by Chen Zelin

Zhangshan Hospital, Shanghai Medical University, Shanghai

reprinted from the Chinese Journal of Integrated Traditional and Western Medicine

Vol. 8, #2, 1988

Editors note:

Improvement in research on tongue diagnosis is being achieved in our country through full utilization of the new methods and instruments of modern science and technology. This is necessary to avoid the subjective errors of naked eye examination. Standard chromatogram and colorimeters have been employed as objective criteria in tongue color differentiation. Scientists have tried to measure different tongue colors by the reflective energy of a tricolor spectrum - red, green and blue. Recently an instrument called a tongue color detector has been manufactured, using which, a comparatively better results have been achieved in differentiating tongue colors with a coincidence rate of 94% in 300 patients.

Recently, by means of microcirculatory microscope, the microcirculation of fungiform papillae has been observed. It clearly showed the structural changes in blood vessels, perivascular exudate and hemorrhage in the papillae. Observation of tongues which were normal pink, pale, crimson and bluish purple in color showed that microvessel structure and microcirculatory blood flow were important factors that affects the color of tongue. Hence tongue microcirculatory examination facilitated the explanation of the mechanism of some pathological tongue features common in TCM.

Contrast observations of the nail fold and tongue tip in patients with coronary heart disease, tumor, chronic hepatopathy and hemorrhagic shock disclosed similar changes in both, which could reflect the degree of illness. Tongue microcirculatory changes tended to be clearer than that of nail fold, and they were more closely related with the color changes of tongue.

Increase or decrease in the swelling or atrophy of tongue fungiform papillae are related to the TCM ideas of deficiency, excess, and cold and heat syndrome. Recognition of their significance would benefit differential diagnosis and aid in prescribing medicine.

The instrument is composed of 3 units: a thermal electric probe to determine temperature, a constant power supply, and a direct current digital voltameter. Lingual superficial blood flow could be measured according to correspondent relationship between the probe temperature-potential and blood flow.

Transmission electronmicroscopes and scanning electron microscopes have been used since 1980 in research on the lingual ultra structural changes. It has been discovered that the formation of tongue coating was closely related with the multiplication speed as well as the quantity of desmosome and membrane-coating granules. All kinds of pathologic tongue features had their own ultrastructural changes, this paved another pathway for research in the pathogenesis of tongue features.

This method has practical value for observation of the rate of epithelial renewal as well as epithelial cell degeneration and necrosis in the following: denuded tongue coating, thick coating, mirror-like tongue, and creamy coating. The method is simple and facilitates observation of the dynamic changes of the tongue coating.

The various pathologic tongue propers have different hemorrheologic peculiarities which are reflected in the plasma viscosity, whole blood viscosity, RBC hematocrit, fibrinogen, erythrocytic electrophoresis time, ESR, etc. Increase in platelet aggregation is related to bluish purple tongue formation, which is a criterion of the TCM idea of blood stasis syndrome.

Reports in this field are relatively few because it is extremely difficult to reproduce animal models of different pathologic tongue features. In Tianjin, an experiment utilizing dogs to perform trachea intubation after anesthesia with artificial respirator to maintain breathing, the relationship between anoxia, retention of CO2, acidosis, vaso-constriction and dilation, and venous congestion with tongue proper changes were observed. This method was simple. The lingual surface structures of rats, dogs, guinea-pigs, rabbits, pigs, cats and monkeys was studied with a scanning electronmicroscope. It was found that the pig's tongue was more suitable for reproducing the model of different tongue features, because its papillae of tongue more closely resembled that of human beings.

In patients with a thin tongue coating, the amount of trace elements Zn, Cu, and Fe in the saliva were higher than that of patients with a thick coating. This suggested that the decrease of these three elements might induce the tongue coating to become thickened or creamy. The salivary Ca amount of patients with thick of creamy tongue coatings was higher than that of those with thin coatings.

In 1980 the tongue features of 5403 healthy subjects were surveyed. The pink tongue accounted for 92%, while the abnormal bluish purple and red tongues accounted for the rest. The normal thin white tongue coatings accounted for 76% , while the rest were yellow, creamy, denuded etc. 94% of sublingual veins were normal. Analysis of tongue features in different normal age groups disclosed that the ratio of pink tongues, tongues with thin white coating and normal tongues proper decreased with age. The ratio of bluish purple tongues and abnormal sublingual veins increased age. Among men and women of the same age, the tongue changes were not the same. In females, denuded tongue coating and pale tongue incidence were higher than in males; the incidence of yellow and creamy coating, and red tongues was higher in males than in females. This data was of significant both in understanding the distribution of various features of healthy subjects tongues, as well as for the proper mastery of traditional tongue diagnosis.

The incidence of bluish purple tongue and abnormal microcirculation in these patients was higher than that of normal persons and was positively proportional to the incidence of blood stasis syndrome and the serious of the hypertension. In hypertensive patients both the vascular changes on the lingual edge and changes in the fundus oculi coult reflect the degree of arteriosclerosis. Besides, the ratio of plasma cAMP/cGMP of hypertensives with pale tongues was apparently lower than that of patients with red tongues.

The tongue in this disease was mostly bluish purple. With ecchymoses the abnormal tongues formed 38% of the total. Next came pale swollen tongue which accounted for 27.5%. The white coating prevailed, forming 66.5% of the total. Syndrome differentiation in TCM indicated that the disease mainly was "Qi deficiency and blood stasis associated with phlegm and Dampness." Applying TCM comprehensive therapy to reinforce the Qi and activate the blood combined with Western medication would elevate the effectiveness. The tongues of patients with petechiae and ecchymosis during early myocardial infarction only accounted for 33% of the tota, but in recurrent patients this number reached 50%. In cases complicated with cardio aneurysm it reached 62.5% . If the tongue color of patients remained normal, their general condition remained stable in 83.5% of cases surveyed. On the contrary, the patients condition usually was unstable if there was a tremendous change of tongue color or pulmonale

.

In the majority of patients with ischemic cerebrovasculor disease the tongue coating is creamy, while the tongue proper is bluish purple. In patients with thin white coating, the bluish purple tongue is rarely exposed. The yellow creamy coating usually accompanies a rise in platelet aggregation. Good effective rates are achieved in cases with a thin white coating and non-bluish purple tongue, 96.6% and 93. l% respectively. In those with yellow creamy coating the effective rate was low, and for those with bluish purple tongues they were even worse. If the tongue coating turned white, it indicated improvement, while the tongue color turning bluish purple with yellow creamy coating shows an aggravation.

Generally a thick and/or yellow coating prevails in gastric disease. Some authors divided the diseases of upper Gl tract into several grades to show the level of gastropathy. i.e. normal superficial gastritis leads to gastric ulcer, which leads to atrophic gastritis which leads to gastric cancer. The corresponding changes in the tongue are from thin to thick coating, from white to yellow and then black coating, from pink to bluish purple, and then finally to denuded and fissured tongue.

The tongue in superficial gastritis usually is red, the coating being thin yellow and creamy. In gastric ulcer the majority of tongue proper are crimson with brown spots, usually with yellow coating, especially a thick creamy yellow one. The tongue feature of duodenal ulcer are mostly devoid of coating. In atrophic gastritis the tongue color is frequently dark, and the tongue coatings are thin or thick creamy color. The incidence of completely denuded coating and fissured tongue were 37. 5% •and 50% respectively. While in gastric cancer most tongues are bluish purple with ecchymocis and petechie on the lingual edge. The incidence of denuded tongue coating and fissured tongue are 49.3% and 62.6% respectively, higher than in other gastric diseases.

In acute enteric hepatitis the tongues are swollen and white creamy coating in most cased. In cases with a thick white creamy coating the GPT elevation is very obvious. Sustained thick white coating denotes a gradual fall in GPT. This tongue configuration is associated with low immune function, and is often swollen with dental indentations. In acute hepatitis the tongue coatings are most commonly yellow thick and creamy, with congestion of the lingual tip and edges and enlarged fungiform Papillae. The GPT rises, while IgG decreases at the same time, so a yellow thick and creamy coating is considered to be an indication of the aggressiveness of the hepatitis.

The changes of tongue in chronic hepatitis and liver cirrosis mainly exist in the tongue proper. They are the dark purple tongue and the purple petechiae and ecchymosis at the lingual edge and tip. The sublingual veins of patients with chronic hepatitis are often varicose or have bleeding petechia.

In cystitis and cholelithiasis, a thin white tongue coating is most commonly seen. In acute cholecystitis without complications the lingual tip is red with thin white or thin tongue coating. In acute purulent cholecystitis the tongue is red with yellow creamy or thick yellow coating In gallbladder performation the tongue is red or cardinal red with yellow ,dry, or prickly coating.

The tongue varies with the location and severity of tumor. but the bluish purple tongue color prevails. The sublingual varicosis are significant in differentiating tumor and non-tumor patients. In 1046 cases of tumor, the bluish purple tongue occurred in 49.5% (3.9 times higher than in normal persons). Sublingual varicose were seen in 49.7%, almost identical to the proportion of bluish purple tongue. In middle and late stages, the denuded tongue coating incidence is higher than that in normals. The incidence of pale swollen tongue (mostly in leukemia) and fissured tongue are 30.2% and 25.4% respectively. Both are higher than that in healthy subjects.

The rate of bluish purple tongue and sublingual varicosity in pulmonary carcinoma patients is 60% higher than that of other cancers, and the fissured tongue is also commoner, ^which indicates the patients have internal "deposits of turbid phlegm and impairment of Yin (TCM).

Besides the bluish purple tongue with petechia, the denuded coating and fissured tongue are commonly seen in gastric cancer, which forms 49 .3% and 52.6% of the total respectively. Cytological examination of the tongue coating shows that among the epithelial cells of the tongue coating in gastric carcinoma, there are scattered large round degenerated eppithelial cells, in which the cytoplasm proper appears greyish blue or light grey. Some of those cells resemble water stain and are called "lightly stained loose giant cells." These cells are of certain diagnositic significance.

The inncidence of eccymosis and petechia in hepatic cancer is very high, being present in 3/4 of the patients, while the bluish purple tongue is seen in 50%.

The rate of the bluish purple tongue in esophageal cancer is 55.2%. Exfolication cytologic study of the esophagus has been carried out in many hospital units on persons with bluish purple tongue. They all confirm that there is a high detectability of esophageal cancer if tongue diagnosis is used. The bluish purple tongue or tongue with purple spots and thick yellow creamy coating symptoms along with a family history of tumor are the criteria for initial screening of esophageal cancer. Nine cases of esophageal cancer and seven of marked cellular hyperplasia were identified in 100 paired observations, while no cancer cases were found in those negative patients. 89.17% with marbled cellular hyperplasia and 88.1% of the esophageal cancer were positive by tongue diagnosis identified by bluish purple tongue or purple spots and thick yellow creamy coatings).

The rate of bluish purple tongue in leukemia patients is 57.6%, and their tongues are mostly light purple. The rate of yellow creamy coating in leukemia is 15% higher than in those with other cancers.

Incidence of tongues with petechiae and ecchymosis nasopharyngeal carcinoma is highest of 11 cancers.

The tongue of healthy new-born infants 48 hours after birth, are pink with a thin white coating. Red tongues without coating form only 2%, and these tongues usually turn pink and have a thin white coating in 48 hours. The rate of red tongue without coating in abnormal new-born infants increases markedly, reaching 11%, among them pale tongue with yellow coating are more often seen than in normal infants.

Observations of the tongues of 1000 healthy children and 1086 ill children discloses that healthy children with normal tongue color form 98.7%, normal tongue propers are found in 99.2% and normal tongue coating in 95%. The rate of abnormal tongue features in sick children is higher. There is a statistically significant differences between healthy children and sick children. Saliva pH of healthy children is mostly neutral, while the rate of abnormal pH is higher in the sick. The temperatures of the center of tongue is higher in the sick than that in the healthy, the difference being statistically significant.

We believe that with the development of modern science and technology, research on tongue diagnosis will continue to make rapid progress.