First, analyze the principle of the formation of thick and greasy tongue coating, then interpret the tongue image pictures, and finally, include a commonly used formula of mine, “Hua Zhuo Tang”.
When we see a thick and greasy tongue coating, we often think of spleen deficiency with excessive phlegm-dampness, and then tell the patient, “Let’s resolve the phlegm-dampness for you!”, and then we use Ping Wei San, Er Chen Tang, Si Jun Zi Tang, San Ren Tang, Da Yuan Yin, and various formulas without much thought.
How is the thick and greasy tongue coating actually formed? I think only by understanding the entire process of its formation can we have a clear understanding in our minds, and only then can the treatment be comprehensive without missing anything. It is best to read the following article after reading this one: Technique Section | Deconstructing the Principle of Tongue Coating Formation in Tongue Diagnosis
In the above article, it was mentioned that the formation of tongue coating is due to the essence of earth qi nourishing the tongue, or it can be said that the essence of food and drink, produced by the coordinated action of the five organs, is transported to the tongue to form the tongue coating. We all know that this thick and greasy tongue coating is due to excessive internal phlegm-dampness, and the generation of phlegm-dampness involves the entire process of the production, transportation, and metabolism of the essence of food and drink.
The following is a description of this process:
Food enters the stomach, and through the grinding and operation of the spleen and stomach, the warming of heart fire and kidney yang, and the propulsion of liver qi, it is transformed into the essence of food and drink.
Then, the essence of food and drink, through the ascending clear function of spleen qi, can be transported upward to the lungs, and through the dispersing and descending function of the lungs, it nourishes the whole body via the hundred vessels.
When food enters the body, part of it turns into the essence of food and drink, while another part, through the function of the small intestine to separate the clear from the turbid, turns into waste, i.e., the turbid qi of food and drink. The turbid qi of food is mainly excreted through the intestines as feces, while the turbid qi of water is excreted through the bladder as urine. Of course, some of the turbid qi is also excreted through the dispersing function of the lungs in the form of sweat.
The lungs and large intestine are externally and internally related, and the lungs and bladder are connected through the theory of organ communication. The dispersing and descending function of lung qi directly affects the excretion of food and drink waste.
For the turbid water to be normally excreted through the bladder, it also requires the warming and transforming function of kidney yang.
As for liver qi, it is a type of wood qi, mainly responsible for free flow and dispersion, participating in the entire process of production, transportation, and metabolism. Therefore, the most commonly used method is to soothe the liver and strengthen the spleen.
From the above analysis, it can be concluded that all five organs and six bowels participate in the entire process of the production, transportation, and metabolism of the essence of food and drink.
When food enters the body, if it is not effectively transformed into the essence of food and drink, it will turn into phlegm-dampness. During the transportation process, if it cannot be properly distributed and remains in the body, it also turns into phlegm-dampness, much like stagnant water turning into a smelly ditch. If the waste produced cannot be excreted from the body in time and accumulates inside, it also turns into phlegm-dampness.
As for how phlegm-dampness is produced when the function of each organ is impaired, combine the above description and analyze it yourself. Below is just a simple example.
For instance, the kidneys: if kidney yang is insufficient, the food lacks the firepower to be transformed into the essence of food and drink, and if not absorbed by the body, it turns into phlegm-dampness. The metabolism of turbid water requires the warming and transforming function of kidney yang, so the bladder can normally open and close to excrete it as urine; otherwise, it will accumulate in the body and turn into phlegm-dampness and water retention. Therefore, the production of phlegm-dampness runs through the entire process of generation, transportation, and metabolism, and is closely related to all five organs and six bowels. Don’t just think of strengthening the spleen and resolving dampness when you see phlegm-dampness.
1. Redefining Thick and Greasy Tongue Coating: Not Just Spleen Deficiency with Phlegm-Dampness
1. Limitations of Traditional Understanding
- Textbook Definition: Thick and greasy tongue coating = spleen deficiency with phlegm-dampness, but clinical findings show:
- Tongue coating distribution does not match the stomach meridian path (e.g., more coating on the tip reflects heart fire)
- Uniform coating over the entire tongue does not necessarily indicate strong stomach qi (e.g., pale tongue with white coating in yang deficiency patients)
- Modern Validation: Studies on tongue microecology have found a significant correlation between tongue coating microbiota and gut microbiota (Nature 2023 study).
2. Phlegm-Dampness Generation Mechanism Involving Five Organs
- Generation Chain:
Food → Spleen and Stomach Transformation (Essence of Food and Drink) → Warming by Heart Fire and Kidney Yang → Liver Qi Dispersion → Lung Qi Dispersing and Descending → Triple Burner Regulation → Water Metabolism - Key Targets: Organ Dysfunction Manifestations Tongue Image Features Spleen transformation weakness Thick and greasy coating in the middle Kidney yang deficiency with water retention White and greasy coating at the root Liver qi stagnation with blood stasis Swollen edges with yellow and greasy coating
2. Analysis and Adjustment Schemes for 18 Tongue Image Charts
1. Typical Tongue Image Classification
Let’s take a closer look at the tongue images. Some tongue coatings are not entirely thick and greasy, but they are included. Only a brief analysis of the tongue image and a brief prescription strategy will be provided.
Technique Section | Deconstructing the Ruyi Tongue (Deficiency of Lower Yuan, Sinking of Upper Qi)
This indicates kidney yang deficiency and sinking of upper qi, with a stiff tongue body also indicating stagnation. It requires warming and transforming cold-dampness, lifting the upper qi, and promoting qi circulation and blood flow.
2. Prescription Logic
| Tongue Image Features | Core Pathogenesis | Recommended Formulas |
|---|---|---|
| Swollen edges with yellow and greasy coating | Liver depression turning into fire | Long Dan Xie Gan Tang + Yu Jin 10g |
| Cracks in the middle with thick and greasy coating | Spleen deficiency with phlegm-dampness | Shen Ling Bai Zhu San + Sha Ren 6g |
| White and greasy coating at the root like accumulated powder | Kidney yang deficiency with cold-dampness | Jin Gui Shen Qi Wan + Cao Guo 10g |
| Red and crimson tip with little coating | Excessive heart fire | Dao Chi San + Lian Zi Xin 6g |
3. Key Points of Hua Zhuo Tang Formula
- Hua Zhuo Tang: Chai Hu, Zhi Ke, Hou Po, Xing Ren, Ji Nei Jin, Huo Ma Ren, Gui Zhi, Dang Shen, Fu Ling, Bai Zhu, Cao Guo, Yuan Shen, Yuan Hu, Ban Xia, Chen Pi
- Core Combinations:
Chai Hu + Zhi Ke (Soothe Liver and Resolve Depression) Hou Po + Xing Ren (Descend Lung and Unblock Bowels) Cao Guo + Yuan Shen (Aromatic to Transform Dampness + Nourish Yin) Gui Zhi + Dang Shen (Warm Yang and Tonify Qi) - Mnemonic Rhyme:
“Chai Zhi Hou Xing Ji Ma Gui, Shen Ling Zhu Cao Yuan Xia Chen” - Contraindications:
- Those with yin deficiency and excessive fire should avoid warming and drying herbs (like Cao Guo)
- Those with damp-heat accumulation should reduce the dosage of Dang Shen
This formula is not meant to be used blindly when phlegm-dampness is seen; it is more of a guiding principle. It involves formulas like Si Jun Zi Tang, Ping Wei San, Er Chen Tang, San Ren Tang, and Da Yuan Yin, and the herbs cover many treatment methods.
Chai Hu and Zhi Ke soothe liver depression and resolve left-side stagnation, Hou Po and Xing Ren descend right-side lung and large intestine qi. Ji Nei Jin indicates digestion, Huo Ma Ren indicates bowel movement, Gui Zhi indicates warming yang and resolving the exterior. Dang Shen indicates tonifying qi, Fu Ling indicates promoting urination, Bai Zhu indicates strengthening the spleen, drying dampness, and promoting diuresis, Cao Guo indicates using aromatic herbs to transform dampness, Yuan Shen indicates nourishing yin and clearing heat, Yuan Hu indicates invigorating blood, Ban Xia indicates drying dampness, and Chen Pi indicates promoting qi circulation.
Drying dampness, aromatic transformation of dampness, promoting qi circulation, strengthening the spleen, soothing the liver, promoting diuresis, unblocking bowels, promoting digestion, tonifying qi, invigorating blood, nourishing yin, warming yang and resolving the exterior. These are the common treatment methods for phlegm-dampness. If you forget a certain method, reciting the mnemonic rhyme will help you not miss any. It involves soothing the liver, strengthening the spleen, warming heart and kidney yang, and descending lung qi. Additionally, phlegm-dampness is mainly metabolized through the bowels and urine, and some skin conditions also use sweating methods, covering all three routes of elimination. For example, if you recite the rhyme and reach Cao Guo, it prompts the use of aromatic herbs to transform dampness, and you can choose different dampness-transforming herbs based on the patient’s condition.
For exterior symptoms, use Huo Xiang and Zi Su Ye; for poor digestion, use Sha Ren; for coughing, use Zi Su Ye; for heat, use neutral dampness-transforming herbs like Pei Lan; for cold, use Bai Dou Kou; for a coating like accumulated powder, use Cao Guo; for head congestion, use Shi Chang Pu.
3. Common Misconceptions and Solutions for Modern People
1. Three Major Misconceptions
- Misconception 1: Use Ping Wei San for thick and greasy coating
- Correct Approach: Greasy coating at the root + lower back pain → kidney deficiency with phlegm-dampness, requires Jin Gui Shen Qi Wan + Cang Zhu
- Misconception 2: Only clear heat for yellow and greasy coating
- Correct Approach: Yellow and greasy coating with pale tongue → spleen deficiency with damp-heat, requires Si Jun Zi Tang + Yin Chen
- Misconception 3: Large and swollen tongue = spleen deficiency with dampness
- Correct Approach: Pale and swollen tongue + fear of cold → spleen and kidney yang deficiency, requires Zhen Wu Tang + Bai Zhu
2. Adjustment Period Planning
- Acute Phase (1-2 weeks): San Ren Tang to unblock the triple burner (Xing Ren + Bai Dou Kou + Yi Yi Ren)
- Relief Phase (3-4 weeks): Shen Ling Bai Zhu San to strengthen the spleen
- Consolidation Phase (5-6 weeks): Gui Lu Er Xian Jiao to consolidate the foundation
The treatment methods and herbs mentioned in the article are for reference by TCM practitioners only. Patients should not self-medicate, as they do so at their own risk.
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