The normal color of the tongue coating in healthy individuals is thin and white. This is due to the differentiation of the filiform papillae at the tip of the tongue mucosa into “keratinized trees”. In the gaps between the branches of the “keratinized trees”, there are often shed keratinized epithelium, saliva, bacteria, fungi, food debris, and exuded white blood cells. These opaque substances cover the red color of the tongue’s capillaries, and the keratinized epithelium can absorb moisture when wet, resulting in the formation of a normal thin, white, and moist tongue coating.
White tongue coating: This often indicates a cold syndrome. A thin and slippery coating is usually due to an external invasion of wind-cold, while a thick white and slippery coating is often associated with cold dampness or phlegm. Yellow tongue coating: This is generally seen in the course of heat-related diseases, indicating a fierce struggle between pathogenic factors and the body’s righteous qi, with the disease having entered the interior and the pathogenic factor transforming into heat.
Black tongue coating: This is primarily caused by the proliferation of the filiform papillae on the tongue turning black. The shades can vary from brownish-black, grayish-black, charred black to pitch black. Traditional Chinese Medicine (TCM) believes that the presence of this coating indicates a long-standing illness with a complex and severe nature. A combination of gray and white or gray, greasy, and thin slippery coating often indicates internal cold, with a prior weakness combined with a heat-related illness, or signs of prolonged illness combined with digestive disorders.
A pale purple tongue with a bluish tint and a smooth, coating-free surface indicates a Yang syndrome of typhoid fever. A brown tongue coating indicates intestinal obstruction. A mirror tongue: This refers to a tongue surface without coating, appearing as smooth as a mirror. In mild cases, it suggests malnutrition or a deficiency of iron or vitamin B2; in severe cases, it indicates a significant deficiency of body fluids, with a serious condition. If a mirror tongue appears in a long-term patient with a scarlet color, it should be monitored for the risk of septicemia. If an elderly person’s tongue appears mirror-like, with two enlarged and elongated veins on the underside, it indicates pulmonary heart disease.
Heart-piercing tongue: This refers to a small area of the tongue coating being absent, indicating a shedding of the coating. A heart-piercing tongue is a manifestation of Yin deficiency, often indicating a lack of nutrition in the body. In children, shedding of the coating indicates nutritional insufficiency, primarily caused by picky eating, leading to a deficiency of certain nutrients and resulting in partial shedding of the tongue coating. Such children have poor resistance and are prone to colds or fevers.
Beef tongue: This refers to a dark red tongue body with a coating that is smooth and peeled, resembling beef. Beef tongue is commonly seen in patients with malignant anemia. Rotten coating: This is a relatively thick, coarse, and loose coating, resembling tofu dregs, piled thickly on the tongue, easily scraped off, but gradually re-accumulates.
Rotten coating suggests that the body’s Yang qi is sufficient, capable of rising and dispersing the turbid and rotten qi in the stomach, indicating a struggle between the righteous and the evil, and a sign of improvement in the disease. Greasy coating: This is thicker in the center and root of the tongue, slightly thinner at the edges and tip, with fine and dense particles tightly adhering to the tongue, difficult to scrape off, and covered with a layer of mucus resembling oiliness, often obscuring the tongue body. Upon magnification, the number and branching of the filiform papillae are increased, with entangled keratinized trees that are not easily shed, containing many mucus and food particles. TCM believes that greasy coating indicates that Yang qi is suppressed by Yin evil, and there must be pathological changes of dampness and phlegm or food accumulation and stubborn phlegm stagnation in the body, such as in acute or chronic gastroenteritis.
Moldy coating: The texture of the coating is similar to rotten coating, floating and loose, but the coating on the tongue surface is not spread out like rotten coating, but appears as grayish-white, resembling spots of mush or rice grains, with varying thickness accumulating on the tongue, thus distinguishing moldy coating. This is generally due to weakness of the body or excessive use of hormones, immunosuppressants, and broad-spectrum antibiotics, leading to a decline in immune function, poor resistance, and dysbiosis, allowing fungi to grow and reproduce. This coating usually first occupies part of the tongue and can later spread to the entire tongue or the whole oral cavity, often indicating a serious condition. Moldy coating has significant diagnostic value for fungal diseases.
Pointed tongue: This refers to the presence of many red prickly clusters protruding from the tongue surface, resembling the fruit of grass mold. Pointed clusters appear at the tip or sides of the tongue, indicating heat accumulation, and can be seen in various febrile infectious diseases or patients with extensive burns; if pointed clusters appear in the middle of the tongue, it often indicates a more severe heat toxin or heat entering the blood, easily leading to shock or coma. Insomnia, constipation, or nighttime work stress can also cause red prickly clusters on the tongue, which TCM refers to as Yin deficiency with excessive fire. Pointed clusters on the tongue can also be painful, but will disappear quickly after rest, adjusting nutritional structure, and ensuring smooth bowel movements. Modern research suggests that pointed clusters are formed by the proliferation or hypertrophy of the filiform papillae on the tongue.
Cracked tongue: The cracks on the tongue surface can be deep, shallow, and in various directions. Shallow cracks resemble wrinkles, while deep cracks appear as if cut or shredded, with irregular grooves. About 0.5% of normal individuals are born with congenital tongue fissures. Modern medicine believes that shallow cracks on the tongue surface are primarily due to atrophy of the tongue mucosa, revealing the original longitudinal and transverse grooves of the tongue muscles; deep cracks are a more severe atrophic change of the tongue, causing the epithelial layer of the tongue muscles to lose its normal structure, with some papillae becoming flat and fused, while others atrophy and break, forming cracks. The patterns of cracks on the tongue can be quite peculiar, with vertical, horizontal, forked, well-shaped, or resembling the grooves of a brain. Pathological tongue fissures often coexist with atrophic tongue and can be seen in chronic wasting diseases, nutritional deficiencies, and chronic glossitis caused by vitamin B complex deficiency, often accompanied by symptoms such as tongue pain and dry mouth.
Long-term geographic tongue can later transform into a cracked tongue. TCM believes that a cracked tongue with a dry surface often indicates insufficient body fluids; if accompanied by excessive heat, the tongue body may also appear scarlet. Smooth tongue: A tongue that is smooth and without moisture, and has no coating, appearing flat like a mirror, is also known as a “mirror tongue”. Regardless of the disease, whenever this tongue appearance is observed, it indicates a sign of the disappearance of Yin fluids in the body, with severe depletion of body fluids. A smooth tongue that is red indicates excessive heat damaging Yin, while a smooth tongue that is pale indicates both Qi and Yin deficiency. TCM considers a smooth tongue to be a critical tongue sign; clinical observations combining TCM and Western medicine indicate that a smooth tongue is characterized by the absence of coating and points, with all filiform and fungiform papillae atrophied, representing the late stage of glossitis. A smooth tongue can be seen in severe vitamin C deficiency, malignant anemia, prolonged high fever, cirrhosis, and the terminal stage of pulmonary heart disease, chronic renal failure, uremia, toxic shock, and cerebral coma. Research has confirmed that various factors causing necrosis of the tongue mucosal epithelial cells can lead to a mirror-like tongue.
Stagnation tongue: This tongue has scattered purple-black spots or bruises on the tip or sides, indicating the presence of “stagnant blood” in the body. Individuals with stagnant blood have slower blood flow, and in certain areas, blood flow may even completely stagnate. People may accidentally bite the edges and tip of the tongue while eating; during illness, the fragility of blood vessels increases, and sometimes blood vessels on the tongue may rupture unknowingly. The tongue is quite sensitive and often bleeds more easily than other parts of the body, making it prone to bruises or spots. Bruises and spots on the tongue are also common in young women, who often experience irregular menstruation, dark menstrual blood, clots, and dysmenorrhea, which TCM considers a manifestation of blood stasis. Using herbs that regulate menstruation and invigorate blood circulation can help restore normal microcirculation in the tongue, alleviating not only menstrual irregularities and dysmenorrhea but also leading to the disappearance of bruises and spots on the tongue. Many cancer patients have bruises and spots on the tongue, sometimes accompanied by a bluish tongue. Statistics show that about 50% of patients with malignant tumors exhibit a purple tongue, while about 20% have bruises and spots; if bruises and spots suddenly appear on the tongue, a detailed examination should be conducted, and attention should be paid!
Swollen tongue: The tongue body enlarges, with teeth marks on the edges, referred to as a “fat tongue”; if the swelling is more pronounced, it is called a “swollen tongue”, filling the mouth and making movement difficult, and in severe cases, it can affect breathing and speech. TCM believes that a fat tongue indicates Qi deficiency or the presence of dampness; a fat tongue with greasy coating often indicates phlegm-dampness or damp-heat. A bright red swollen tongue often indicates heat in the heart and stomach; a purple swollen tongue is often due to alcohol toxicity; if the tongue swelling also involves the lips, resulting in swelling and bluish discoloration, it indicates blood stagnation, often caused by drug or food poisoning. Modern medicine believes that tongue swelling is primarily caused by hyperplasia of the connective tissue of the tongue, tissue edema, or obstruction of venous and lymphatic return, commonly seen in patients with hypothyroidism, acromegaly, chronic nephritis, uremia, and acute poisoning. Some patients may experience swelling of the tongue due to pressure on the throat or neck, such as severe laryngeal edema or extreme thyroid enlargement.
Thin and withered tongue: The tongue body becomes thin and emaciated. Modern medicine believes that a thin and withered tongue is caused by systemic malnutrition, leading to atrophy of the tongue muscles and epithelial mucosa. This is often seen in chronic wasting diseases, often accompanied by overall weight loss, such as severe pulmonary tuberculosis, pulmonary heart disease with secondary infections, and late-stage cancer. Additionally, long-term gastrointestinal dysfunction, vitamin and protein deficiencies, and malignant anemia can also cause the tongue body to become thin. TCM believes that the tongue muscle is related to the heart and spleen, and if there is deficiency in both, the tongue will be thin and withered. If the tongue is pale and thin, it indicates deficiency of both Yin and Yang, with insufficient Qi and blood failing to nourish the tongue body, leading to its thinness over time; if the tongue is red and thin, it indicates excessive fire due to Yin deficiency, with Yin becoming more deficient and fire becoming more rampant, resulting in changes such as the tongue body becoming thin and withered. Whether in new or chronic diseases, the presence of a thin and withered tongue indicates that the condition is unlikely to be mild; if the tongue is thin and withered without moisture, and the color is dark, the prognosis is often poor.
Fringed tongue: The tongue extends beyond the corners of the mouth and is noticeably swollen and tender, with teeth marks on the edges, resembling the hem of a woman’s skirt. A fringed tongue is due to malnutrition in the body, especially a deficiency of protein, leading to tongue edema. The tongue tissue is more sensitive than other organs, so there may be signs of edema in other parts of the body at this time. Thorny tongue: This refers to the tongue having thorn-like projections. TCM believes this is caused by hidden heat toxins, excessive heart and lung fire, or substantial heat in the stomach, commonly seen in high fever and pneumonia. Regular consumption of coarse foods, such as sugarcane, can also irritate the tongue papillae, leading to thorny projections, which can be distinguished based on the presence of other symptoms.
Flowering tongue: This refers to partial shedding of the tongue coating, revealing the red tongue body beneath. Children with flowering tongues often have allergic constitutions, are prone to conditions like milk rash and asthma, and often have picky eating habits, primarily avoiding vegetables, leading to malnutrition, anemia, vitamin deficiencies, and intestinal parasites. Western medicine refers to some flowering tongues as geographic tongues, as the central depression appears bright red, while the edges are grayish-white with small protrusions, resembling the winding borders of a map. TCM believes that flowering tongues often indicate congenital insufficiency and require regular consumption of kidney-tonifying herbs to improve constitution, such as He Che Da Zao Wan and placental powder. In adults, flowering tongues are often associated with Yin deficiency and blood loss. Among these, shedding in the front half of the tongue indicates heart Yin deficiency, which is relatively mild; shedding at the root of the tongue indicates liver and kidney Yin deficiency, which is more severe; a tongue with a strip of smooth shedding coating in the middle, commonly referred to as “chicken heart tongue”, indicates severe Yin injury.
Pale white tongue: The color of a pale white tongue has more white than red, and based on the ratio of red to white, it can be divided into two categories: one is slightly lighter than the normal tongue color but still shows some red; the other is a completely pale white tongue, devoid of blood color, with pale lips and gums. A pale white tongue body is generally larger than normal, with a moist surface, appearing as if excess dampness has soaked in, making it appear swollen and tender; on the edges of the tongue, due to pressure from the teeth, there are noticeable teeth marks, resembling the edges of a lotus leaf surrounding the tongue. A pale white tongue is an important sign of deficiency and cold syndromes. If the tongue color is pale white, and the tongue body is not enlarged, resembling the size of a normal person, or slightly smaller, with a smooth surface but not overly moist, accompanied by symptoms such as shortness of breath, fatigue, low voice, spontaneous sweating, palpitations, dizziness, tinnitus, pale or sallow complexion, it can be diagnosed as a deficiency of both Qi and blood. If the tongue color is pale white, the tongue body is plump and tender, moist and abundant, with teeth marks on the edges, and accompanied by symptoms such as cold limbs, edema, drowsiness, loose stools, and a slow pulse, it can be diagnosed as Yang deficiency with internal cold. Modern medicine confirms that a pale white tongue is often seen in patients with anemia and protein deficiency, as well as malnutrition. Additionally, chronic nephritis, hypothyroidism, hypotension, late-stage schistosomiasis, and myxedema can also be accompanied by a pale white tongue, primarily due to endocrine disorders, reduced metabolism, peripheral vasoconstriction, and decreased blood flow, leading to a pale tongue color. Due to protein metabolism disorders, insufficient total protein, and decreased albumin, tissue edema can occur, leading to a tongue that appears swollen and tender, further contributing to the pale appearance of the tongue.
Scarlet tongue: The normal color of the tongue body is light red and moist. If the tongue body is bright red, it is referred to as a red tongue; if the tongue is red and dark in color, it is referred to as a scarlet tongue. A scarlet tongue often appears after a red tongue, and the clinical significance and formation mechanisms of the two are similar, often indicating that a red scarlet tongue is a symbol of heat and fire, differing only in the degree of heat. A scarlet tongue is caused by high fever damaging Yin, commonly occurring in infections, poisoning, vitamin deficiencies, dehydration, anemia, and coma. A bright red or dark red tongue indicates heat entering the nutrient blood, but the nature of the heat can differ between deficiency and excess. The distinctions are as follows:
——Excess heat type scarlet tongue: Mostly caused by acute warm diseases, occurring shortly after onset, with the pathogenic factor being strong but the righteous qi not yet weakened, resulting in high heat, even leading to confusion and delirium. The tongue body is bright red, often with increased and protruding red prickles, and the tongue surface is dry and cracked, with yellow or dark black coating, indicating that the warm pathogen has invaded the nutrient level. The main contradiction lies in the excess heat toxin, and even if Yin is damaged, it is not severe, requiring immediate use of large doses of heat-clearing and cooling nutrient herbs. As the febrile disease improves, the scarlet tongue will also fade.
——Yin deficiency type scarlet tongue: Often seen in chronic wasting diseases or the later stages of warm diseases, where the heat has subsided, but the consumption of Yin blood and body fluids is excessive, with a prominent phenomenon of weak righteous qi, which may present with afternoon heat surges, flushed and hot complexion. Internal heat, scanty dark urine, dry mouth, and thirst are also common. At this time, the tongue body is red or scarlet, but the color is darker and less bright, with little or no coating, and the tongue surface is dry and lacking moisture, with the edges and tips of the tongue particularly red, and prickles may also be present. This indicates that the main contradiction lies in Yin deficiency, requiring large doses of Yin-nourishing and fluid-replenishing herbs for treatment. If the tongue body is scarlet and dark in color, with a smooth surface like a mirror, and the tongue body is dry and withered, it indicates extreme depletion of Yang in the stomach and kidneys, with significant damage to body fluids. In this case, not only should the dosage of nourishing Yin herbs be large, but attention should also be paid to the spleen and stomach, and the treatment duration should be longer. The above refers to the tongue body being entirely red and scarlet; if the red and scarlet color appears only in certain areas of the tongue, it also has clinical significance. Based on the distribution of the tongue surface, the tip of the tongue corresponds to the heart, the middle section corresponds to the spleen and stomach, and the sides correspond to the liver and gallbladder. Therefore, when the tongue color is mostly light, with some areas being bright red, distinctions can be made based on the different locations. For example, redness in the middle of the tongue indicates fire in the spleen and stomach, redness at the tip indicates heart fire, and redness on the sides indicates liver and gallbladder fire. Pale white with red is often indicative of excess fire.
Scarlet tongue is commonly seen in cases of infection and fever, as well as some chronic wasting diseases, such as epidemic hemorrhagic fever, Japanese encephalitis, septicemia, cholecystitis, bacterial endocarditis, and during the febrile phase or after heat subsides in heat stroke, as well as in tuberculosis and cancer during the course of long-term low-grade fever. Dry syndrome, dehydration, and postoperative fluid balance disorders can also present with a scarlet tongue. Any condition that elevates the basal metabolic rate, such as hyperthyroidism, hypertension, and diabetes, can also cause the tongue color to become red. In patients with cirrhosis and ascites, excessive use of diuretics can lead to dehydration and decreased serum potassium, resulting in a scarlet and dry tongue. A red and smooth tongue indicates that a patient with cirrhosis is about to enter a state of hepatic coma, requiring early preventive measures.
Blue-purple tongue: There is a distinction between a completely blue-purple tongue and a partially blue-purple tongue. A completely blue-purple tongue refers to a uniformly distributed blue or purple color across the entire tongue, or a blue-purple hue appearing within a scarlet tongue (purple with a blue tint), or a light red tongue mixed with blue (more blue than purple). A partially blue-purple tongue appears on the left or right side of the tongue, or on both sides, with one or two longitudinal blue-purple bands along the sides of the tongue and the central groove; or it may only present as blue-purple spots or patches, while other parts of the tongue do not show blue or purple.
Yangmei tongue: This refers to a red tongue with prickles, resembling yangmei (waxberry). It is commonly seen in patients with scarlet fever or those with high fever lasting several days. A red tongue edge is often seen in hypertension, hyperthyroidism, or during fever. A red tip of the tongue may be due to prolonged work hours, frequent insomnia, and excessive heart fire, leading to excessive consumption and a lack of vitamins or other nutrients. A tongue that remains dark red or purple for a long time should raise suspicion of cancer. A survey conducted by Shanghai Medical University and 33 hospitals and research institutions across the country on 12,448 cancer patients indicated that most cancer patients have a dark red or purple tongue, especially in esophageal cancer and cardia cancer, with an occurrence rate of about 80%, followed by leukemia and lung cancer. Nasopharyngeal cancer has the lowest occurrence rate, at about 20%; late-stage patients are more common than early-stage patients. Rigid tongue: A rigid tongue refers to a tongue that is neither swollen nor shrunk, but is stiff and loses its usual softness and flexibility, also known as “stiff tongue”. Due to the stiffness of the tongue, it cannot move freely, often accompanied by slurred speech or unclear articulation, or discontinuous speech.
“Stiff tongue” is often seen in more severe conditions, such as coma, convulsions, etc. It may appear suddenly after fainting, often accompanied by hemiplegia or facial droop; its appearance during fainting is an emergency warning for stroke. Modern medicine believes that a stiff tongue often indicates a malfunction of the central nervous system, and this tongue sign is commonly seen in patients with epidemic type B encephalitis, high fever coma, hepatic coma, cerebrovascular accidents, concussions, and cerebral contusions. In a few cases, local factors such as severe tongue ulcers or thick coatings on the tongue can also cause stiffness, but this can usually be distinguished from stiffness caused by central nervous system lesions.
Flaccid tongue: A normal tongue is soft, but if the tongue is flaccid and weak, unable to extend or retract, it is referred to as a flaccid tongue. Flaccidity in any part of the body has various causes, but the main reason is the loss of nourishment to the muscles and tendons. A flaccid tongue with a pale white color is often due to deficiency of Qi and blood in the heart and spleen, insufficient to nourish the tongue’s muscles and tendons; a flaccid tongue with a red scarlet color indicates extreme heat damaging body fluids, or excessive Yang fire, leading to deficiency of both Qi and body fluids in the stomach and kidneys, resulting in the loss of nourishment to the tongue’s muscles and tendons. A flaccid tongue with a dry scarlet color and no moisture indicates extreme depletion of Yang, representing a serious condition.
Deviated tongue: When the tongue is extended, the tip deviates to one side, either left or right, referred to as a deviated tongue. The tongue muscles on the affected side are paralyzed and unable to contract, causing the tongue to deviate when extended. This condition is commonly seen in strokes, i.e., cerebrovascular accidents. In cases of localized disease, it may be caused by compression or damage to the hypoglossal nerve or facial nerve. Any unexplained deviation of the tongue should raise suspicion and warrant investigation for intracranial lesions.
Trembling tongue: When the tongue is extended, it exhibits involuntary trembling, caused by excessive liver Yang, heat stirring wind, or Qi deficiency. Due to excessive liver Yang and heat stirring wind, it often presents with a red scarlet tongue; in cases of Qi deficiency, it often presents with a pale white tongue. Trembling of the tongue can be seen in high fever, hyperthyroidism, hypertension, and certain neurological diseases.
Constricted tongue: The tongue body contracts and cannot extend; in some cases, it cannot even reach the teeth. This condition can be seen in congenital short frenulum, where the frenulum pulls and prevents the tongue from extending, requiring surgical correction to restore tongue movement quickly. If the constriction of the tongue is due to disease, it often coexists with a flaccid tongue, where the tongue is not only unable to extend but also loses flexibility in movement. The cause of a constricted tongue is often due to critical diseases that separate Yin and Yang, or extreme heat damaging Yin, or excessive Yang Qi.
Extended tongue: The tongue often extends outside the mouth, with difficulty retracting, or cannot retract at all, leading to continuous drooling, referred to as an extended tongue. An extended tongue with a deep red color, a swollen tongue body, and unclear consciousness, often laughing inappropriately, is caused by phlegm-heat disturbing the heart spirit. An extended tongue that is numb is often due to Qi deficiency. In children with hypothyroidism, the tongue often enlarges, extending between the teeth or hanging outside the mouth.
Manipulating tongue: Repeatedly extending the tongue outside the mouth and licking the lips is referred to as manipulating the tongue. This is often due to heat in the heart and spleen, a precursor to wind disturbance, or developmental delays in children. The difference between extending the tongue and manipulating the tongue is that the former is difficult to retract, while the latter can extend and retract but repeatedly sticks the tongue out.
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