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Text | Excerpt from “Illustrated Tongue Diagnosis”
When observing the tongue, we mainly look at the tongue quality and tongue coating.
How to Observe Tongue Quality
When observing the tongue, we mainly focus on two parts: the tongue quality and the tongue coating. Other aspects are generally for the doctor’s observation and are not commonly used by the general public.
In TCM lectures, it is usually emphasized to first observe the tongue spirit, which refers to the state of the tongue. Some may wonder: how can the tongue have a spirit like the face? In fact, the tongue’s spirit refers to its condition; whether it is agile indicates whether the tongue is flexible. Of course, observing the tongue spirit is primarily the responsibility of TCM doctors, and the general public does not usually encounter this. Why? Because those with a lifeless tongue are often in critical condition, which ordinary people do not experience.
Additionally, if there are issues with the tongue’s mobility, such as difficulty extending the tongue, this is called tongue atrophy, which generally occurs in stroke patients. When stroke patients are in critical condition, this situation may arise. For those whose tongues are lifeless, moving is slow, and even slight movement is laborious, this is not something ordinary people typically encounter. However, we can understand our own and our family and friends’ health conditions by observing the tongue, so we only need to learn to observe the tongue quality and tongue coating.
(1) What is the tongue quality of normal and abnormal individuals?
The tongue quality, also known as the tongue body, refers to the muscular and vascular structure of the tongue. We can also observe the part of the tongue body that is not covered by the tongue coating.
a. Normal tongue quality
We observe the color of the tongue within the border of the tongue. If the body is healthy, the color of the tongue quality should be light red, also known as light red tongue (with a thin white coating).
b. Abnormal tongue quality has two types
First, the tongue quality develops towards a pale white direction.
The color of the tongue quality is not as rosy, but pale white, known as pale white tongue, which is relatively common. A more severe case is the withered white tongue, but this is rare; generally, when a withered white tongue is observed, it indicates that the person’s health is already very poor.
Second, the tongue quality develops from light red to red.
The tongue quality first turns red, then becomes crimson (deep red). Further development may lead to a bluish-purple color, resembling a purple hue with a hint of blue.
(2) A tongue quality that trends towards pale white indicates blood deficiency or internal cold, and insufficient yang energy.
If a person’s tongue quality is pale, it indicates blood deficiency or internal cold, and the paler the tongue quality, the more severe the internal cold.
For cold, one must learn to observe the symptoms. First, cold can come from the outside, known as excess (excess cold evil); second, cold can come from within the body, indicating insufficient yang energy.
Therefore, after excluding blood deficiency, if a person’s tongue quality is pale, there are two indicators: one is excess cold evil from the external environment, and the other is insufficient yang energy within the body.
For example, in the northern winter at -30°C, when it is cold outside, people are prone to cold, and at this time, the tongue color will change towards white—indicating excess cold evil from the outside.
The other situation is insufficient yang energy, for instance, when you go on vacation to Sanya in the summer, and it is very hot, while others wear short sleeves and shorts, you still feel cold even in a shirt; this indicates that your kidney yang is insufficient, and there is internal cold.
However, whether it is external cold or insufficient yang energy, it indicates that you are in a state of low body temperature. This can be caused by many factors.
A person’s pale tongue quality may also be due to a combination of external cold and internal cold, where external cold is strong, and internal yang energy is insufficient, leading to a drop in body temperature. For example, some people drink ice beer, iced drinks, and eat ice cream, which suppresses their internal yang energy; at this time, their internal dampness is heavy, and yang energy is insufficient. If they are exposed to cold air conditioning, they will be infected by cold evil.
Thus, a person’s cold condition is caused by multiple factors, both external and internal. These are mutually causal; external cold can lead to insufficient internal yang energy, and insufficient internal yang energy makes the body more susceptible to external cold.
Nowadays, many people do not pay attention to keeping warm; for instance, some women dress inappropriately in winter, wearing a down jacket on top and leather boots below, but only a pair of stockings on their legs. I once saw a girl at the airport when the winter temperature in Guangzhou was around 10°C, and she was only wearing a very thin spaghetti strap dress, and the dress was very short, shivering from the cold. It is puzzling why she would dress like this in such cold weather.
If you also expose yourself to such cold, it will gradually lead to insufficient yang energy, ultimately causing bodily imbalance. Many women experience conditions like cold in the uterus, which are related to this.
Those who have long-term depletion of kidney energy, leading to insufficient yang energy, are more susceptible to external cold. For example, some men who stay up late excessively and engage in unrestrained sexual activity lead to insufficient kidney yang, frequent nighttime urination, sore lower back and knees, and cold hands and feet. At this time, even a slight exposure to cold air can cause them to have a runny nose and feel cold, while others do not have any issues. This is due to their insufficient internal yang energy, leading to external cold invasion.
In both cases, whether it is external cold or insufficient yang energy, the tongue quality will trend towards a pale color.
(3) A change in tongue color to red indicates the presence of external heat evil or an increase in internal heat.
The other direction of tongue quality development is a change in color to red. If your tongue quality gradually turns red, then crimson, and finally purple, it indicates an increase in internal heat. This may be caused by two factors.
On one hand, it may be due to external environmental heat. For example, in winter, everyone’s tongue quality may be slightly pale, but starting in June, as summer begins, the tongue appearance will change, and people’s tongue quality will start to become redder, indicating that their internal qi and blood are abundant.
Therefore, we must observe the tongue appearance in relation to the weather; when the external weather is hot, it will lead to the tongue appearance developing towards red. However, this change is slight, and we should not assume that this indicates an increase in internal heat.
I have always emphasized that tongue diagnosis is a dynamic process; it must be observed dynamically. One cannot say that a certain tongue appearance is standard and remains the same throughout the year, morning and night. This is not the case. Everyone must have this understanding.
True external factors that can increase internal heat are external evils.
What are external evils? They are warm diseases. For example, when a person contracts an infectious disease, leading to dry stools, sore throat, and fever, this is caused by external evil qi, which is heat in nature. At this time, the person’s tongue appearance will develop towards red. Because when the tongue quality is invaded by warm heat evil, it will noticeably turn red, so warm disease scholars use tongue diagnosis as a primary diagnostic tool.
On the other hand, an increase in internal heat can also cause the tongue appearance to turn red. How does internal heat arise? There are two types. One is self-generated excess heat, such as when there is food stagnation, especially from meat, which can transform dampness into phlegm and accumulate heat. This type of heat is excess heat, which is surplus; in TCM, this situation is called “excess.” At this time, the patient’s tongue quality is likely to turn red, and the tongue coating may become yellow and greasy. This heat can easily combine with heat caused by external evils, leading to more pronounced heat symptoms.
The other situation is deficiency heat, such as that caused by yin deficiency. What is yin? It refers to the moistening and static substances in the body, including body fluids and blood, which are yin and primarily serve to nourish the static aspects of our body. It is like the lubricating oil in a car engine; when the engine has lubricating oil, it generates very little heat during operation, which is normal. If the lubricating oil is low or absent, the engine will run dry, generating a lot of heat in the process.
The human body is similar; when the substances responsible for moistening, such as body fluids and blood, are sufficient, the body will generate a normal amount of heat; conversely, when they are insufficient, deficiency heat will arise. Therefore, TCM states that “yin deficiency generates internal heat,” and this internal heat can also cause the tongue quality to turn red. The more severe the internal heat, the redder the tongue quality.
Thus, the color of the tongue quality changing from pale white to light red, then to red, crimson, and finally purple indicates an increase in internal heat.
By observing the changes in the color of our tongue, we can determine what state our body is in and whether it is imbalanced. If there is excess heat, we need to clear the heat; if there is insufficient yin, we need to nourish the yin. After supplementing the moistening substances, the deficiency heat will decrease, and the tongue color will return to normal. (The heat generated by insufficient internal yin is called deficiency heat; the heat caused by external evils invading or internal blood stasis is called excess heat.)
Different methods are required to address deficiency heat and excess heat. For deficiency, we nourish it, meaning that when there is insufficiency, we need to provide nourishment, and gradually the body will return to normal. For excess evils, we simply need to eliminate them.
However, distinguishing between excess heat and deficiency heat can be very tricky, and even many TCM practitioners spend considerable time deliberating when adjusting a patient’s body. Why? Because excess heat and deficiency heat can sometimes combine, and the proportion of herbs used must be considered. Therefore, some people with red tongues may not respond to heat-clearing herbs like Huanglian (Coptis) or Lianqiao (Forsythia) but may return to normal with nourishing herbs like Shengdihuang (Rehmannia), Shashen (Adenophora), or Maidong (Ophiopogon), indicating that their internal heat is deficiency heat, which requires nourishment.
Some individuals may have a red tongue due to deficiency heat but mistakenly believe they have internal heat and self-medicate with heat-clearing remedies like Niuhuang Jiedu Wan (Bovine Gallstone Detoxifying Pill), resulting in no effect. At this time, using nourishing herbs will improve their condition. Conversely, sometimes no amount of nourishing will help, and clearing heat will resolve the issue, indicating that the heat is from an external source.
Internal heat and deficiency heat often combine; when external heat is strong, it can deplete internal body fluids. Therefore, during treatment, one must clear heat while also adding some nourishing herbs; once the heat evil decreases, more nourishing herbs can be added. This process is a balancing act, a two-way adjustment process.
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