bubble_chart Concept

The tongue extends out of the mouth and is difficult or unable to retract, with continuous drooling, known as protracted tongue.

Protracted tongue was first mentioned in Lingshu. Hanrebing: "Protracted tongue with drooling and distress, treat the Shaoyin meridian of the foot." Later generations have referred to it as "tongue protruding out of the mouth," "tongue extension," and "sticking out the tongue."

Protracted tongue should be distinguished from "waggling tongue," where the tongue intermittently protrudes out of the mouth and quickly retracts. For more details, refer to the relevant section.

bubble_chart Pattern Analysis

1. Exuberance of Heart Fire︰The tongue is elongated, with a deep red, firm, and dry tongue texture, difficulty or inability to retract, flushed face, dysphoria, thirst, dark urine, and a rapid, forceful pulse. If accompanied by phlegm, the tongue protrudes and does not retract, the tongue body is swollen, and there is excessive phlegm, unconsciousness, or erratic laughter, with a yellow, greasy tongue coating and a slippery, rapid pulse. This is often caused by excessive mental exertion, hidden depletion of heart yin, intense heart fire, and heat stagnation in the tongue, preventing the release of qi. Its characteristic is a deep red, firm, and dry tongue texture, frequently protruding with difficulty retracting. Cao Bingzhang described it as "elongated and slow to retract," while Wu Kun believed that "a protruding tongue results from internal heat stagnation seeking to vent qi, and the inability to retract is due to prolonged pathogenic qi residing in the tongue, making it stiff and inflexible." Externally, apply five fen of high-quality borneol to the tongue to open orifices, relax tendons, and vent qi. Internally, take Heart-Draining Decoction to purge fire-heat pathogens. For cases with phlegm, the tongue's qi and blood are further obstructed by phlegm blocking the collaterals, causing stagnation and elongation, preventing retraction, with continuous drooling, a red and swollen tongue body, and phlegm congestion obstructing orifices, leading to excessive phlegm, unconsciousness, or erratic laughter. Treatment should focus on clearing the heart and purging heat, or opening orifices and resolving phlegm. The recommended formulas are Heart-Draining Decoction combined with Two Old Ingredients Decoction, augmented with Arisaema cum Bile, Bamboo Juice, Stiff Silkworm, Lindera, Acorus, and raw Typha.
2. Liver Qi Depression︰The tongue extends and cannot retract, with no obvious systemic symptoms, or symptoms such as chest and hypochondriac distension, emotional depression, frequent sighing, poor appetite, etc., and a wiry pulse. It is often caused by anger or depression, leading to impaired liver dispersion and stagnation of qi rushing upward, resulting in an unretractable tongue. The key points for pattern identification are: a clear history of emotional stimulation, a dark tongue texture, and accompanying symptoms of liver qi depression such as chest and hypochondriac distension and emotional depression, making it easier to identify. Treatment should focus on soothing the liver and relieving depression, using the formula Peripatetic Powder. For prolonged cases with signs of heat, Skullcap Root and Gardenia can be added.
3. Qi Deficiency︰The tongue is elongated and numb, the tongue texture is pale, tender, flaccid, and weak in retraction, accompanied by general fatigue, lack of strength, shortage of qi, reluctance to speak, spontaneous sweating, a thin white tongue coating, and a weak pulse. This syndrome is caused by qi deficiency leading to malnourishment, slackening of the tendons and vessels, and flaccidity and weakness of the tongue. Hence, the tongue is elongated, the tongue texture is pale and tender, and is accompanied by systemic manifestations of qi deficiency such as spontaneous sweating and shortage of qi. The treatment should focus on tonifying the middle and replenishing qi, and the prescription selected is Middle-Tonifying Qi-Replenishing Decoction.

The diagnosis of a protracted tongue should be differentiated based on the shape and color of the tongue body as well as systemic symptoms. In terms of the shape and color of the tongue body, apart from the common feature of an elongated tongue that does not retract, those with exuberance of heart fire exhibit a red or deep red, dry, and firm tongue texture; those with qi deficiency present a pale, tender, and flaccid tongue texture; and those with liver qi depression show no significant changes in the color of the tongue form. Regarding systemic symptoms, individuals with exuberance of heart fire are accompanied by manifestations of heat disturbing the heart spirit; those with liver qi depression exhibit signs of impaired dispersion and discharge; and those with qi deficiency display evidence of qi deficiency. Clinically, protracted tongue is more commonly seen in excess pattern and less frequently in deficiency pattern.

bubble_chart Documentation

1. Shoushi Baoyuan．Mouth and Tongue: "The tongue protrudes and cannot be retracted, named priapism."
2. Zhengzhi Huibu．Chapter on Lips and Mouth: "(Tongue) qi deficiency causes numbness and looseness."
3. 《Bian She Zhi Nan．Guan She Zong Gang》: "If fever causes lockjaw, and the tongue protrudes several inches before death, this is a relapse due to sexual intemperance, and extreme deficiency of yang qi. Yin-yang transmission causing the tongue to protrude several inches is a sign of death. The tongue protruding several inches can also be due to postpartum conditions or severe poisoning and shock, treat according to the symptoms, and survival is still possible. In children, if the tongue protrudes and cannot be retracted, it is due to the dispersion of heart qi, and is incurable." "If the tongue protrudes and cannot be retracted, and speech is impossible, it is a sign of heart failure."