult or complex cases, or when conventional treatments are ineffective, one must re-examine the four diagnostics, fill the gaps, and carefully identify this 'lone manifestation,' because the truth is often hidden within it."

"Correct!" Li Yu gave him a big thumbs-up.

He paused for a moment before saying, "You may now proceed with the inquiry."

Zhang Jing was startled. He had assumed Li Yu prevented him from asking questions earlier to test his pulse and tongue diagnostic skills, expecting him to provide a diagnosis based on those two alone. Why could he suddenly question the patient now? This was clearly not following the routine; Li Yu was truly difficult to fathom.

Zhang Jing couldn't help but scratch his head.

"Confused as to why I didn't let you ask questions earlier?" Li Yu clearly saw through his thoughts and smiled slightly.

Zhang Jing nodded repeatedly.

"The four diagnostic methods of TCM are inspection, listening/smelling, inquiry, and palpation. Many people think these are the four sequential steps. However, I believe pulse diagnosis should come first, so that one can achieve clarity of mind before proceeding."

"Because pulse diagnosis relies on the physician's knowledge and clinical experience to perceive; the true pulse does not manifest objectively. If you perform the other three diagnostics first, it is easy to become biased, which affects your judgment," Li Yu explained after a brief pause.

"Oh..." Zhang Jing suddenly realized. It was just like the principle often mentioned in martial arts novels—that one must have a clear mind to cultivate deep internal energy.

Now, the formal inquiry began. Zhang Jing remembered the "Ten Questions Song" for diagnostic inquiry well: first ask about cold and heat, second about sweat, third about head and body, fourth about bowels, fifth about diet, sixth about the chest, seventh about hearing and thirst, and eighth/ninth/tenth about past illnesses and causes.

Before that, however, he had to understand the patient’s chief complaint: "Hello, could you tell me where you are primarily uncomfortable?"

"Doctor, it's like this: for the past two months, my body has been itching. It gets worse at night, and I often can't sleep all night long."

The male patient spoke quickly, likely having been bursting to speak after being kept silent for so long.

Since it was body itching, it was a skin issue. And since it was a skin issue, it naturally had to be inspected.

"Where is the itch? Please lift your clothes so I can see."

Unexpectedly, the patient looked up at Li Simeng, who was sitting behind, and seemed hesitant.

"What, you're embarrassed? Should I have her step out?" Zhang Jing raised his voice intentionally, clearly meant for Li Simeng to hear.

"No... that's not it. It... it's just that it's much worse at night, and during the day, only my thighs itch. I was just worried that if I took off my pants in front of you, the female doctor might feel awkward." The patient explained stammeringly.

"I just won't look!" Li Simeng retorted loudly.

"Simeng, mind your attitude. Carefully record the case based on the doctor's inquiry," Li Yu said sternly, handing the medical record book to her.

"Got it," Li Simeng muttered.

By then, the patient had taken off his outer trousers.

Zhang Jing looked closely. On the outer sides of both his thighs were several red, raised patches. He remembered descriptions from his university textbooks; it looked very much like urticaria, also known as 'hidden rash' in TCM.

He turned to Li Yu, confident, seeking confirmation.

Unexpectedly, Li Yu said calmly, "The name of the disease is correct, but do not be too constrained by it. TCM emphasizes differentiation and treatment, not just diagnosing the disease and applying a fixed treatment."

Zhang Jing understood and continued with the inquiry.

"Uh, do you feel cold or hot during this period?"

"I don't fear the cold; in fact, I'm especially sensitive to heat in the summer."

"How has your sweating been lately? Is it a lot or a little?"

"I sweat a lot in the summer; I'd be drenched just from moving a little. Even though it's autumn now, I still sweat more easily than others."

...

Zhang Jing asked very thoroughly. About seven or eight minutes later, he had inquired about every situation he could think of. Moreover, to avoid leading the patient, he did not add his own subjective inferences, keeping the questions entirely objective.

He knew that many "quack doctors" in society performed pulse diagnosis for less than a minute and then asked leading questions like, "Do you have such-and-such symptoms?" The more positive answers they received, the more they boasted about their diagnostic skills. In reality, this was a deceptive tactic, no different from a street fortune-teller.

Li Yu nodded, satisfied with Zhang Jing's performance.

He then turned to Li Simeng and said, "Read out the recorded case."

"Yes," Li Simeng said, picking up the patient's medical record.

"Patient, male, 43 years old. Chief complaint: body itching for over two months, worsening at night, affecting sleep. Current symptoms: red hidden rashes on both lateral thighs. Usually no obvious aversion to cold; fears heat in summer, prone to sweating on the head. Appetite normal; bowel movements once daily, sticky; urine slightly yellow; no obvious dry mouth; little water intake. Examination: tongue substance red, tongue body slightly plump with faint tooth marks, tongue coating yellow, greasy, and moist; first-degree sublingual stasis; pulse floating and taut."