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White Coating on the Tongue

In Yangming disease, if there is hardness and fullness in the hypochondrium, constipation, and vomiting, Xiaochaihu Tang (Minor Bupleurum Decoction) should be used (see detailed discussion on Fullness in the Stomach). In Yangming disease, if the pulse is floating and tight, the throat is dry, the mouth tastes bitter, there is abdominal fullness and wheezing, fever and sweating without aversion to cold but with aversion to heat, and the body feels heavy; if purgation is mistakenly applied, it will lead to an empty stomach, disturbance of rebellious Qi in the diaphragm, resulting in shortness of breath, irritability, and a feeling of stifling discomfort in the chest. In such cases, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used (formula see section on Irritability). Patients with dampness diseases may only sweat from the head, experience stiffness in the back, and desire to cover themselves and approach fire for warmth. If purgation is applied too early, it will lead to hiccups, chest fullness, and dysuria, because there is heat in the Dantian (lower abdomen) and cold in the chest.

Diagnosis: If the pulses at the cun, guan, and chi positions are all tight, breath comes out of the mouth, lips and mouth are dry, the person curls up and lies down, feet are cold, nasal discharge occurs, and there is a slippery coating on the tongue, do not treat recklessly. Around the seventh day, if the patient has slight fever and warm hands and feet, this indicates that the disease is about to resolve. If after the eighth day there is instead high fever, this is difficult to treat. If accompanied by aversion to cold, vomiting is likely; if there is abdominal pain, diarrhea is likely. (Mr. Haicang stated: For aversion to cold and desire to vomit, use Xiaochaihu Tang; for abdominal pain, use Lizhong Tang.) Zangjie (Organ Binding) presents symptoms similar to Juxiong (Chest Binding), but food intake remains normal, with frequent diarrhea. The cun pulse is floating, the guan pulse is small, fine, deep, and tight, and the tongue has a slippery white coating; this is difficult to treat. If there are no Yang syndrome signs, no alternating chills and fever, and the patient appears unusually quiet, attack methods should not be used. (See discussion on Zangjie).

Cheng Wuji commented: The tongue is the external manifestation of the Heart, corresponding to the Fire element of the South. It should naturally be red and moist. After three or four days of Shanghan (Cold Damage), a membrane slippery like a coating may appear on the tongue; in severe cases, it may become dry, rough, yellow, or black. These variations are due to the depth and severity of the pathogenic factor. When the pathogen is in the exterior, there is no coating on the tongue. When the pathogen transmits to the interior and fluids bind and coagulate, a coating forms on the tongue. When cold pathogens initially transmit and have not fully transformed into heat, or are in the half-exterior/half-interior stage, or when pathogens lodge in the chest, the tongue shows a white and slippery coating. The Classics state: "A tongue resembling a coating" indicates heat in the Dantian and cold in the chest, signifying the initial transmission of the pathogen to the interior. In Yangming disease, with hardness/fullness in the hypochondrium, constipation, vomiting, and a white tongue coating, Xiaochaihu Tang can be given, indicating the pathogen is in the half-exterior/half-interior. If Taiyang disease is mistakenly purged, leading to an empty stomach, disturbance of rebellious Qi in the diaphragm, stifling discomfort, and a coated tongue, Zhizi Chi Tang is the primary treatment, indicating the pathogen is lodged in the chest. If the disease is in the Zang organs and purgation seems appropriate, but the tongue coating is slippery, attack methods must not be used 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: "Shanghan unresolved after seven or eight days, heat bound 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," treated with Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction). This indicates heat consuming body fluids, changing from slippery to dry. If heat gathers in the Stomach (purgation is suitable), the tongue coating turns yellow, indicating deep heat. The *Jin Gui Yao Lue* states: "If the tongue is yellow and purgation has not been used, purgation will remove the yellow." If the tongue is black (untreatable), it represents extreme heat. The *Zhen Jing* (Needle Classic) states: "Heat disease with dry mouth and black tongue leads to death." This is because the Heart is the sovereign organ, opening into the tongue. Black is the color of the Kidney. Seeing black in the Heart region (Fire) implies that Water (Kidney) evil heat is extreme, overcoming Fire (Heart), leading to death.

Yuanqu Shi noted: After purgation, if cough worsens, add Wuweizi (Schisandra Fruit) and Maimendong (Ophiopogon Root); if the tongue has a slippery coating, it indicates cold in the chest, so do not use these yin-nourishing herbs. For slight cold in the chest, add acrid-warm agents for immediate effect. For a dry, rough tongue like a bayberry thorn, apply thick slices of fresh ginger dipped in honey to rub the tongue; the thorns disappear immediately with miraculous effect.

Anonymous author noted: Bohe Mi (Mint and Honey) treats a dry, rough white tongue coating with distorted speech. First, wipe and wash with thick slices of fresh ginger dipped in honey water. Then, mix equal parts of natural mint juice and white honey, and apply to the tongue. Good effect.

Tao Hua noted: For any tongue coating in Shanghan, regardless of being slippery, white, yellow, or black, soak a green cloth piece in well water, clean the tongue, then frequently dip slices of fresh ginger in water and scrape the tongue. The coating will naturally recede. Any black tongue coating like thorns indicates death, as deep heat toxin causes nine deaths out of ten due to Kidney Water overcoming Heart Fire. For a protruding tongue that cannot retract, sprinkle a small amount of Bingpian (Borneol) on the tongue to retract it.

Attached: Du Qingbi's Verification of Tongue Signs

[White Coated Tongue]
A slippery white coating indicates the pathogen has just entered the interior. Heat in the Dantian and cold in the chest constitute a Shaoyang half-exterior/half-interior syndrome. Treat with Xiaochaihu Tang or Zhizi Chi Tang.

[Plague-Approaching Tongue]
A red tongue indicates heat accumulating internally. Regardless of the meridian involved, use Tou Ding Qing Shen San (Top-Penetrating Spirit-Clearing Powder).
Formula for Tou Ding Qing Shen San: Zhu Ya Zao Jiao (Gleditsia Sinensis Fruit), Xi Xin (Asarum), Bai Zhi (Angelica Dahurica), Dang Gui (Angelica Sinensis) in equal parts. Grind into fine powder and mix evenly. Have the patient hold a mouthful of water, blow a small amount of powder into the nose, spit out the water, and induce sneezing. Repeat until sneezing occurs. Suitable for all households affected by plague, whether infected or not.

[Baked-In Tongue]
A red tongue with a black shape like a small tongue inside indicates pathogenic heat bound in the interior. Excessive Ministerial Fire mimicking Water transformation. Treat with Liang Ge San (Cool the Diaphragm Powder) or Da Chaihu Tang (Major Bupleurum Decoction) via purgation.

[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 (Resolve Macules Decoction).

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

[Black-Tipped Tongue]
A red tongue with a cyan-black tip indicates Water deficiency and Fire excess, caused by Kidney heat. 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 collaterals and pathogenic fire stagnation, with extreme Water亢 (hyperactivity). Treat with Chengqi Tang (Chengqi Decoction).

[Human-Shaped Crack Tongue]
A red tongue with cracks shaped like the character 'Ren' (人) indicates scorching Ministerial Fire and ascending heat toxin causing fissures. Treat with Liang Ge San.

[Insect-Bitten Color Tongue]
A red tongue with red spots resembling insect bites indicates extreme heat toxin, with Fire above and Water below failing to interact. Treat with Xiao Chengqi Tang (Minor Chengqi Decoction) via purgation.

[Inner Black Tongue]
A red tongue with dry, hard black areas shaped like a small long tongue with thorns indicates extreme heat toxin firmly binding the Large Intestine. Metal is controlled by Fire and cannot regulate Water. Urgently treat with Tiao Wei Chengqi Tang (Regulate the Stomach Chengqi Decoction) via purgation.

[Jueyin Tongue]
A red tongue with black streaks indicates Yin toxicity reversing in the Liver Meridian. The Liver governs sinews, hence the thread-like appearance. Warm with Lizhong Tang combined with Sini Tang (Reverting Yin Decoction).

[Death-Revealing Tongue]
A black tongue clearly shows Water overcoming Fire. There is no cure for one hundred patients; physicians must exercise caution.

Xue Ji noted: While in the capital, the sister-in-law of Zheng Rudong, Director of Public Works, suffered from Shanghan and presented this tongue sign. Hospital physician Zeng Xi prescribed Fuzi Lizhong Tang, causing shock among colleagues, so it was stopped, and she could not be treated. She became critically ill and was prepared for burial. Living next door, I examined her and advised using the previous prescription as there was still hope. The family, having accepted death, agreed. After several doses, she recovered. Generally, black tongues can result from extreme Fire resembling Water (as Mr. Du described "firewood turning to black charcoal"), requiring cooling agents like Liang Ge San to drain Yang; or from Water overcoming Fire (the case treated by Dr. Zeng), requiring Lizhong Tang to dissipate Yin shadow. Additionally, rub the tongue with sliced old ginger; if the color fades slightly, it is treatable; if firm and unchanging, it is untreatable. In the Xinyou year of Hongzhi, Jiang Menghui from Jintai suffered Shanghan with this tongue, presenting cold limbs and persistent hiccups. Other physicians treated it as Fire, nearly causing death. Vice President Wu Renqi cured him with Fuzi Lizhong Tang. Medicine requires matching the herb to the disease. Aconite treats cold effectively, yet society deems it unusable, preferring to let people die. Is this not tragic? For conditions where extreme Fire resembles Water, proper medication yields results; do not dismiss them as untreatable.

[Yellow Coated Tongue]
A white tip and yellow root indicate the exterior syndrome is not yet resolved. Resolve exterior heat before attacking internally. For constipation, use Liang Ge San plus Mangxiao (Mirabilite) and Huanglian (Coptis) taken as a soak. For dysuria, use Wuling San plus Mutong (Akebia Stem) combined with Yiyuan San plus a little ginger juice, mixed with boiling water.

[Black-Centered Tongue]
A white border with a black center and deep, faint pulse is difficult to treat. A floating, slippery pulse allows sweating; a deep, solid pulse allows purgation. Appearance of this color at onset is extremely critical. Quickly administer Tiao Wei Chengqi Tang for purgation.

[Fifteenth Tongue]
Two parts white coating at the tip, one part black at the root. Likely body pain and aversion to cold. If drinking is not severely impaired, use Wuling San. For spontaneous sweating and thirst, use Baihu Tang. For diarrhea, use Jiedu Tang. This is also a critical condition.

[Sixteenth Tongue]
A white coating with scattered small black dots indicates remaining exterior syndrome. Although the disease progression is ominous, mildly release the exterior with Liang Ge San. Once the exterior resolves, purge internally with Tiao Wei Chengqi Tang.

[Seventeenth Tongue]
A grayish tongue with two black halos in the middle indicates heat affecting the Kidneys and Mingmen (Gate of Vitality). Purge urgently. Administer Jiedu Tang 3-5 times; delay makes it difficult to treat. Increase dosage with rice wine-soaked Rhubarb if first dose fails.

[Eighteenth Tongue]
A slightly yellow tongue appearing at onset with delirium indicates loss of sweating allowing exterior pathogen to enter the interior. Use simultaneous sweating and purging with Shuangjie San (Double Release Powder) plus Jiedu Tang in equal parts.
Formula for Shuangjie San Plus Jiedu Tang: Fangfeng (Saposhnikovia), Chuanxiong (Ligusticum), Danggui (Angelica), Shaoyao (Peony), Dahuang (Rhubarb), Mahuang (Ephedra), Lianqiao (Forsythia), Mangxiao (Mirabilite), Jingjie (Schizonepeta), Baizhu (Atractylodes), Zhizi (Gardenia) each 0.5 liang; Shigao (Gypsum), Huangqin (Scutellaria), Jiegeng (Platycodon) each 1 liang; Gancao (Licorice) 2 liang; Huashi (Talc) 3 liang. Take 1 liang per dose, decoct with 1.5 cups of water and 3 slices of ginger until 0.8 cup remains. Take anytime. Some versions include Guizhi (Cinnamon Twig) 2 liang.

[Nineteenth Tongue]
White coating in the center with slight yellow outside indicates impending diarrhea. Take Jiedu Tang. For aversion to cold, take Wuling San.

[Twentieth Tongue]
Slightly yellow tongue indicates unresolved exterior syndrome. Treat with Xiaochaihu Tang combined with Tianshui San (Heavenly Water Powder). If purgation is indicated, use Da Chaihu Tang. Resolve both exterior and interior; judge clinically.

[Twenty-first Tongue]
Yellow tongue always changes from initial white. Exterior transmitting to interior, heat entering the Stomach. Purge urgently. Delayed purgation leads to black tongue, a malignant sign of extreme harm and overcoming elements, indicating deep pathogen, untreatable. Use Tiao Wei Chengqi Tang.

[Twenty-second Tongue]
Left side white tongue coating with spontaneous sweating contraindicates purgation. Take 3 qian of Baihu Jia Renshen Tang.

[Twenty-third Tongue]
Right side white slippery tongue coating indicates disease in muscles, pathogen in half-exterior/half-interior, with alternating chills and fever. Harmonize with Xiaochaihu Tang.

[Twenty-fourth Tongue]
Left side white slippery tongue coating indicates Zangjie (Organ Binding), pathogen merging into Zang organs, difficult to treat.

[Twenty-fifth Tongue]
White perimeter with yellow center indicates impending irritability, thirst, and vomiting. With exterior signs, combine Wuling San and Yiyuan San. Wait until yellow disappears before purging.

[Twenty-sixth Tongue]
Yellow tongue with small black dots indicates pathogen spreading through Six Fu organs, entering Zang organs. Urgently purge with Tiao Wei Chengqi Tang. Follow with Hejie San (Harmonizing Powder); save 4-5 out of 10.

[Twenty-seventh Tongue]
Yellow tongue with white tip indicates less exterior, more interior. Take one dose of Tianshui San and two doses of Liang Ge San together. If pulse is wiry, use Fangfeng Tongsheng San.

[Twenty-eighth Tongue]
Yellow, rough tongue with partitions indicates heat in Stomach and deep pathogen. Heart Fire with irritability/thirst: urgently purge with Dachengqi Tang. For jaundice, use Yinchen Tang. For blood in stool, use Didang Tang. For fluid in hypochondrium, use Shizao Tang. For severe Juxiong, use Daxiexiong Tang. For Pi (fullness), use Dahuang Xiexin Tang.

[Twenty-ninth Tongue]
Slightly red edges with gray-black center result from missed purgation. Purge with Dachengqi Tang. Heat subsides and recovery follows. Must purge 3-4 times to subside; if not subsided after five purges, it is untreatable.

[Thirtieth Tongue]
Yellow tongue with scattered black dots indicates thirst and delirium. Solid pulse indicates survival; coarse pulse indicates death. Grasping clothes and bed indicates untreatable. Black stool after purgation also indicates untreatable. Purge with Dachengqi Tang.

[Thirty-first Tongue]
Yellow center with black extending to tip indicates deep heat. In concurrent contraction, 9 out of 10 die. Severe aversion to cold also leads to death. Non-aversion to cold with diarrhea is treatable; use Tiao Wei Chengqi Tang.

[Thirty-second Tongue]
Pale red exterior with pale black center. If aversion to wind and exterior unresolved, use half Shuangjie San plus half Jiedu Tang for mild sweating. After sweating, purge urgently. Juxiong with irritability and fixed gaze is untreatable. Non-Juxiong is treatable.

[Thirty-third Tongue]
Gray tongue with yellow tip, no aversion to wind/cold, floating pulse allows purgation. If aversion to wind/cold, use Shuangjie San plus Jiedu Tang. After 3-4 purges, black stool indicates untreatable.

[Thirty-fourth Tongue]
Gray-black tongue with black streaks. Solid pulse: urgently purge with Dachengqi Tang. Floating pulse with thirst: resolve with Liang Ge San. Save 2-3 out of 10.

[Thirty-fifth Tongue]
Slightly black root, yellow tip, slippery pulse allows purgation. Floating pulse: nourish Yin, retreat Yang. If aversion to wind/cold, mildly sweat with Shuangjie San. If diarrhea, use Jiedu Tang; save 7-8 out of 10.

[Thirty-sixth Tongue]
Slightly black root, yellow tip, hidden or single streak. Solid pulse: urgently purge with Dachengqi Tang. Floating pulse with thirst: resolve with Liang Ge San. Save 1-2 out of 10.

The above thirty-six tongue signs are quick verification methods for Shanghan. Apply them carefully in clinical practice for near-perfect accuracy.