Strawberry Tongue In-Depth Analysis: The Tongue Image Code of the Four Stagnations of Qi, Blood, Water, and Fire – With 14 Practical Charts and Conditioning Plans
Note: The treatments and medications mentioned in the text are for reference by TCM practitioners only. Patients should not take them without professional guidance, as they do so at their own risk. Introduction: Deconstructing strawberry tongue, the term “strawberry tongue” here does not refer to the traditional concept but rather views the entire tongue as a strawberry. Any spots on the tongue are referred to as strawberry tongue, and these spots can be caused by fire stagnation, water stagnation, qi stagnation, or blood stasis. Some spots are flat, while others are raised.
I. Redefining Strawberry Tongue: A New Interpretation of Tongue Appearance Centered on the Morphology of Stagnation Spots
1. Breaking Through Traditional Understanding
Classic Definition: Strawberry tongue = red spots on the tongue resembling strawberry seeds (prickly tongue).
Innovation in This Article: Classifying based on the morphology of “stagnation spots” (fire, water, qi, and blood stasis), covering a broader range of pathological states.
Traditionally, strawberry tongue is used to describe the appearance of red, raised papillae on the tongue’s surface, resembling the surface of a strawberry, also known as prickly tongue or red star tongue.
Strawberry seeds on a strawberry are usually black or yellow, so the strawberry tongue described here is not based on color but on shape. The entire tongue is considered the body of the strawberry, and any spots on the tongue, similar to strawberry seeds, are called strawberry tongue.
Commonly visible stagnation spots include fire stagnation spots, water stagnation spots, qi stagnation spots, and blood stasis spots, some of which are flat, while others are depressed.
2. Tracing the Pathogenesis of the Four Stagnation Spots
Fire Stagnation Spots: Liver qi stagnation turning into fire/phlegm-dampness turning into fire → red spots on the tongue surface. Fire stagnation spots are the most common, appearing as red spots on the tongue surface, some flat, some raised. The raised ones are also known as prickly tongue, which is well-known. These fire stagnation spots are often seen in cases of liver qi stagnation turning into fire, phlegm-dampness turning into fire, hyperactive heart fire, yin deficiency with hyperactive fire, and yang deficiency with floating yang. Both deficiency and excess can occur.
Water Stagnation Spots: Internal retention of water-dampness → transparent blisters on the tongue surface (referred to as “pearl tongue” in “Tongue Diagnosis Guide”). Water stagnation spots appear as small blisters on the tongue surface, as small as rice grains, crystal clear. Ancient texts also mention them as pearl tongue. These small blisters on the tongue surface are more commonly seen in children. They often occur after using antibiotics or receiving IV fluids during an external contraction, when sweating is incomplete, or when water-dampness remains internally after an external contraction. In “Tongue Diagnosis Guide” by Cao Bingzhang, it is described: [Tongue Mirror] White blisters on the tongue like pearls indicate the transformation of extreme fire into water, which is more severe than the prickly tongue described by ancient people as purple, red, yellow, or black. It is advisable to use Sweet Dew Detoxification Drink with added gypsum, rhinoceros horn, scutellaria, figwort root, forsythia, plus trichosanthes root, honeysuckle, and gold juice. There are also cases where the tongue shows white coating forming a ring, as seen in winter with cold damage and vomiting, mistakenly treated with White Tiger Decoction, with a sunken pulse, and the tongue coating forming a ring like white leopard spots, treated with Regular Qi Powder with added cassia bark, clove, and baked ginger, cured after several doses.
Qi Stagnation Spots: Liver qi stagnation → flat colored spots (consistent with the base color of the tongue). Qi stagnation spots appear as small flat spots on the tongue surface, often consistent with the base color of the tongue, and relatively larger compared to other stagnation spots.
Blood Stasis Spots: Blood stasis obstructing the collaterals → dark purple stasis spots (sticky and greasy tongue coating). Blood stasis spots appear as dark purple or black spots on the tongue surface, sometimes forming stasis patches, which are well-known and will not be elaborated further.
II. Analysis of 14 Tongue Appearance Charts and Adjustment Plans
1. Classification of Typical Strawberry Tongue
Let’s look at the specific analysis of tongue appearances, focusing only on the content related to stagnation spots, without a comprehensive analysis of tongue appearances.
This tongue appearance is clearly a fire stagnation spot, also a classic, traditional strawberry tongue. Generally, a method of dispersing heat with cool and acrid herbs is used, following the principle of expelling fire stagnation. Here, one can learn from Yin’s tongue diagnosis method, determining the dosage of medication based on the area of red spots in the upper jiao, using herbs from Lonicera and Forsythia Powder. If there are few stagnation spots, mint and forsythia can be used; if more, honeysuckle, forsythia, mint, and arctium fruit can be added; if even more, the entire formula can be used. The approach is quite straightforward. Modified Ascending and Descending Powder can also be used.This tongue shows a pattern of yin deficiency with hyperactive fire, with some tongue coating but not much, and the patient usually experiences heat in the five centers. In such cases, the treatment generally involves nourishing yin and reducing fire. One can choose to use Leading Fire Decoction, Three Talents Marrow Sealing Pill, etc. A formula I commonly use is Black and Figwort Marrow Sealing Pill, composed of black plum, figwort root, and raw oyster shell added to Marrow Sealing Pill. This is my empirical formula. For restraining deficient fire, I usually modify this formula. For severe yin deficiency with hyperactive fire, figwort root is used heavily, and raw rehmannia root is added. Black plum, figwort root, and raw oyster shell can all nourish yin. Ancient texts mention that figwort root can activate kidney water to control floating fire, and Peng Ziyin mentioned that black plum can restrain ministerial fire, while raw oyster shell’s function of subduing yang is well-known. If time permits, this can be discussed in detail later, but not here.This is a tongue appearance of ice-covered tongue, with a foundation of yang deficiency and cold congealing. The patient’s symptoms include sore throat and frequent oral ulcers. This is caused by floating deficient fire due to yang deficiency, and it should not be treated by clearing fire but by subduing and descending floating fire. One can use Yang Subduing Marrow Sealing Pill. I usually use Black and Figwort Marrow Sealing Pill with added prepared aconite, cassia bark, or morinda root for treatment. Chen Shiduo mentioned that morinda root can also lead fire back to its origin. Especially for those with insufficient yin, using aconite and cassia bark to lead fire back to its origin might harm yin due to their acrid and hot nature, so morinda root is used to lead fire back to its origin, warming without being drying. In this tongue appearance, the stagnation spots are no longer red but somewhat dark, indicating a gradual transition from fire stagnation spots to blood stasis spots, and blood-activating herbs should also be used. However, from the symptoms, the pathogenesis of floating fire still exists.This tongue appearance shows water stagnation spots, blister tongue, with many rice grain-sized blisters at the front of the tongue, crystal clear. It is often caused by incomplete sweating during an external contraction or residual water-dampness after an external contraction. Commonly used formulas include Schizonepeta and Ledebouriella Defeating Toxin Powder, Ephedra, Forsythia, and Red Bean Decoction, Three Seed Decoction, Sweet Dew Detoxification Pill, etc., often combined with Minor Bupleurum Decoction. In summary, if there are exterior symptoms, it is treated by promoting sweating; if not, it is treated by promoting urination.This is also a water stagnation spot, water-dampness tongue. This tongue appearance might be less common for some people, so more images are provided. The pathogenesis and treatment are the same as the previous tongue appearance. This type of tongue appearance is more commonly seen in children.This tongue appearance shows qi stagnation spots, with the sides of the tongue slightly swollen and many relatively large spots spread flat on the tongue surface, not raised, and the same color as the base of the tongue. This indicates some degree of qi stagnation, slowly expanding the inside of the tongue. When qi stagnation becomes severe, it can turn into fire and become raised, forming prickly spots. At this point, the main treatment is to soothe the liver qi, using formulas like Frigid Extremities Powder, Bupleurum Liver-Soothing Powder, etc.This tongue appearance has blisters and red spots, with some spots also darkening. This indicates a mixture of water-dampness, depressed heat, and blood stasis, so the treatment should address all three aspects: clearing and draining damp-heat, and activating blood to resolve stasis. Formulas like Three Seed Decoction and Tangkuei and Peony Powder can be combined and modified.This tongue appearance is similar to what Cao Bingzhang described as white blisters on the tongue like pearls, indicating the transformation of extreme fire into water, which is more severe than the prickly tongue described by ancient people as purple, red, yellow, or black. It is advisable to use Sweet Dew Detoxification Drink with added gypsum, rhinoceros horn, scutellaria, figwort root, forsythia, plus trichosanthes root, honeysuckle, and gold juice. It can be seen that this tongue is without coating, and the internal fire has lifted the true yin to form blisters, requiring cooling the blood and nourishing yin.This is a blood stasis tongue. The image of this tongue is not well-taken, as the root of the tongue is not exposed, but the appearance of blood stasis is very clear, so it is shared here. The tongue surface has many blood stasis spots and patches, all purple or gray. The tongue coating is sticky and greasy, indicating the presence of phlegm and stasis. Commonly used blood-activating formulas include Cinnamon Twig and Poria Pill, and for more severe cases, blood-breaking herbs like corydalis, zedoary, and curcuma are used, and in even more severe cases, leeches and earthworms are used.This is also a qi stagnation tongue, with relatively large stagnation spots on the tongue surface, flat, and the same color as the base of the tongue, generally possessing these three characteristics. Of course, this one is starting to protrude a bit. The sides of the tongue are also swollen, indicating obvious liver qi stagnation.This tongue appearance has appeared before in an article about skin diseases. It is also a tongue appearance with both phlegm and stasis. The dark stasis spots are very prominent.This tongue appearance also shows very clear blood stasis spots, and the entire tongue is cold, undoubtedly an ice-covered tongue. It is a tongue appearance of cold, stasis, and phlegm congealing.Overall, this tongue is an ice-covered tongue, with the coating at the root of the tongue originally very thick, but after taking medication, a piece of the coating fell off. Upon closer inspection, there are some small red spots at the root of the tongue. The patient’s urine is also yellow and turbid. In the basic formula for warming yang, phellodendron was added to slightly clear the depressed fire in the lower jiao.The last image shows a tongue with a spoon-shaped base (for analysis of spoon-shaped tongue, refer to the previous article). This tongue appearance shows fire stagnation spots at the tip and sides of the tongue, with the sides of the tongue swollen, indicating liver qi stagnation turning into fire. For liver qi stagnation turning into fire, I usually use moutan bark and gardenia. The upper jiao can still be treated with mint and forsythia to expel fire stagnation.
2. Medication Logic for Typical Strawberry Tongue
Tongue Appearance Features
Core Pathogenesis
Recommended Formulas
Fire stagnation spots + red and purple tongue
Liver qi stagnation turning into fire
Gentiana Liver-Draining Decoction + Moutan and Gardenia Free Wanderer Powder
Water stagnation spots + white and slippery tongue coating
Dampness obstructing the spleen
Three Seed Decoction + Five-Ingredient Powder with Poria
Cinnamon Twig and Poria Pill + Peach Kernel and Safflower Four Substances Decoction
3. Analysis of Classic Formulas
Sweet Dew Detoxification Drink Modified (Heavy damp-heat):Talc + Capillaris + Scutellaria (clearing heat and promoting diuresis) Forsythia + Mint (dispersing heat through the surface) Belamcanda + Fritillaria (resolving phlegm and benefiting the throat)
Black and Figwort Marrow Sealing Pill (Yin deficiency with hyperactive fire): “Black plum restrains ministerial fire, figwort root activates kidney water, raw oyster shell subdues yang” (modified from “Medical Insights into Western and Chinese Medicine”).
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