TONGUE DIAGNOSIS

Part 1

33

Copyright Giovanni Maciocia

 TONGUE DIAGNOSIS IN CHINESE MEDICINE
TABLE OF CONTENTS

Limitations of tongue diagnosis

Items of observations of the Tongue
Aspects of tongue diagnosis
Normal Tongue
Topography of tongue
Tongue areas
Chest/ breast area
Swollen on the sides: differentiation between Liver Spleen and chest
Sides, Uterus
Spleen area on sides
Spleen-Yin deficiency cracks
Thick coating on root
Circumvallate papillae
Pale tongue
Red tongues
Red tongue areas
 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 tongue
Yin Xu and Empty Heat on tongue
Degrees of Yin Deficiency
Degrees of Empty Heat
Purple Tongue
Differentiation between reddish-purple and bluish-purple
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
 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
 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
Gastroscopy Results and Tongue Coating
Correlation between Gastric Acidity and the Tongue
Types of Tongue in Cases of Perforated Ulcer
Body Shape and Sublingual Veins
Tongue in Stomach Cancer-Body Colour
Tongue and Colonoscopy- Body Colour
Correlation between Atrophic-Necrotic Epithelial Cells of the
Tongue and Yin-Xu Epigastric Pain
Correlation between Atrophic-Necrotic Epithelial Cells of the
Tongue and Yin-Xu Epigastric Pain
Epithelial Cells of the Tongue in Three Groups
Wen Bing and tongue diagnosis
 How to observe the tongue

1) Lighting
The only good lighting is natural light. If you see a patient on a
cloudy, dark day (as I often did in England) I would take the patient
to stand right next to the window, or even outside if necessary. The
same applies if you work in a room without windows. You cannot
do tongue diagnosis in a dark room, the tongue will look much
darker than it really is.

2) Timing
Let the patient stick out the tongue no longer than about 15-20
seconds. Longer than that, the tongue will become darker. Ask the
patient to put the tongue back in and then out again. You can do this
several times.
 Strength of Tongue Diagnosis

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

The progress, or lack of progress, of disease can be monitored e.g.:

• 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

 Strengths of Tongue Diagnosis

1) It is an important of diagnosis

2) It allows use to treat for prevention

3) It guides the choice of treatment principle

4) It guides the choice of dosage of herbal prescriptions

 Limitations of Tongue Diagnosis

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.

Do not expect the tongue to reflect all the aspects of a pathology.

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 in the Intestines the pulse is Wiry on both
Chi positions.)
 Order of observation of the tongue

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:
1) Body colour
2) Body shape
3) Coating
4) Moisture
5) Shen
The importance of looking at a tongue systematically cannot be
overemphasized.
1.

Body Colour: • Heat or Cold

• Yin or Yang deficiency

2.

Body Shape: • Xu
• Shi

3.

Coating: • Fu (Stomach)
• Hot/ Cold
• Xu/ Shi
 • State of body fluids
4.
Moisture: • Cold/Heat conditions
• Yang deficiency
• Yin deficiency

5.
Shen of • “Dull” – no shen.
Tongue:
• “With lustre” – with shen

In general:
Body colour = Zang
Coating = Fu

Please note that in all slides, when I refer to the “right” or “left”
side of a tongue, I mean the patient’s right or left.
 Aspects of Tongue Diagnosis

Aspect Specific Clinical Significance Eight

Factor Principles
Patterns
Tongue Good or poor prognosis
Shen
Tongue Colour Zang, Blood Ying Qi Cold- Heat
Body Yin/Yang
Shape Zang, Blood, Qi Deficiency,
Excess
Tongue Colour Heat/Cold, Fu organs Heat/Cold
Coating
Thickness Strength of pathogenic Deficiency
factor or weakness of Excess
body’s Qi, Fu organs
 Aspect Specific Factor Clinical Significance Eight
Principles
Patterns
Tongue Distribution Exterior conditions: Interior
Coating progression of pathogenic
continued factor Exterior
Interior conditions: location
of pathogenic factor
Root Strength of body’s Qi, Deficiency
particularly Stomach and Excess
Kidney Qi
Tongue Condition of body fluids Heat/ Cold
moisture Yin/ Yang
 Normal Tongue

1. Body colour  Pale-red

2. Body shape  Not thin, not swollen
Not stiff, not flabby
Without cracks
3. Coating  Thin – white
4. Moisture  Slightly moist
5. Shen  “With shen”, fresh, radiant, brilliant
 Topography of Tongue

Lower Burner

Middle Burner

Upper Burner

HE Heat

LU Heat
Please note that the Lung area encompasses
the Heart area
 Tongue areas

Heart / tip Liver / sides Liver and Heart /

sides and tip

Stomach / centre Stomach and Spleen / Lungs / front third

sides in central section
 Differentiation between Liver and Spleen swelling

Liver swelling
Spleen swelling

Spleen swelling Spleen swelling

 Poll no. 1

This tongue indicates:

a) Spleen-Heat
b) Liver-Heat
c) Liver-Qi stagnation
 Chest/breast area
The “chest” area is on the sides of the tongue, 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 (usually purple or red)
2) Changes in body shape (usually swollen or with teeth marks)
3) Red points
4) Coating (absence of coating)

lung/heart

breast
It is important to differentiate between changes in the sides due to
the Liver, Spleen or chest.

Liver Stomach and Spleen Chest area

Liver Stomach and Spleen Chest area

Differentiation between Liver, Stomach/Spleen and chest areas

Thin, long band = Liver Broad band, middle section

= ST/ SP

Chest/breast Chest/breast
The chest area reflects pathologies of the lungs, heart or breast but
in a Western medical sense. A change in 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:

1) In the absence of an obvious lungs/heart pathology

2) Especially when it is unilateral
 Dark macules

Dark lips
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 the
condition of heart/ lungs/ breast, I call this the “chest area”.

Swollen chest area Purple 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 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 in women occurring against a background
of Yin deficiency.

Teeth marks Teeth marks Red points breast No coating breast

breast area on breast area on area on right area left side
left right
In conclusion, as far as the Heart is concerned, we can say that the
tip reflects a pathology of the Heart in a Chinese sense, i.e.
problems of the Shen, while the chest area reflects a pathology of
the heart in a Western sense (e.g. coronary heart disease)

Heart Chinese sense (Shen) = tip Heart Western sense

In this case: Heart-Heat from emotional (chest area, left side)
problems In this case: Heart-Blood stasis
 Poll no. 2

Please choose one the following:

a) I see changes in the breast area frequently

b) In my clinical experience, changes in the breast area
are rare
c) I never heard of the breast area before today
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
 Area on sides around centre

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 centre: ST Heat Red on the sides around the

centre: ST/SP Heat
If the area on the sides around the centre has transversal cracks, it
denotes Spleen-Yin deficiency.

Swollen on sides around centre Small, transversal cracks on the sides

(worse on the right) = Spleen around the centre = Spleen-Yin
deficiency with Dampness deficiency
 Root of tongue
Thick-sticky-yellow coating with red spots on the root = Damp-Heat in
the Bladder, Intestines, Kidneys, prostate or uterus
 Circumvallate papillae
It is important to note that, in Chinese tongue diagnosis, we do not look
at the two large papillae (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.

Circumvallate papillae
 Normal tongue
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 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 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 Kidney-
Yang).
 Normal tongue

• ST-Fluids Tongue Pale

Pale-Red (Normal)
• HE-Blood Tongue Red

Minister Fire KI HE Tongue Normal Red

This tongue is almost normal in terms of body colour Minister Fire

and shape and coating. The only abnormality is a slight
swelling
 Pale (too pale)
By “Pale” is meant a tongue that is too pale, not a normal pale-red
tongue. The tongue may be pale either because not enough Blood
reaches it (Blood deficiency) or because a deficient Yang fails to
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 from the tongue only
which organ is primarily affected by Blood deficiency.

Pale, dry Pale, dry

Yang deficiency may involve especially the Spleen and/or the
Kidneys. Again, one cannot pinpoint from the tongue which of
these two organs is involved.
However, we can say that, in Yang deficiency, the Spleen is
usually involved first and Kidney-Yang is involved in more
chronic conditions.
Therefore, we can deduce that there is Kidney-Yang deficiency if
the tongue is particularly pale; we can also deduce the same if the
tongue is particularly wet.
In a statistic from my practice based on 2500 patients, 32% had a
pale tongue.

Pale, very Pale, very Pale, very slightly wet,

slightly wet slightly wet concave, pale points
 Blood Xu Yang Xu
• Slightly dry • Slightly wet
• Slightly thin • Slightly swollen
• Women • Men and women

Frequently Occasionally
pale on sides orangey in
in LIV-Blood Severe LIV-
Xu Blood Xu

The tongue is never pale only on the tip

 Red Tongue

By “Red” is meant a tongue that is too red, not a normal, pale-red

tongue. Obviously, “red” refers to the colour of the body and not to
that of the coating.
A red tongue indicates pathological Heat. The first question we need
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 and, for this
reason, if a tongue is too red and lacks a coating, it indicates Empty
Heat deriving from Yin deficiency.

Red with coating = Normal colour, Red without coating =

Full Heat without coating = Empty Heat
Yin deficiency
Without coating, normal colour = Yin deficiency

Without coating, red = Yin deficiency with Empty Heat

 Poll no. 3

If a Pale tongue indicates Yang deficiency, therefore a Red

tongue indicates Yin deficiency:

a) True
b) False
 YIN XU VS EMPTY HEAT

= Yin
= Empty Heat

Time
Tongue without coating Red tongue without coating
 Normal Pale-Red RED (Too red) Dark red

Coating with = Full Heat

root
Red = Heat
No coating or
coating without
= Empty Heat
root

Too thin Without root Partially without Totally no

Red with normal coating coating coating

Full Heat 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 centre
• The sides (Liver area)
• The sides around the centre (Stomach/Spleen area)
• The tip (Heart area)
• The front third (Lung area)

Centre Sides (LIV) Sides (ST/SP) Tip (HE) Front third

(ST) (LU)
 RED TIP

Redder tip on red tongue with Redder tip on red tongue without
coating = Heart Full Heat coating = Heart Empty Heat

RED SIDES
(LIVER)

Redder sides on red tongue with Redder sides on red tongue without
coating = Liver Full Heat coating = Liver Empty Heat
 RED SIDES
(ST/SP)

Red sides around centre

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

RED FRONT
(LUNG)

Redder front (LU area) on Redder front (LU area) on

red tongue with coating = red tongue without
Lung Full Heat coating = Lung Empty
Heat
 RED
CENTRE

Red centre on tongue with Red centre on tongue without

coating = Stomach-Heat coating = Stomach Empty
Heat

Red: 40% Red points: 6% 46%

Statistic on body colour based on Pale 32%
database of 2500 patients (UK) Purple 16%
Pathological total 94%
Normal 6%
 The tongue body colour in exterior conditions
In exterior conditions with invasion of external Wind, the tongue may
not change much if the 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 front (i.e. same area as the “chest
area” defined above).

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

Exterior Wind-Heat When centre becomes red, pathogenic factor has

moved to Interior
 Differentiation between Heat and Fire

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

Chinese books do not always use the terms “Heat” and “Fire”
consistently. The confusion arises also because the term “Heat” has
two different meanings. In a broad sense, it indicates any syndrome
characterized by Heat, including Fire; thus, for example, Liver-Fire is
a “Heat” pattern.

In a narrow sense, “Heat” is used as opposed to “Fire”. This

distinction between Heat and Fire stems from the Yang Ming patterns
of the 6 Stages in the Shang Han Lun.
Within the Yang Ming stage of the 6 Stages, there are two patterns:
Channel Syndrome and Fu Syndrome. The Channel Syndrome is
characterized by Stomach-Heat with the “four bigs”, 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”.
 YANG MING CHANNEL SYNDROME
Characterized by Heat, no dryness in Intestines, “Heat without form”.
Clinical manifestations
High fever, intense thirst, profuse sweating, Big or Overflowing pulse.
(“4 Bigs”) tongue: red with yellow coating. Other symptoms:
irritability, restlessness, breathlessness, red face, delirium.
If the Heat is very intense and hidden in the Interior so that it cannot
flow outwards, there may be cold limbs = false Cold, true Heat.

Treatment
BAI HU TANG
This is Heat without “form” (无 形 邪 热), treated with cold-pungent herbs
to expel Heat outwards (泄 热) (xie= to discharge, let out, give vent to)
YANG MING FU SYNDROME
Characterized by Heat, dryness in Intestines, “Heat with form”. More
serious.
Clinical manifestations
High fever, intense thirst, profuse sweating, abdominal fullness and
pain, constipation, dry stools, pulse Deep-Full
Tongue: red with thick-dry-dark-yellow-brown-black coating. Other
symptoms: irritability, restlessness, breathlessness, red face, delirium
(more likely than in Channel syndrome).
Especially in children, this pattern may lead to the development of
interior Wind (i.e. going straight to the Blood level with Wind).

Treatment
TIAO WEI CHENG QI TANG
This is solid Heat “with form” (有 形 实 热). 泻 火 xie huo
 HEAT FIRE

Red body, thin yellow coating: Heat

Redder body, thick, dry, dark yellow/ brown/

black coating: Fire
In terms of the 4 Levels, both Heat and Fire are at the Qi Level; within
the 4 Levels, “Stomach-Heat” pertains to Heat and “Intestines Dry
Heat” pertains to Fire.

Although the Identification of Patterns according to the 6 Stages and

the Identification of Patterns according to the 4 Levels are separated
by about 15 centuries, the Yang Ming stage of the 6 Levels is
essentially the same as the Qi Level in the 4 Levels.

More specifically, the Yang Ming Channel Syndrome within the 6

Stages is the same as the Stomach-Heat pattern of the Qi Level within
the 4 Levels; the Yang Ming Fu Syndrome within the 6 Stages is the
same as the Intestines Dry-Heat pattern within the Qi Level of the 4
Levels.
 6 STAGES 4 LEVELS

YANG MING CHANNEL STOMACH-HEAT

QI
LEVEL

YANG MING FU STOMACH-INTESTINES-DRY-

HEAT
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 herbs (such as Bai Hu Tang

White Tiger Decoction) which expel Heat outwards.

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 Conducting Qi Decoction or Cheng Qi
Tang Conducting Qi Decoction are the representative formulae to
drain Fire at the Qi Level.
 The 4 Levels

Expelled outwards towards

the surface with pungent-
cold herbs (Bai Hu Tang)

WEI LEVEL
QI LEVEL HEAT
FIRE
YING LEVEL
Drained downwards through
BLOOD LEVEL the Intestines with bitter-cold
herbs (Cheng Qi Tang)
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 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
• Affects Shen more: agitation, mental restlessness,
insomnia
• May cause bleeding: epistaxis, coughing up blood,
vomiting blood, blood in urine or stools

Tongue signs:
Red tongue with thick,
dry, yellow/ brown or black
Tongue signs: Red tongue coating
with yellow coating

Treatment principle: Clear

Heat with pungent-cold herbs Treatment principle: Drain Fire with bitter-cold herbs which
to push Heat outwards 泄 热 move downwards 泻 火
 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.

Red points front Three large red spots

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

The ancient Chinese called the fungiform papillae “red grains”. “Red
grains” are a normal, physiological structure of the tongue 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 of normal heat deriving from the Minister Fire.

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, “red grains” are called “red points” or “red spots”.
RED POINTS AND SPOTS DIAN 点 and BAN 斑

Physiological Minister “Red grains” Normal

Tongue
Fire (fungiform papillae)

Pathological Red points Red grains - Redder

(Dian) become: - protruding

Points = Dian 点
Spots = Ban 斑

Spots indicate Heat with some Blood stasis

(more common on root)
Red points tip
Red points tip
 Red points/spots sides and root

Red points sides Red spots root

 Red points/spots sides and root

Red points front, chest/breast area and Red spots on root

on Stomach/Spleen area, worse on right
 Red points Lung/ breast area

Red points breast area left side (also some Red points Lung area
on the side, on the right) (and also SP area right side)
 Poll no. 4

Please choose one of the following:

a) I have always been familiar with the difference between

Heat and Fire
b) I am aware of the difference between Heat and Fire but I am
still not clear
c) I have never heard of a difference between Heat and Fire
 White vesicles

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

White vesicles (Dampness)

 Shen disturbances and tip of the tongue

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, redder tip
• Red body colour, redder tip with red points
• Red body colour, redder 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.
 Normal colour, red tip Red body, red tip Red body & tip with red points

Red body, with red, swollen Red body, red tip, Red body, red tip, Stomach-
tip with red points Heart-crack Heart-crack with sticky-dry-
yellow coating inside it
 Yin Xu and Empty Heat on tongue

The tongue shows conditions of Yin 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.

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 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
so:

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

EMPTY
HEAT

Tongue without coating Tongue red without coating

 Yin Xu and Empty Heat on tongue

That Yin deficiency can occur without Empty Heat is demonstrated by

tongue diagnosis as many patients have a tongue that lacks a coating
(indicating Yin deficiency) but is not red.

This tongue partially lacks This tongue lacks a This tongue lacks a
a coating and the other coating (Yin coating (Yin
coating is rootless (Yin deficiency) and has a deficiency) and is
deficiency) and normal colour (no slightly red in the
has a normal colour Empty Heat) centre (beginning of
(= no Empty Heat) Stomach Empty Heat)
 Yin Xu and Empty Heat on tongue

This tongue lacks a coating and has This tongue lacks a coating (Yin
cracks (Yin deficiency) and is of a deficiency) and is not red (no Empty
normal colour (no Empty Heat). Heat). However, it is also purple,
However, it is slightly redder on the indicating Blood stasis
front third indicating mild Empty
Heat in the Lungs
This tongue lacks a coating
(Yin deficiency) and is red
(Empty Heat)
 Yin Xu and Empty Heat on tongue

NO COATING YIN XU

NO COATING YIN XU WITH

RED BODY EMPTY HEAT

WITH COATING FULL HEAT

RED

EMPTY
WITHOUT COATING 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:
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.
 No coating, redder body =
No coating, normal body Yin Xu + slight Empty
colour = Heat
ST-Yin Xu
Empty Heat (red without coating)

With coating- Full Heat Without coating Without Coating (Reddish Red without coating
Purple)
Deficiency of Stomach-Yin With Stomach Empty Heat
(no coating in centre and red)

Coating missing in the centre, red centre:

Stomach-Yin Xu with Stomach Empty Heat
 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 2

Coating missing entirely, colour Coating entirely missing, slightly

normal: Stomach-Yin Xu, no red body: Deficiency of Yin of
Empty Heat. Note that the Stomach and possibly Kidneys
tongue is also swollen and with some Empty Heat. The
therefore there is Phlegm. widespread presence of cracks
indicates a deeper stage of Yin
deficiency
 Degrees of Yin Deficiency

3 4

Coating entirely missing, red body: Entirely without coating everywhere:

Yin deficiency of Stomach and deficiency of Yin of Stomach and
possibly Kidneys with Empty Heat. Kidneys. As the tongue is also deep
The presence of a Heart crack also red, there is intense Empty Heat. This is
leads us to deduce that there is possibly very severe Yin Xu and this patient had
also Heart-Yin Xu. liver cancer.
 Purple Tongue

Purple is one of the pathological colours of the tongue body. Chinese

books regularly say that in Qi stagnation the 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.
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.
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 the case of a purple tongue, it allows us not only to
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.

Very slightly purple, more Severely purple, more

on the left side on the right side
There are two pathological purple colours: bluish-purple and reddish-
purple, the former indicating Blood stasis associated with Cold and/or
Yang deficiency, and the latter associated with Heat. Therefore, the
bluish-purple tongue develops from a pale tongue, while the reddish-
purple tongue develops from a red tongue.

Bluish-purple Reddish-purple
 Purple Tongue

YANG
DEFICIENCY HEAT
COLD (Pale tongue) (Red tongue)
Cold congeals Blood Heat condenses Blood

BLOOD
STASIS

BLUISH- REDDISH-
PURPLE PURPLE
Severely Bluish-Purple, more so on the left side.
This patient had a large myoma.
 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 a specific area. The three areas that are commonly
partially purple 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 sides Purple chest/breast area Purple centre
(Blood stasis in (Blood stasis in chest/breast – (Blood-stasis in
Liver/Uterus) LU, HE, breast) the Stomach)
 Bluish-Purple Bluish-Purple

Reddish-Purple Bluish-Purple
Bluish-Purple

Reddish-Purple

Reddish-Purple Reddish-Purple
Bluish-Purple Reddish-Purple

Bluish-Purple Bluish-Purple
 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 system rather
than in the Liver itself.
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 menstrual 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
 Blood stasis in women

Four degrees of severity of Blood stasis

1. Normal body colour 2. Purple veins underneath

3. Purple sides 4. Whole body Purple

 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 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.
 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 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.

Bluish-Purple Purple, peeled Reddish-Purple

chest/breast area chest/breast area chest/breast area
 Sublingual Veins

Observation of the tongue should always include observation of the

veins under the tongue. Under normal 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 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.

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
• White-slippery = Cold-Dampness
• Dark-dry veins: severe Yin Xu with Empty Heat

Normal sublingual veins Dark sublingual veins

Sublingual veins slightly dark Sublingual veins dark and
distended

Sublingual veins very dark

on the left side
Yellowish shiny sublingual veins: Very slightly purple sublingual veins
Damp Heat on the right side
 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.

• Distended-dark and crooked veins: hardening of the arteries, high

blood pressure. If veins also stick out a lot and 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.
TONGUE DIAGNOSIS

Part 2
 Tongue-body shape

Observation of the tongue-body shape should come immediately after

that of the tongue-body 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.
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.
 XU

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

SHI

TONGUE-BODY SHAPE = FULL/EMPTY

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

Pale = Yang Xu, Cold Red = Heat

TONGUE-BODY SHAPE = XU/SHI

This tongue is Thin This tongue is red,

(from Blood Xu), but also swollen
compare with Pale (Phlegm)
tongue above
 Pale = Blood Xu
THIN
Tongue
Without coating = Yin Xu

Thin-Pale = Blood Xu Thin without coating = Yin deficiency

Statistic from practice = 1.9% of tongues are Thin

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 is rare (it is in fact very 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.

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.
In fact in women Blood deficiency and Dampness or Phlegm often co-
exist.

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.
 SP-Qi Xu Blood Xu Thin
(Pale)

Dampness/ Swollen
Phlegm

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.
Swollen sides
Swollen sides

Thin
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 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.
 Swollen Tongue

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.
Just as when the tongue is smaller 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 indicates the
presence of an excess of a substance that should not 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 Swollen tongues

 Swollen 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
Partial swelling due to Heat
due to Phlegm (Liver)
(Lungs)
 Partial swelling of the Tongue

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:

• Tip
• Front third
• Sides between the centre and the tip
• Sides (central section)
• Sides (the whole side)
 Partial swelling of the tongue

Swollen front third Swollen chest/breast area

Swollen tip

Sides (central section, ST-SP) Sides (the whole side, LIV)

 Partial Swelling of the Tongue

Swollen tip (HE) Swollen front third (LU) Swollen chest/breast area

Sides (central section, ST-SP) Sides (the whole side,

LIV)
 Swelling of Tip

A swelling in the tip indicates

emotional stress affecting the Shen. It
usually appears in conjunction with a
redness of the tip.
 Swelling of chest/breast area
(heart/ lungs/breast)
As indicated earlier, changes in the area between the centre and the tip
reflect a pathology of the heart, lungs or breast in a Western medical
sense. A change in 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:

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 the
condition of heart/ lungs/ breast, I shall call this the “chest area”.
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.
 Swelling of front third of tongue

A swelling in the front third of the tongue indicates retention of

Phlegm in the Lungs. This is often a residual pathogenic factor from
previous invasions of Wind.
 Swelling of sides, central section

A swelling in the central section on the sides indicates retention of

Dampness with Spleen deficiency
 Swelling of sides (Liver area)

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

 Teethmarks

Teeth marks indicate Spleen-Qi deficiency. Please note that the

presence of teeth marks does not necessarily indicate that the tongue
is Swollen as teeth 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. 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.
 In general cracks indicate Yin deficiency

Heart crack Stomach crack Stomach cracks

Stomach/Heart crack
 In general cracks indicate Yin deficiency

Lung crack Lung cracks Lung/Stomach crack

Spleen cracks Old age cracks Kidney crack

 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.
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, this indicates not an actual Heart pattern
but simply the constitutional tendency to mental-emotional stress. In
other words, when subject to the same stress, a person with a shallow
Heart crack will suffer more emotional problems than one without.

Heart cracks
 HE crack HE crack HE crack

ST crack ST crack ST - LU crack

ST – LU crack ST – LU crack ST – INT crack

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

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

just Ren-12

Stomach cracks
 Scattered Stomach cracks

Scattered Stomach cracks may be all over the tongue. They are either
small horizontal cracks or irregular cracks that in Chinese books are
described as being the shape of the ren character 人
The clinical significance of the scattered Stomach cracks is either a
Stomach-Yin deficiency or a constitutional tendency to Stomach
patterns.

Scattered Stomach cracks

 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
deficiency. LU-9 and Ren-12.

Lung crack

Ice-floe cracks (old age Yin-

Xu)
 Diagonal Lung cracks

Diagonal Lung cracks indicate a past lung disease such as whooping

cough in childhood.

Lung cracks

Ice-floe cracks (old age Yin-

Xu)
 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/Stomach crack

Ice-floe cracks (old age Yin-

Xu)
 Spleen cracks

Spleen cracks are small transversal cracks on the edges of the

tongue: they indicate Spleen-Yin deficiency.

Spleen cracks

Ice-floe cracks (old age Yin-

Xu)
 Old age cracks

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

Old age cracks

Ice-floe cracks (old age Yin-

Xu)
 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),
from overwork.

Kidney crack

Ice-floe cracks (old age Yin-

Xu)
 Stiff

The Stiff tongue indicates a tongue that is stiff and hard. The Stiff
tongue has three possible clinical meanings:
1. Internal Wind
2. Blood stasis
3. Yin deficiency

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 Blood stasis
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.

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.

QUIVERING = SP-Qi Xu Rapid, trembling with a small

amplitude
MOVING = Internal Wind Slow, side to side movement with a
large amplitude
 Deviated
The Deviated tongue 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.

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.
 Deviated

DEVIATED = Internal Wind

(except occasionally in young people = Heart and Pericardium Xu)
 Preventative value of tongue 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 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 in doubt, invigorate Blood and resolve Phlegm

 Preventative value of tongue diagnosis in the elderly

1) DEVIATED, MOVING Internal Wind

2) RED, WITHOUT COATING Severe Yin Xu – Empty Heat

Wind -Stroke

3) SWOLLEN BODY, STICKY COATING Phlegm

4) PURPLE, STIFF Blood Stasis

1) Reddish-Purple = Blood stasis

2) Deviated and Stiff = internal Wind
3) Swollen (slightly) = Phlegm
4) Coating missing in patches = Yin deficiency
 Tongue Coating
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.
Thus, in Chinese medicine a coating with root indicates that Stomach-
Qi 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 the fact that the patient’s 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.
 Poll no. 5
Of these two tongues which is worse?

a b
 Poll no. 6
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 severe Heat in the Stomach
and Large Intestine, but the other tongue signs indicate that the
patient’s Qi is 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.
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 the
pathogenic factor).

A Xu condition is characterized by the weakness of Zheng Qi.

 Normal

ST
By-product of Thin-white
Stomach activity of coating
digestion

When evaluating the tongue coating we should look at the following

six aspects:

1) Coating or no coating
2) With or without root
3) Thickness
4) Colour
5) Consistency (e.g. sticky)
6) Distribution
 Coating/absence of Coating
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 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.

Normal, thin-white coating Thick, yellow coating No coating

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 tongue gives an accurate indication of the degree of Yin

deficiency and of the Empty Heat resulting from it.

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

Empty Heat may develop at any of these stages but it is more likely
to develop at the third stage.
 The photos below show different degrees of Yin deficiency by itself
and with Empty Heat in increasing order of severity.

YIN XU

EMPTY HEAT

Rootless coating: mild Coating Coating Coating missing Coating missing

ST-Qi Xu partially missing partially, body entirely, body
missing: entirely: Red: ST-Yin Xu Red: ST- and KI-
ST-Yin Xu ST-Yin with Empty Heat Yin Xu with
Xu Empty-Heat
 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 2

Coating missing entirely, Coating entirely missing, red body:

colour normal: Stomach-Yin deficiency of Yin of Stomach and
Xu, no Empty Heat. Note that possibly Kidneys with some Empty
the tongue is also swollen and Heat. The widespread presence of
therefore there is Phlegm. cracks indicates a deeper stage of Yin
deficiency
3 4

Coating entirely missing, red body: Entirely without coating

Yin deficiency of Stomach and everywhere: deficiency of Yin
possibly Kidneys with Empty Heat. of Stomach and Kidneys. As
The presence of a Heart crack also the tongue is also deep red,
leads us to deduce that there is there is intense Empty Heat
possibly also Heart-Yin Xu.
When the tongue is partially without coating, it gives a clear
indication of the organ affected by Yin deficiency.
When the coating is partially missing the most common areas
where it is so are:

Front third
Sides

Centre

Scattered small areas

Root
 Lung-Yin Deficiency (no coating in front third)

Without coating in front third: Without coating in front third:

Lung-Yin Xu, also Empty-Heat as it Lung-Yin Xu
is red
 Deficiency of Stomach-Yin (no coating in centre)

Without coating in centre: Without coating in centre and

Stomach-Yin Xu front third: Lung- and Stomach-
Yin Xu (and Empty Heat)
 Deficiency of Yin of Stomach and Intestines
(coating partially missing in patches)

Without coating in patches on the Coating missing on root, left side:

root: deficiency of Yin of Stomach deficiency of Yin of Stomach and
and Intestines Intestines
DEFICIENCY OF YIN OF STOMACH AND INTESTINES

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”.

ST SP Earth
YANG
MING
L.I.
Deficiency of Spleen-Yin (coating missing on the sides)

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)
 Deficiency of Kidney-Yin

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 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.

Coating missing in the centre: Coating completely missing, very

Stomach-Yin deficiency red: deficiency of Stomach-Yin
and of Kidney-Yin with
pronounced Empty Heat
 Partially without coating

Stomach-Yin Xu Stomach-Yin Xu Stomach- and Lung-Yin

(possibly antibiotics) Xu

Stomach- and Liver-Yin Kidney-Yin Xu Yin Xu of Stomach

Xu and Intestines
 Sudden appearance or 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 suddenly on a

previously peeled tongue; 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.
 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, the fact that the coating
appears or disappears on a specific area; second, the fact that
the coating appears or disappears suddenly.
 Sudden appearance or disappearance
of partial coating

LIV

LIV

LU

LU

Sudden disappearance of coating Sudden appearance of coating

 Root of coating
The normal coating should grow out of the body of the tongue like
blades of grass grow out of the soil: when this happens, the coating
is said to have a “root”. Also from the western anatomical point of
view, the filiform papillae (the “coating” in Chinese medicine) grow
out of the body of the tongue like blades of grass.
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.
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 scattered on it.

With root Without root

 Filiform Papillae

Normal filiform
papillae (coating
with root)

Filiform papillae
lying side by
side (coating
without root)
With Root Rootless
 Thick coating with
root

Thick coating without root

 Coating without root

Thin, white coating without root

Small patch of thin, Thick coating without root

white coating without
root
 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.

Note that a thick coating may also lack a root: I call this the “worst of 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 it reflects an acute, passing problem.

Normal coating Thick coating

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 (if the coating is thick) or tonifing the body’s Qi (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 pathogenic factor.
 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-Qi good
2) Thin, white coating without root = Stomach-Qi weakened, Empty
condition
3) Thick coating with root = pathogenic factor present, Stomach-Qi
intact, Full condition
4) Thick coating without root = pathogenic factor 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).
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

THICK WITH ROOT = PATHOGENIC FACTOR

COATING
WITHOUT ROOT = PATHOGENIC
FACTOR ON BACKGROUND OF ST XU =
SHI/XU
(“worst of both worlds”)
 1) Thin; white; with 2) Normal colour;
root = Normal ST- coating without root;
Qi good thin = ST-Qi Xu

3) Thick coating with

root = pathogenic 4) Thick coating but without
factor but ST-Qi is still root = strong pathogenic
good 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”.
 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 short-
term influences and it is therefore somewhat less significant than the
body colour in diagnosing Heat or Cold.

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.
The pathological coating colours are:

-White = Cold White Cold

- Yellow (or brown) = Heat Yellow Heat

Green Heat
- Green = Heat
Cold if wet
- Grey = Heat if dry, Cold if wet Grey Heat if dry
Extreme Cold if wet
- Black = Heat if dry, Cold if wet Black Extreme Heat if dry
 Coating Distribution

ST GB GB

GB ST/ INT
 Sticky (Ni 腻) Slippery (Hua 滑) Mouldy
• Thicker in centre • Thicker in centre • Thick and patchy
• Slippery but rougher than • Oily, smooth • Crumbly like tofu
“slippery” • As if covered in oily fluid • Without root
• As if covered in oily fluid which “slips” • Can be scraped off
which adheres firmly • Papillae seem to be hidden
• Papillae can be seen • Cannot be scraped off
• Cannot be scraped off
 Tongue Diagnosis and Herbal Therapy

Nourish ST-Yin and Resolve Dampness or Phlegm

resolve Dampness or (because of the swelling of the
Phlegm (because the lack body)
of coating indicates
Stomach-Yin deficiency
and the swelling of the
tongue body indicates
Phlegm)
Nourish Yin, clear Tonify Qi
Empty Heat, and/or Blood
resolve Dampness (because the
(because the lack of pale and dry
coating indicates body indicates
Yin deficiency the Blood
redness of the body deficiency)
indicates Heat and
the stickiness of the
coating indicates
Dampness)

Clear Heat Resolve

(because of the Phlegm, clear
redness of the Heat, invigorate
body and the Blood (because
yellow coating the swelling of
with root) the body
indicates
Phlegm, the
redness
indicates Heat
and the Purple
colour indicates
Blood stasis)
Examples of treatment principles in Chronic Fatigue Syndrome

Nourish Stomach-Yin Nourish Stomach-

and Kidney-Yin,
resolve Dampness,
clear Empty Heat

1. Tonify Qi 2. Resolve Dampness, 3. Tonify Qi and

clear Heat resolve Dampness
2) Differentiation between deficiency of Qi or Yin of the
Stomach and Spleen

SP-Qi Xu ST-Qi Xu
(Pale, swollen sides) (rootless coating,
LIU JUN ZI TANG ST crack)
(PROSPEROUS SHEN LING BAI ZHU
EARTH) SAN
(CENTRAL MANSION)

ST-Yin Xu ST- and SP-Yin Xu

(No coating, (lateral cracks and
ST crack) central crack)
SHA SHEN MAI SHA SHEN MAI
DONG TANG DONG TANG
(JADE SPRING) (JADE SPRING)
3) Differentiation between Heat at the Qi or Ying/ Blood level
and that between Heat and Fire.
Red body, thin coating = Red body, thin coating = Red body, no coating =
clear Heat Qi level clear Heat Qi level clear Empty Heat, nourish
Yin, Ying-Blood level

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

 Patient Statistics from Giovanni Maciocia’s practice

Total = 2220: Men 765 = 34% / Women 1455 = 66%

• Swollen 814 = 36%

• Swollen sides 52 = 2.3%
• Thin 43 = 1.9%
• Sticky coating 454 = 20%

• Red (including red points) 1012 45%

• Red Points 128 = 6%
• Red 884 = 40%
• Pale 706 = 32%
• Purple 363 = 16%

Normal colour: 6%
• Purple (Total) 363 = 16%
• Bluish-Purple 31= 8%
• Reddish-Purple 106 = 6.5%
• Purple sides 34 = 1.5%

ST-crack 195 = 9%
HE-crack 151 = 7%
ST-HE crack 36 = 2%

Only 6% were normal

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
Gastroscopy Results and Tongue Coating
Correlation Between Gastric Acidity and the Tongue
Types of Tongue in 255 Cases of Perforated Ulcer
 Body Shape

Sublingual Veins
The Tongue in Stomach Cancer - Body Colour
Coating
The Tongue and Colonoscopy - Body Colour
Coating
Correlation between Atrophic-Necrotic Epithelial
Cells of the Tongue and Yin-Xu Epigastric Pain
Correlation between Atrophic-Necrotic Epithelial Cells of the
Tongue and Yin-Xu Epigastric Pain
Epithelial Cells of the Tongue in Three Groups
 Wen Bing

Warm Disease was conceived of in the late Ming, early Qing

dynasty.

Ye Tian Shi
Wu Ju Tong (Formulated Yin Qiao Pills)
Wu You Ke

a) Wind-Heat
b) Fever
c) Nose-Mouth
d) Infectious
e) Changes quickly, progresses
rapidly
f) Easily damages Yin
g) Leads to complications
 Wind-Heat

Normal Wind- Wen Bing Wind-

Heat Heat

Measles, Chicken Pox,

German Measles, Polio,
Meningitis,
Mononucleosis
 Ye Tian Shi Wen Bing Lun 1746

4 Levels = HEAT

Wei Exterior

Qi

Ying Interior

Xue

Wei = Exterior
Wei = Tongue Body not Red, just Red spots on the sides

Qi = Red body, thick-yellow tongue coating:

Heat

Fire
(thicker; darker; drier, body redder)

Ying/ Blood = Red without coating