The Four Examinations, Part 2 (Tongue Diagnosis in Chinese Medicine)

The tongue is one of the major pillars of diagnosis, the other main one being the pulse. The tongue body proper is going to give you information more about the Yin organs, the blood organs in particular. How much is it feeding? The tongue coating is the result of digestion. So we’re looking at two overall things. We’re looking at a body and we’re looking at a fur coat. Now the body itself is going to have not only color, but a size and shape to it. And it might have cracks, and it might have red raised areas. And whether or not you can hold it out and it stays firms or moves around and quivers is going to mean something. And the tongue fur, it’s going to have a color and a thickness to it. And it’s going to have areas that it’s distributed in, and maybe some areas that it’s not.

When reviewing the tongue, the best light to look it is natural light. And foods also affect the tongue (change the color, etc.). Pepto Bismal does a nice job on a black tongue. Eggs make it yellow and orange juice also makes it yellow. Cigarettes do lots of things… stain it a little bit of brown.

The tongue is a muscle. It reflects the Yin organs. All channels are indirectly reflected in the tongue. SP connects w/ root of tongue and scatters over bottom; KI goes to root; HT connecting vessel goes to root; UB and SJ tendinomuscular channels go directly to tongue. Mostly it reflects the state of the Spleen and Heart. It shows the state of the Blood and it shows the state of Yin. The tongue coat shows the state of digestion. When you digest, the Stomach and Spleen digests, part of the Essence is said to go up to the tongue to become dirty dampness – it coats the tongue. Tongue coat shows the effect of the organs, especially the Stomach Qi. Now, when you’re dealing with a pathogenic invasion, the tongue coat tells you about the penetration of the pathogen. For instance, when you first get sick, the coat doesn’t change. As it (pathogen) progresses in, it (tongue coat) gets thicker; it might change color.

Eg. Somebody comes in with a Wind Cold attack. The cold penetrates in. Two days later, it’s now trapped heat. The tongue coat was nothing; now it’s thicker white. Then it becomes thicker and it’s going to turn yellow. Now the cold has changed to heat, they now have a fever of 104-105. They’re sick. Now the tongue is very red and the tongue coat is yellow. Three days later this person has burnt up all their Yin. The tongue coat falls off. Now they have a bright red tongue with cracks and it’s peeled. It’s absolutely glossy. Now it’s really deep in. They break out with delirium, macules and now they’re dead.

A normal tongue should be pale red (they say the color of fresh meat). So it should be red, but not bright red. It should be supple, soft and flexible, even shaped and it should have no cracks. And it should have an even, slightly moist, thin, white coat.

The very tip of the tongue – that’s said to be the Heart. The area behind the tip, that’s associated with the Lung. The area in the middle is associated with the Stomach and Spleen. The rear of the tongue is associated with the Kidneys, but also with the whole Lower Jiao area, so it also includes the intestines, both small and large, the bladder and the uterus. Now the Liver and Gallbladder are on the sides. The right side is thought to be more associated with the Gallbladder and the left side is associated with the Liver, but most folks just say Liver and Gallbladder. So that’s the most common use. Another easier way is to say that the back of the tongue is the Lower Jiao, the middle of the tongue is the Middle Jiao and the front of the tongue is the Upper Jiao.

The tongue body shows the condition of Zang Fu organs, especially Zang, the Yin organs. Especially about blood. The overall color, that’s the state of the blood. The tongue is the only muscle that you can see and reflects what the muscles look like inside; that’s how much they’re nourished.

SPIRIT reflects good moisture/fluids, qi and blood
1. thriving: soft, flexible, moist
2. withered: dry, stiff, can’t protract, emaciated, dusky: no spirit

We look at the color first. It’s either going to be paler, redder or purplish or bluish.

Pale: A tongue can be slightly pale, but when you see a pale tongue, it almost looks white. It looks like it’s not being fed blood. Pale being Qi and Blood deficiency, Yang deficiency and Cold.
Difference between Qi insufficiency and Blood insufficiency is going to be in the moisture. If the tongue is insufficient in Qi or Yang, it’s going to be moist. If a tongue is insufficient in Blood, that’s going to be more of a dry tongue.

Repletion cold: fur is white slippery and thick, pale body
Vacuity cold: body pale and enlarged and tender, damp and scalloped

Red tongue. This is going to be either a full heat or empty heat.
Full/replete heat, the whole tongue is red.
Empty heat, the tip of the tongue is redder. The tip of the tongue is the Upper Burner (heat rises). Can be tender, with little or no fur.
If red in specific area, heat in that organ

Crimson, scarlet or deep red color – it just means there’s some extreme heat in the body. Usually they’ll have some febrile disease or you’re really insufficient in Yin. Can also be blood stasis. Heat in blood level.
Vacuity heat: little fur left/peeled
Blood stasis: crimson w/ stasis macules: usually skin disorders, too

Purple or dusky – usually the Qi or Blood is static. Now purple’s a mixture of two colors – blue and red. If it’s more blue-purple, it’s usually dealing with some cold. And if it’s a red-purple, it’s usually dealing with more heat stagnating.
Cold: cold in LV/KI and tends to be dampness
Qi and blood stagnation creating heat: stasis macules, a dry mouth (w/o desire to drink)
Purple: heat in blood
Swollen and large: alcohol toxins affecting HT
Purple or Blue-Green: less severe stasis, just certain areas, usually LV/GB first

Every once in a while there’s an orange color to a tongue (on the sides). Giovanni and Hammer say it’s liver blood insufficiency.

When you talk about size and shape, you’re talking about something that’s either too big or too small. Flabby or swollen usually has to do with either Qi or Yang is insufficient to hold it, or there’s excess Damp that’s making it too big. Sometimes there’s teethmarks on the side. That’s called scalloping. It’s usually worse in the morning.

Tough and Tender:
a. Tender: looks like beaten meat; indicates vacuity
b. Tough: appears hard and rough: indicates repletion

Swollen w/ scallops: spleen qi defic w/ dampness
Swollen and pale: yang qi defic: replete yin
Swollen pale white tender and moist: SP/KI yang vacuity
Swollen and red: damp heat

Thin or narrow:
Thin and red: Yin insufficiency
Thin and pale: Qi insufficiency. Can also still be Yin/Blood Insufficiency as they often come together.

Prickles: if papillae stick up high
Usually reddish: heat

Fissures/Cracks: usually yin defic.
Crack down center, depending on length, can indicate severity of disease and progression
Crack in Center: SP/ST yin defic
Crack down center to tip: HT pathology

Scallops: SP qi vacuity often w/ dampness

Tongue Sores: usually LV/GB and HT
Protruding, tight, painful, red: heat toxins in HT
Ulcers, herpes-type: heat in LV usually (can be HT)
Less painful and not protruding or tight: yin defic heat

Sublingual Veins/Network Vessels: under tongue
If dark and distended: blood stagnation
How far does the vein go?

The demarcations that you look for are cracks or raised areas. The cracks, they might be congenital, otherwise they mean something has eaten up the fluids. If you find cracks that are horizontal, that almost always means Yin Insufficiency. If you find cracks on a pale tongue, it usually means that the Qi and the Blood is deficient. And if you find cracks on a red tongue, it usually means that there’s heat – either excess heat that’s burned up the tongue or there’s insufficiency of Yin, usually Stomach Yin. You’ll start finding that (vertical) central crack that usually gets deeper and deeper. That’s usually Stomach Yin burning up.

The eruptions, the red areas that get raised, the little prickles – they’re always replete heat. Most people have it in the back of the tongue and the other place you’ll find them is on the side.

How one moves the tongue. Now the tongue should be able to be flexible and it should be able to sit there for a little while without shaking or moving around like a snake.
Rigid, can’t stick out – Wind. Or it can be a problem with Phlegm heat or Heat, but really extreme though. Delirium.
Deviated, that actually pulls off to the side, shows that there’s some obstruction of Wind and Phlegm in the channels. Wind stroke.
Trembling: heat creating wind; Wind or Qi or Yin Insufficiency. When it’s Qi or Yin insufficiency it’s really mild. When it’s Wind… their tongue is wandering all over.
Dog tongue, the panting or lolling tongue: replete heat.
Limpness: floppy soft w/o strength, hard to turn from side to side or curl: usually in serious conditions
Limp and pale: serious qi and blood defic
Limp dry and red: heat burning yin
Stiffness: hard stiff and straight, not flexible, diffic to stick out or retract: lack of ST qi (critical)
Contracted: unable to extend out of mouth. Critical sign: wind-stroke or extreme heat burning yin
Protrusion and Worrying: licking lips constantly
Developmental problems, ie source qi defic
If adult and red: heat in HT and SP
If adult and purple: epidemic toxin affecting HT
If occurs suddenly in children: fright wind (childhood epilepsy)
Tongue Doubling: veins under tongue swollen and distended, looks like second tongue: due to fire heat surging up HT channel
Palsy: numb and doesn’t move flexibly: due to blood defic causing stirring of LV wind or wind-phlegm
Protracted: extends out, difficult to retract; long and hangs out
If numb: qi and blood defic
If deep red and drool: wind phlegm, phlegm fire

Tell us about circulation. When diseased, they are swollen, distended; one side or the other or both. They become bluish-purplish – tells us about blood stasis. The distention tells more of Qi stag; the purple/blue/black tells of blood stasis.

This is the excess of the turbid Stomach qi. Good stomach qi produces a good tongue coat. It’s part of the healthy digestive process. Normal coat is thin white smooth and evenly distributed and slightly moist. Abnormal coat is generated by evil qi.

The coat can also tell of a pathogenic invasion and location. How deep the pathogen has penetrated.
white: cold, exterior conditions, dampness
body red, coat thin white moist: external wind heat
body normal, coat thin white moist: wind cold
thin white and dry fur: ext evil transforming into heat and damaging fluids (body usually red)
thick white glossy: damp turbidity or cold damp, usually w/ pale white body
thick white can mean heat in certain situations: if looks like snow powder and body is red can be damp heat internally or epidemic type disease or hidden heat
Yellow: heat, deeper the color means stronger the pathogen
Yellow thin: wind heat or wind cold transforming
Yellow thin and dry: heat damaging fluids
Yellow thin and moist: fluids still ok
Yellow thick and glossy: damp heat accum and stag in SP/ST
Yellow thick and dry: heat evil damaging fluids
Yellow thick w/ pale white enlarged body: SP/ST defic w/ water dampness
Yellow slimy: damp heat in SP/ST or phlegm or food accum
Yellow burnt w/ cracks and prickles: extreme heat consuming qi and yin
Yellow and white together: evil moving internal
Grey black: extreme heat (w/ crimson body) or cold (w/ pale body and moist/swollen)
White → yellow → grey (chronic) → black
Repletion Heat: black dry burnt w/ red body
(Yang) Deficiency Cold: thin black damp w/ pale white body and tender or pale purple

Moldy Sauce: mixed colors: yellow/red/black
Long term chronic damp heat complicated w/ summerheat

Peeling: where is it peeling?
If many sections: depletion of ST qi/yin

True fur has root (ST qi rooted). If fur can be scraped off → false fur (no ST qi)

Thin: can see thru coat: normal
Thick: can’t see tongue body: excess repletion. Thicker the coat: stronger the pathogen
Tofu: large clumps of fur, unrooted,
Loose: can be brushed off: severe dampness; stomach not transforming; repletion heat evaporating and transforming turbid dampness in SP/ST
Moldy: over entire tongue or in spots: improper rottening and ripening of ST
Pus-like: thick and sticky and looks like sores: internal abscess
Greasy: pathogen plus dampness
Slimy: greasy and dirty; smaller pellets/clumps which are sticky: damp turbidity
Peeled: no coat: either stomach yin defic (can’t make coating) or Kidney yin defic if no coat all over and red

Topography: see diagram above

Moisture: tells about state of body fluids; normal is moist w/ no pooling, supple
Too wet: yang qi not transforming or dampness
Dry: heat or body fluid dryness (blood)

Water makes tongue more moist
Olives, coffee, plums, turn fur black/yellow
Vitamins C, riboflavin, tea, cigarettes, stain yellow
Milk makes fur white
Antibioitics cause tongue to peel and/or thick tongue fur
Eggs stain fur orange
Candy will change fur color

Tongue Body reflects:
a. circumstances of right qi: change in color, form or bearing reflect right qi, viscera and bowels; ie. Thin=qi vacuity; pale=blood vacuity; deviated=wind/blood stasis
b. vacuity and repletion of zang fu
c. debility/exuberance of qi and blood

Tongue Fur reflects:
a. circumstances of evil qi: yellow=heat; white=normal or cold
b. depth of disease: tongue fur thicker if interior.
c. existence of ST qi

One Comment

  1. Just wanna say thanks for this tongue diag. page… I’ll be bookmarking your site for the next round of studying 😉 – Juliana, TCM student, SF, CA, up at 5:30am studying