White Coating on the Tongue

In Yangming disease, if there is hardness and fullness under the hypochondrium, constipation, and vomiting, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used (see detailed discussion on Stomach Excess). In Yangming disease, with a floating and tight pulse, dryness in the throat, bitter taste in the mouth, abdominal fullness, panting, fever, sweating, aversion to cold absent but aversion to heat present, and heaviness of the body. If purgation is mistakenly applied, it leads to an empty stomach, agitation of pathogenic factors in the diaphragm, resulting in shortness of breath, irritability, and inner restlessness (Ao Nao); Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used (formula see section on Irritability). Patients with dampness conditions may exhibit sweating only on the head, stiffness in the back, and a desire for covering and warmth near fire. If purgation is applied too early, it results in hiccups, chest fullness, and dysuria, due to heat in the Dantian (lower abdomen) and cold in the chest.

Diagnosis: When both Yin and Yang pulses are tight, with breath exiting the mouth, dry lips and mouth, curling up while lying, cold feet, nasal discharge, and a slippery coating on the tongue, do not treat rashly. After seven days, if the person has slight fever and warm hands and feet, this indicates the disease is resolving. Or, if after eight days there is sudden high fever, this is difficult to treat. If there is aversion to cold, vomiting is likely; if there is abdominal pain, diarrhea is likely. (Haizang stated: For aversion to cold with urge to vomit, use Xiao Chai Hu Tang; for abdominal pain, use Li Zhong Tang.) The Zang Jie (Organ Knot) syndrome presents like Xiong Jie (Chest Knot), with normal appetite but frequent diarrhea, floating pulse at the Cun position, and small, fine, deep, and tight pulse at the Guan position, along with a slippery white coating on the tongue; this is difficult to treat. If there are no Yang symptoms, no alternating chills and fever, and the patient appears quiet, attack methods should not be used. (Discussion see Zang Jie section)

Cheng Wuji's Commentary: The tongue is the organ of the Heart, corresponding to the Fire element of the South, naturally red and lustrous. After three or four days of Shang Han (Cold Damage), a membrane slippery like a coating may appear on the tongue; severely, it may become dry, rough, yellow, or black. These variations are due to the depth of pathogenic Qi. When pathogenic factors are in the Exterior, there is no coating on the tongue; when they transmit to the Interior and fluids condense, a coating forms. When Cold pathogenic factors first transmit and have not fully transformed into Heat, whether in the Half-Exterior/Half-Interior or lodged in the Chest, the tongue shows a white and slippery coating. The Classics state: "A coating like appearance on the tongue" indicates heat in the Dantian and cold in the upper chest, signifying pathogenic factors initially transmitting to the Interior. In Yangming disease, with hardness/fullness under the hypochondrium, constipation, vomiting, and a white tongue coating, Xiao Chai Hu Tang can be used, indicating pathogens in the Half-Exterior/Half-Interior. If Taiyang disease is treated with purgation, leading to an empty stomach, agitation of pathogenic factors in the diaphragm, inner restlessness, and tongue coating, Zhi Zi Chi Tang governs, indicating pathogens lodged in the Chest. If the disease involves the Zang organs and purgation is indicated, but the tongue coating is slippery, attack is contraindicated because the pathogen has not fully transformed into heat and still carries Exterior Cold. When the pathogen transmits and transforms into Heat, the tongue coating becomes rough rather than slippery. The Classics state: "Shang Han for seven or eight days unresolved, heat knotted in the Interior, Exterior and Interior both hot, occasional aversion to wind, great thirst, dry and irritable tongue, desiring to drink several liters of water," governed by Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction). This indicates heat consuming fluids, changing from slippery to dry. If heat gathers in the Stomach (indicates purgation), the tongue turns yellow, indicating deep heat. *Jin Gui Yao Lue* states: "If the tongue is yellow and not yet purged, purging will remove the yellow." If the tongue is black (untreatable), it represents extreme heat. *Zhen Jing* states: "Heat disease with dry mouth and black tongue is fatal." The Heart is the Sovereign Officer, opening into the tongue. Black is the color of the Kidney; appearing in the Heart region (Fire), while the Kidney is Water. Extreme pathological heat of Water overcoming Fire (Ghost Thief interaction) indicates certain death.

Yuanqu's Commentary: After purgation, if cough worsens, add Wu Wei Zi (Schisandra Fruit) and Mai Dong (Ophiopogon Tuber). If the tongue has a slippery coating, it indicates cold in the chest; do not use these cooling/moistening herbs. For slight cold in the chest, add acrid-warm agents for immediate effect. For a tongue that is dry and rough like a lychee pit, apply thick slices of fresh ginger dipped in honey to wipe the tongue; the roughness disappears immediately with miraculous effect.

Anonymous Commentary: Bo He Mi (Mint and Honey) treats white tongue coating that is dry and rough, causing unclear speech. First wipe the tongue with thick slices of fresh ginger dipped in honey water. Then apply equal parts of natural mint juice and white honey to the tongue. Good result.

Tao Hua's Commentary: For Shang Han with any tongue coating (slippery, white, yellow, or black), soak a blue cloth piece in well water, clean the tongue, then frequently dip slices of fresh ginger in water and scrape the tongue to make the coating recede. Any black coating like thorns indicates death, as deep heat toxin overcomes Heart Fire with Kidney Water. For prolapsed tongue, sprinkle a little Bing Pian (Borneol) on the tongue to retract it.

Appendix: Du Qingbi's Verification of Tongue Methods

[White Coated Tongue]
A slippery white coating indicates pathogenic factors just entering the Interior. Heat in the Dantian and cold in the chest constitute a Shaoyang Half-Exterior/Half-Interior syndrome. Treat with Xiao Chai Hu Tang or Zhi Zi Chi Tang.

[Plague Approaching Tongue]
A red tongue indicates heat accumulating internally. Regardless of the meridian, treat with Tou Ding Qing Shen San (Top-Penetrating Spirit-Clearing Powder).
Formula: Zhu Ya Zao Jiao (Gleditsia Sinensis Spine), Xi Xin (Asarum), Bai Zhi (Angelica Dahurica), Dang Gui (Angelica Sinensis) in equal parts. Grind into fine powder. Have the patient hold a mouthful of water, blow a small amount of powder into the nose to induce sneezing, then spit out the water. Repeat until sneezing occurs. Suitable for all members of households affected by plague, sick or healthy.

[Baked Tongue]
A red tongue with black shapes resembling small tongues inside indicates heat knotting in the Interior. Imperial Fire blazing excessively mimics Water transformation. Treat with Liang Ge San (Cool the Diaphragm Powder) or Da Chai Hu Tang (Major Bupleurum Decoction) to purge.

[Spotted Tongue]
A red tongue with small black centers indicates heat toxin entering the Stomach through deficiency, causing macules. Treat with Yuan Shen Sheng Ma Ge Gen Tang (Scrophularia, Cimicifuga, and Pueraria Decoction, i.e., Scrophularia and Cimicifuga Decoction plus Pueraria) or Hua Ban Tang (Macule-Resolving Decoction).

[Red Star Tongue]
A pale red tongue with large red stars indicates excessive heat of Shaoyin Ministerial Fire. The unconquered element borrows fire power to insult Spleen Earth, a precursor to jaundice. Treat with Yin Chen Wu Ling San (Artemisia Capillaris Five-Ingredient Powder).

[Black-Tipped Tongue]
A red tongue with a bluish-black tip indicates Kidney heat due to Water deficiency and Fire excess. Treat with Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction).

[Inner Circle Tongue]
A pale red tongue with a red halo in the center surrounded by pure black indicates residual toxins lingering between the Pericardium and Collaterals,郁结 with pathogenic fire, and extreme亢盛 of Water. Purge with Cheng Qi Tang (Order the Qi Decoction).

[Human-Shaped Crack Tongue]
A red tongue with cracks resembling the character 'Ren' (Human) indicates Imperial Fire scorching and heat toxin flaring upward, causing cracking. Treat with Liang Ge San.

[Insect-Bitten Color Tongue]
A red tongue with red spots resembling insect erosion indicates extreme heat toxin, with Fire above and Water below unable to interact. Treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to purge.

[Inner Black Tongue]
A red tongue with dry, hard black shapes resembling long tongues with thorns indicates extreme heat toxin firmly knotted in the Large Intestine. Metal (Lung)受制 by Fire cannot regulate Water. Urgently purge with Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction).

[Jueyin Tongue]
A red tongue with black streaks indicates Yin toxicity stagnating in the Liver Meridian. The Liver governs sinews, hence the thread-like appearance. Warm with Li Zhong Tang combined with Si Ni Tang (Frigid Extremities Decoction).

[Death Manifestation Tongue]
A black tongue clearly shows Water overcoming Fire. There is virtually no cure; physicians must exercise caution.

Xue Ji's Commentary: While in the capital, the sister-in-law of Zheng Rudong, Director of Public Works, suffered from Shang Han and presented this tongue. Hospital physician Zeng Xi prescribed Fu Zi Li Zhong Tang (Aconite and Magnolia Bark Regulate the Middle Decoction), causing shock among others who stopped the treatment. The condition worsened, and coffins were prepared. Zeng, living nearby, visited and insisted the prescription could save her life. The family, having accepted death, agreed. After several doses, she recovered. Generally, black tongue syndromes include those where extreme Fire resembles Water (as Du described as charcoal burning) and those where Water overcomes Fire (as Zeng treated). For Fire resembling Water, use Liang Ge San to clear Yang heat. For Water overcoming Fire, use Li Zhong Tang to dissipate Yin shadow. Also, rub the tongue with sliced old ginger; if color fades slightly, it is treatable; if firm and unchanged, it is untreatable. In the Xinyou year of Hongzhi, Jiang Menghui from Jintai suffered Shang Han with this tongue, presenting cold extremities and incessant hiccups. Other physicians treated it as heat, nearly causing death. Vice President Wu Renqi cured him with Fu Zi Li Zhong Tang. Medicine requires matching drugs to diseases. Aconite treats cold effectively. Yet society deems it unusable, preferring to let people die. Is this not tragic? For Fire resembling Water, proper medication yields effects; do not dismiss it as incurable.

[Yellow Coated Tongue]
White tip and yellow root indicate Exterior syndrome persists. Resolve Exterior heat before attacking Interior. For constipation, use Liang Ge San plus Mang Xiao (Mirabilite) and Huang Lian (Coptis) taken as a soak. For dysuria, use Wu Ling San plus Mu Tong (Akebia Stem) combined with Yi Yuan San plus a little Ginger Juice, mixed with boiling water.

[Black-Centered Tongue]
White edges and black center with deep, faint pulse are difficult to treat. Floating and slippery pulse allows sweating; deep and solid pulse allows purging. Appearance at onset is extremely critical. Quickly administer Tiao Wei Cheng Qi Tang to purge.

[Fifteen Tongue]
Two parts white coating at tip, one part black at root. Likely body pain and aversion to cold. If mild thirst, Wu Ling San; if spontaneous sweating and thirst, Bai Hu Tang; if diarrhea, Jie Du Tang. This is also a critical syndrome.

[Sixteen Tongue]
White coating with chaotic small black dots indicates remaining Exterior syndrome. Although severe, mildly release Exterior with Liang Ge San. Once Exterior resolves, purge with Tiao Wei Cheng Qi Tang.

[Seventeen Tongue]
Grayish tongue with two black halos in the center indicates heat affecting Kidney and Ming Men (Gate of Life). Purge urgently. Take Jie Du Tang 3-5 times; delay makes it difficult to treat. Increase dosage of Da Huang (Rhubarb) soaked in yellow wine for initial doses.

[Eighteen Tongue]
Slight yellow color acquired at onset with delirium indicates loss of sweating allowed Exterior pathogen to enter Interior. Use simultaneous sweating and purging. Shuang Jie San (Double Resolution Powder) plus Jie Du Tang in equal parts.
Formula: Fang Feng (Saposhnikovia), Chuan Xiong (Ligusticum), Dang Gui (Angelica), Shao Yao (Peony), Da Huang (Rhubarb), Ma Huang (Ephedra), Lian Qiao (Forsythia), Mang Xiao (Mirabilite), Jing Jie (Schizonepeta), Bai Zhu (Atractylodes), Zhi Zi (Gardenia) each 0.5 liang; Shi Gao (Gypsum), Huang Qin (Scutellaria), Jie Geng (Platycodon) each 1 liang; Gan Cao (Licorice) 2 liang; Hua Shi (Talc) 3 liang. Take 1 liang per dose, boil in 1.5 zhong of water with 3 slices of ginger until 0.8 zhong remains. Take anytime. Some versions add Gui Zhi (Cinnamon Twig) 2 liang.

[Nineteen Tongue]
White coating in center with slight yellow outside indicates likely diarrhea. Take Jie Du Tang. For aversion to cold, take Wu Ling San.

[Twenty Tongue]
Slight yellow color with unresolved Exterior syndrome. Use Xiao Chai Hu Tang combined with Tian Shui San (Heavenly Water Powder). If purgation is suitable, use Da Chai Hu Tang to resolve both Exterior and Interior. Apply clinically with discretion.

[Twenty-One Tongue]
Yellow coating always changes from white. Indicates transmission from Exterior to Interior, heat entering Stomach. Purge urgently. Delayed purging turns it black, becoming a malignant syndrome of extreme harm and Ghost Thief pathology, which is untreatable. Use Tiao Wei Cheng Qi Tang.

[Twenty-Two Tongue]
Left side white coating with spontaneous sweating: Do not purge. Take Bai Hu Jia Ren Shen Tang (3 qian).

[Twenty-Three Tongue]
Right side white slippery coating indicates disease in Muscles, pathogens in Half-Exterior/Half-Interior. Alternating chills and fever expected. Harmonize with Xiao Chai Hu Tang.

[Twenty-Four Tongue]
Left side white slippery coating indicates Zang Jie syndrome, pathogens merging into Zang organs. Difficult to treat.

[Twenty-Five Tongue]
White perimeter with yellow center indicates likely irritability, thirst, and vomiting. With Exterior signs, combine Wu Ling San and Yi Yuan San. Wait until yellow disappears before purging.

[Twenty-Six Tongue]
Yellow coating with small black dots indicates pathogens pervading Six Fu organs, about to enter Five Zang organs. Urgently purge with Tiao Wei Cheng Qi Tang, then follow with He Jie San. Four or five out of ten may survive.

[Twenty-Seven Tongue]
Yellow with white tip indicates less Exterior, more Interior. Take one dose Tian Shui San and two doses Liang Ge San together. If pulse is wiry, use Fang Feng Tong Sheng San.

[Twenty-Eight Tongue]
Yellow, rough coating with septa indicates heat entered Stomach, toxin deep. Heart Fire irritability and thirst: urgently purge with Da Cheng Qi Tang (Major Order the Qi Decoction). For jaundice, use Yin Chen Tang; for blood bleeding, use Di Dang Tang (Leech Decoction); for fluid in hypochondrium, use Shi Zao Tang (Ten Jujube Decoction); for severe chest knot, use Da Xian Xiong Tang (Major Draining Chest Decoction); for Pi (fullness), use Da Huang Xie Xin Tang (Rhubarb Draining Heart Decoction).

[Twenty-Nine Tongue]
Slightly red edges with gray-black center caused by missed purgation. Purge with Da Cheng Qi Tang. Heat subsides and recovery follows, usually requiring 3-4 purges. If not resolved after 5 purges, it is untreatable.

[Thirty Tongue]
Yellow with chaotic black dots indicates thirst and delirium. Solid pulse indicates survival; coarse pulse indicates death. Grasping bed sheets and clothes is untreatable. Passing black stool after purging is also untreatable. Purge with Da Cheng Qi Tang.

[Thirty-One Tongue]
Yellow with black extending to tip indicates deep heat. In concurrent contraction (Liang Gan), nine out of ten die. Severe aversion to cold also fatal. Non-aversion to cold with diarrhea is treatable; use Tiao Wei Cheng Qi Tang.

[Thirty-Two Tongue]
Pale red exterior with pale black center. If aversion to wind and Exterior unresolved, use half Shuang Jie San plus half Jie Du Tang for slight sweating. After sweating, purge urgently. Chest knot with irritability and fixed gaze is untreatable. Non-chest knot cases are treatable.

[Thirty-Three Tongue]
Gray tongue, yellow tip, no aversion to wind/cold, floating pulse: can purge. If aversion to wind/cold, use Shuang Jie San plus Jie Du Tang. After 3-4 purges, black stool indicates untreatable.

[Thirty-Four Tongue]
Gray-black with black streaks. Solid pulse: urgently purge with Da Cheng Qi Tang. Floating pulse with thirst: resolve with Liang Ge San. Two or three out of ten may survive.

[Thirty-Five Tongue]
Slightly black root, yellow tip, slippery pulse: can purge. Floating pulse: nourish Yin, retreat Yang. If aversion to wind/cold, slight sweat with Shuang Jie San. If diarrhea, use Jie Du Tang; seven or eight out of ten may survive.

[Thirty-Six Tongue]
Slightly black root, yellow tip, faint or single streak. Solid pulse: urgently purge with Da Cheng Qi Tang. Floating pulse with thirst: resolve with Liang Ge San. One or two out of ten may survive.

The above thirty-six tongue diagnoses are swift verification methods for Shang Han. Apply them carefully in clinical practice for near-perfect accuracy.