Won Institute of Graduates: Acupucture Program

Tongue Diagnosis-Acs 530 Dr. Cao Wei 2012

Observation of Tongue

A. The Relation between Tongue and Viscera

Spleen, Stomach, Kidney, Liver, Heart, and Lung

Heart meridian, Spleen meridian, Kidney meridian, Liver meridian, Bladder meridian, and Triple Jiao meridian.

Spleen and Stomach: liquids and essence are closely related to Spleen qi and Stomach qi

Heart: blood circulation and speech communication are controlled by Heart qi

Kidney: Kidney channel ascends to the tongue and ends at its root

Liver: Liver channel reaches the tongue

B. Significance of Tongue Inspection

Tongue Body: to exhibit conditions of five zang-viscera, indicating the qi and blood of the viscera and the deficiency or excess of genuine-qi and severity of disease. (tongue body color and tongue body shape)

Tongue Coating: to show conditions of six-fu-viscera, indicating the cold or heat (nature) of evils and the location (depth) of disease.

Tongue Spirit (shen): to observe the tongue’s vitality, referring to the qualities of brightness, sheen and vitality.

The Method of Observation of the Tongue

The Topographical Tongue and the Zang-Fu Organs

Root of tongue (lower-jiao), Middle of tongue (middle-jiao), Tip of tongue (upper-jiao)

Root of tongue –Kidney (Bladder), Middle of tongue - Spleen (Stomach), Tip of tongue – Heart (Lung), Margins of tongue – Liver (Gallbladder)

Four Important Factors: Light, Posture, Diet, False Factors

Normal Tongue

Pale Red Color and Luster Tongue with Thin, White Coating (w/ root)

A normal tongue is of proper size, soft in quality, free in motion, slight (pale) red in color, luster, and a thin layer of white coating which is neither dry nor over moist, with root. (vein underneath the tongue are not distended).

Contents of Tongue Diagnosis

I.Tongue Texture (Body, Proper)

Tongue Spirit: a. Flourish; b. Withered

Tongue Body Color

• Pale-red

• Pale

• Red

• Crimson

• Purple

Tongue Shape and Mobility

• Rigid and tender

• Swollen and thin

• Cracked

• Tooth markings

• Thorny

• Flaccid (Atrophy) and stiff

• Quivering (Tremor)

• Deviated

• Moving

• Shortened

1. 舌神 Tongue Spirit (Vitality, Shen)

- A general Impression (the qualities of brightness, sheen and vitality)

Flourish of Tongue - “Have spirit”

Withering of Tongue- “Have no spirit”

2. 舌色 Tongue Body Color

– To reflect primarily the state of the yin organs and blood, to show conditions of heat or cold and of yin and yang deficiency

Pale Red Tongue

- Normal

- Mild disease

Pale Red, w/ Pale Edges Tongue – Spleen qi deficiency, Stomach yin deficiency

Pale Tongue

- Deficiency (qi or blood deficiency, or yang deficiency)

yang deficiency-wet

qi or blood deficiency-dry

- Cold

Pale Withering (dry) Tongue -Blood deficiency

Pale and Swollen (w/ teeth-printer) Tongue - Deficiency syndrome, especially

deficiency of Spleen (Spleen qi and Spleen yang, accumulation of dampness)

Pale & Thin Tongue – Spleen qi deficiency, Liver blood deficiency

A pale tongue w/ normal shape & coating – slight deficiency of Lung & Spleen qi

Pale Tongue (Indications)

Pale and slightly wet: yang deficiency

Pale and slightly dry: blood deficiency

Slightly pale: Qi deficiency

Pale on the slides all along edges: Liver blood deficiency

Pale on the sides in central section: Spleen (qi) & blood deficiency

Pale without coating: deficiency of qi and blood; sever Liver blood deficiency

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 35, pp117

Red, Crimson Tongue

- Heat (exterior or interior, excess or deficiency)

The deeper red is, the extreme heat is.

w/ coating w/ root - Excess-heat

w/o coating, or only partially, or w/ rootless coating – Deficiency-heat

Red Color at the Tongue Tip - Hyperactivity of Heart fire

Red Tongue in Bilateral Margins -Extreme heat in the Liver and Heart

Red Points along the Edges and at the Tips –Internal Heat, Heat in the Liver & Heart

Crimson Tongue with Prickles – Excess heat

Deep Red Tongue No Coating: Mirror- Like Tongue - Extreme heat, consumption of yin fluid (Kidney yin deficiency)

Crimson w/ Cracked Tongue Yellow, Sticky & Dry Tongue Coating

- Damp-heat in the qi system

- Intense heat damages body fluid

Crimson Tongue w/ Gray-Black, Dry Tongue Coating

- Extreme Heat

- Impairment of yin

Red Tongue (Indications)

Red tongue with coating: Excess-Heat

Red tongue without coating: Deficiency-Heat

Normal tongue without coating: Blood deficiency

Red points on the tongue:

- Tip area: Heart fire

- Both sides: Liver heat

- Centre area: Stomach heat

- Front sides: Lung heat

- Root area: Damp-heat in the Bladder

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 64, pp106, pp72, pp76,, pp125, pp126, pp158

Purple Tongue –Blood Stasis

Pale Bluish Purple Tongue

- Blood stasis (excess of yin due to yang deficiency, stagnation of blood)

Reddish-Purple Tongue - Extreme heat in Yin & Xue stage; - Blood stasis

Purple Spots Tongue - Stagnation of blood

Purple Tongue (Indications)

Red Purple (reddish-purple) tongue: Extreme heat and blood stasis

Pale Purple (bluish-purple) tongue: Extreme yin cold and stagnation of blood

Purple areas on the tongue:

- Both sides areas: Liver blood stasis

- Tip areas: blood stasis in the Heart

- Centre: blood stasis in the Stomach

Self-study: “Atlas of Chinese Tongue Diagnosis” pp193

Summary I Tongue Body Color

To Reflect primarily the state of the Yin organs and Blood

To Show conditions of Heat or Cold and of Yin or Yang deficiency

Summary I Tongue Body Color (Continued)

• Pale-Red Tongue Normal color of the tongue body; Mild disease

• Pale Tongue Deficiency; Cold

• Red Tongue Heat (Excess type and deficiency type)

• Crimson Tongue Extreme heat; Hyperactivity of fire due to yin deficiency

• Purple Tongue Extreme Heat and blood stasis; Extreme yin cold and stagnation of blood

3. 舌的形 质 Tongue Shape (Form of the Tongue Proper) – To reveal primarily

conditions of deficiency or excess, to add more information to that gleaned from observation of the tongue body color.

A.Rigid and Tender - To differentiate the deficiency and excess

Rigid Tongue – Excess; -Heat

Tender Tongue – Deficiency; - Cold;

B. Swollen and Thin - To indicate qi, blood and body fluid, water-dampness

Swollen (Corpulent) Tongue - Retention of water-dampness; - Phlegm

Thin Tongue - Deficiency syndrome (qi & blood deficiency, yin deficiency)

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 35, 51

C. Cracked Tongue - Insufficient yin fluid, blood deficiency, or health person

- Excessive heat, consumption of yin (red tongue color)

- Deficiency of blood (pale tongue color)

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 71, 72, 74

D. Tooth Markings - Deficiency syndrome, especially deficiency of the Spleen

Swollen Tongue w/ Tooth-Print - Qi deficiency; - Yang deficiency (accumulation of dampness)

No Swollen Tongue w/ Tooth-Print

- Spleen deficiency;

- Qi or qi & blood deficiency

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 30, 33

E. Thorny (Red Points & White Points) Tongue - Intense heat

Red Thorny Tongue & White Star Tongue

- Different heat in the different zang organs (different thorny tongue area)

Self-study: “Atlas of Chinese Tongue Diagnosis” pp212, pp219,

4. 舌的 动态 Tongue Mobility – To show that the disease is rather severe (wind syndrome,

heat syndrome, and severe diseases)

A. Flaccid (Atrophy) Tongue: Severe disease

- Deficiency of qi and blood

- Yin fluid consumption due to heat, exhaustion of yin in the Liver and Kidney

B. Stiff Tongue

-In the febrile disease, heat into the Pericardium

- A sign of windstroke, epilepsy or tetanus.

C. Quivering (Tremoring) Tongue

- In febrile disease, extreme heat producing wind

D. Deviated Tongue

- Wind syndrome, mostly seen in windstroke accompanied with deviation of the eyes and mouth

E. Shortened Tongue

- Critical stage (heat, cold, phlegm, deficiency)

F. Playing with the Tongue: Critical Sign

- In febrile disease, invasion of the Heart by evil

- Heat in the Heart and Spleen

- Infantile convulsion, or children with congenital mental deficiency

Self-study: “Atlas of Chinese Tongue Diagnosis” pp182, pp183

5. 舌下 络脉

Sublingual Vein (Hypoglossal Vessels) – To observe deficiency or excess, cold or heat, especially in blood stasis

Normal:

Two veins are barely visible and have a very faint. Pale-red colour. Diameter <2.7mm. Length<3/5 of tongue tip to bottom. No spot.

Thick, Dark and Swollen & Purple Dark, Distended, and Diffuse Varicosity - Blood stasis

Summary II Tongue Body Shape and Mobility

To reflect primarily conditions of Deficiency or Excess

To add more information to that gleaned from the tongue-body color

Summary II Tongue Body Shape and Mobility (Continued)

Tongue Body Shape

• Rigid and tender: to differentiate of deficiency and excess

• Swollen: phlegm or dampness

• Thin: deficiency syndrome

• Cracked : blood or yin deficiency

• Tooth markings: Spleen deficiency

• Thorny: intense heat

Tongue Body Mobility

• Flaccid (Atrophy): severe disease, lack of body fluid, blood deficiency

• Stiff: mostly in febrile disease, internal wind, blood stasis, severe yin deficiency

• Quivering (Tremor): deficiency (qi, blood, yang, or body-fluid) in chronic disease, internal wind in exogenous disease or alcohol intoxication

• Deviated: wind syndrome

• Moving: Liver-wind

• Shortened: critical sign, severe yang deficiency or severe yin deficiency

•

II.Tongue Coating

Tongue Coating and the Eight Principles

Thick coating: Excess & Lack of coating: Deficiency---The strength of the genuine qi

White coating: Cold & Yellow coating: Heat ---The nature of diseases

Tip of the tongue: Exterior of the body (Yang) & Middle and posterior third of the tongue: Interior of the body (Yin)--- The location of diseases

1. 苔色 Tongue Coating Color- To yield a differentiation of the nature and severity of a

disease

A. 白苔 White Coating

White Coating

- Exterior syndrome

- Cold syndrome

- Dampness syndrome (mild)

Thin White Coating - Normal tongue coating; - Exterior syndrome

Thick White Tongue

- Excess-Cold syndrome

- Cold-Dampness syndrome

- Phlegm

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 230, 231, 234, 237, 238

B. 黄苔 Yellow Coating

Yellow Coating

- Interior syndrome

- Heat syndrome

Pale (Light) Yellow Coating

- Exterior Heat syndrome

- From exterior cold changes to heat, or exterior syndrome to interior syndrome

The deeper yellow the color is, the more severe the pathogenic heat is.

Deep Yellow Coating - Interior heat syndrome; - Damp-Heat syndrome

Black Yellow Coating (Brown Coating) - Interior intense heat syndrome

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 231, 232, 235, 236, 237, 239

C. 灰苔 , 黑苔 Gray Coating, Black Coating

Gray Coating

- Interior syndrome: Interior heat, Interior cold

- Retention of phlegm syndrome

Black Coating: Critical sign

- Interior heat syndrome

- Interior cold syndrome

Gray-Black Coating

- Extreme Heat syndrome; consumption of body fluid

Black, Thick, Greasy, Dry Coating (Red Tongue, Pale Sides)

– Retention of Phlegm-Heat,

-Excess Heat

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 239, 240

Summary III Tongue Coating

To reflect primarily the state of the Yang organs, especially of the Stomach

To reflect conditions of Deficiency and Excess

To show conditions of Heat or Cold

Summary III Tongue Coating (Continued)

White Coating

• Exterior syndrome

• Cold syndrome

• Dampness syndrome

Yellow Coating

• Interior syndrome

• Heat syndrome

Gray Coating

• Interior syndrome, including interior heat and interior cold

• Phlegm-Retention syndrome

Black Coating

• Interior syndrome, including extreme heat or extreme cold, Critical condition

2. 苔 质 Tongue Coating Quality

A. Thick or Thin - To differentiate the depth and severity of a disease

Thin Coating - Mild disease; - Located superficially

Thick Coating - Serious disease; - Located in the interior

B. Moist or Dry - To understand the condition of the body fluids

Moist Coating - Normal tongue; - The body fluids are not damaged

Slippery (Smooth, Wet) Coating

- Cold (yang deficiency)

- Dampness (water retention)

Dry Coating - Insufficiency of body-fluid due to heat; - Depletion of yin

C. Curdy and Greasy (Granular, Sticky Mouldy)

- To diagnose the condition of turbid dampness in the Spleen and Stomach

Sticky (Greasy) Coating

- Retention of turbid damp

- Phlegm

- Retention of food

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 234, pp235

Granular (Putrid, Curdy, Mouldy) Coating - Tofu-Like

- Excessive yang-heat steaming the turbid qi up

Mouldy-Purid Coating

- Upward of turbid qi, Stomach qi damaged

- Retention of turbid phlegm

- Retention of food

D. Exfoliated (Peeling) Coating

- To diagnose the condition (sign) of consumption of qi & yin of Stomach

No coating: Mirror-Like (Glossy) Coating; Critical sign

- A sign of exhaustion of Stomach yin

- Severe damage of Stomach qi

Peeled Off Coating in the Center of Tongue -Deficiency of Stomach qi & yin

Peeled Off Irregularly: Geographic (Map) Tongue - Deficiency of Stomach qi & yin

Self-study: “Atlas of Chinese Tongue Diagnosis” pp 53, 73, 76, 80

Summary IV Tongue Coating Quality

• Thick or thin : the depth and severity of a disease

• Dry or moist : the condition of the body fluids

• Curdy and greasy (granular and sticky): the condition of turbid dampness in the Spleen and Stomach

• Exfoliated (Peeled) coating: the insufficiency of Stomach-qi or body fluid

• Wax and Wane: the state of the genuine-qi and evil, and the prognosis of the disease

Summary IV Tongue Coating Quality (Continued)

Greasy (Sticky) Coating: Dampness or Phlegm (cold or heat)

Slippery (Smooth) Coating: Cold (yang deficiency) and Dampness (water retention)

Granular (Curdy, Mouldy) Coating: Retention of food, Phlegm with Stomach yin damage, Turbid qi.

Special Tongue

Black, Hairy Tongue – Retention of damp-heat, Fluids injured by antibiotics

-A fungus infection

Patch Tongue Coating – Stomach Yin Deficiency

Combining Consideration of Tongue Body (Proper, Texture) and Coating

The Correlation Between the Tongue Body (Proper) and the Tongue Coating

1. To combining the spirit, color, shape, and quality of the tongue body with the color and quality of the tongue coating

2. The indications are the sum of both

Common Tongue Pictures and indications

Tongue Proper (Body) Tongue Coating Indications

Pale red Thin, white Wind-cold exterior syndromeNormal tongue picture

Pale Thin, white Yang deficiency,Deficiency of both qi and blood

Thin, white, with peeling in the center

Deficiency of both qi and blood,Insufficiency of Stomach yin

Yellow, greasy Weakness of Spleen and Stomach,Retention of damp-heat in the interior

Gray, black Internal cold due to yang deficiency,Retention of phlegm-dampness in the interior

Without coating Yang deficiency in chronic disease,Deficiency of both qi and blood

Pale red or red tip of the tongue (Red tip) white coating Wind-heat exterior syndrome,Hyperactivity of heart-fire

White, thin Exterior syndrome due to exogenous pathogenic factors

White, greasy Retention of phlegm-dampness,Retention of food

White, curdy Retention of phlegm and food,Retention of heat in the Stomach

White, thick Damp-heat at the initial stage, or abscess of internal organs

White, dry Exhaustion of body fluids and dryness of blood,Constipation

Red White Febrile disease penetrating from defensive system to ying system gradually

Thin, yellow Excessive heat in the qi system

Yellow, greasy Damp-heat in the qi system

Yellow, thick Inward transmission of pathogenic heat,Formation of interior excess

Without coating Deficiency of both qi and yin

Crimson Deep yellow Heat in the stomach and Intestines,Interior heat system of excess type

Black, dry Impairment of yin due to extreme heat

Without coating Penetration of heat into xue system,Hyperactivity of fire due to yin deficiency

Green-blue (Purple) Yellow, dry Exhaustion of yin and blood,Stirring up of deficiency-fire

White, moist Extremely severe internal cold,Stagnation of qi and blood

Tongue Changes in Deficiency of QI, Blood, Yin and Yang

Qi Deficiency:

• General qi deficiency-pale tongue

• Spleen qi deficiency-pale tongue w/ tooth marks, or swollen/ partially swollen on sides or in the center section

Blood Deficiency:

• General blood deficiency- pale and dry

• Liver blood deficiency-pale on sides

Yin Deficiency:

• General yin deficiency- red tongue w/ lack of coating

• Stomach yin deficiency-red tongue w/ no coating in the center

• Lung yin deficiency-red tip tongue w/ no coating in front third section

• Kidney yin deficiency- red tongue w/ no coating all over the tongue with red tongue body

Yang Deficiency:

• General yang deficiency - pale tongue w/ moist coating

• Heart yang deficiency – pale tongue with white thin coating

• Spleen yang deficiency – pale and swollen, tooth marks tongue body, white and slippery tongue coating

• Kidney yang deficiency – pale, swollen tongue body w/ white/black slippery tongue coating

Tongue Changes in Four Level (Phase) Differentiation Diagnosis

Wei (Defensive Phase)

Slightly red tongue on the sides/front

Qi Phase

Red tongue with dark yellow coating

Yin (Nutrition) Phase

Red tongue without coating

Xue (Blood) Phase

Dark red (crimson) tongue without coating