Research status and prospect of tongue image diagnosis analysis based on machine learning / 数字中医药（英文）

@#Image-based intelligent diagnosis represents a trending research direction in the field of tongue diagnosis in traditional Chinese medicine (TCM). In recent years, machine learning techniques, including convolutional neural networks (CNNs) and Transformers, have been widely used in the analysis of medical images, such as computed tomography (CT) and nuclear magnetic resonance imaging (MRI). These techniques have significantly enhanced the efficiency and accuracy of decision-making in TCM practices. Advanced artificial intelligence (AI) technologies have also provided new opportunities for the research and development of medical equipment and TCM tongue diagnosis, resulting in improved standardization and intelligence of the tongue diagnostic procedures. Although traditional image analysis methods could transform tongue images into scientific and analyzable data, recognizing and analyzing images that capture complicated tongue features such as tooth-marked tongue, tongue spots and prickles, fissured tongue, variations in coating thickness, tongue texture (curdy and greasy), and tongue presence (peeled coating) continues posing significant challenges in contemporary tongue diagnosis research. Therefore, the employment of machine learning techniques in the analysis of tongue shape and texture features as well as their applications in TCM diagnosis is the focus of this study. In the study, both traditional and deep learning image analysis techniques were summarized and analyzed to figure out their value in predicting disease risks by observing the tongue shapes and textures, aiming to open a new chapter for the development and application of AI in TCM tongue diagnosis research. In short, the combination of TCM tongue diagnosis and AI technologies, will not only enhance the scientific basis of tongue diagnosis but also improve its clinical applicability, thereby advancing the modernization of TCM diagnostic and therapeutic practices.

Research on Objective Characteristics of Tongue Manifestation in 315 Patients with Coronary Heart Disease / 中医杂志

ObjectiveTo investigate the objective characteristics of tongue manifestations in patients with coronary heart disease （CHD）. MethodsA total of 315 participants with CHD were recruited in the CHD group， and 211 healthy participants who underwent physical examination were recruited as the healthy control group. In addition， according to the common comorbidities （primary hypertension， carotid atherosclerosis， type 2 diabetes mellitus， fatty liver， hyperlipidaemia， heart failure， and cerebral infarction） in 315 participants with CHD， each comorbidity was classified into a group of comorbidities with that disease and a group of non-comorbidities. Tongue images were captured using a TFDA-1 tongue diagnostic instrument to characterise the tongue body （TB） and tongue coating （TC）， comparing the RGB， HIS， and Lab colour spaces in the chromaticity index （R， red； G， green； B， blue； H， hue； I， intensity； S， saturation； L， lightness； a， red-green axis； b， yellow-blue axis）， the tongue coating thickness index （per-All）， contrast （CON）， angular second moment （ASM）， entropy （ENT）， and mean （MEAN） in texture metrics. ResultsCompared with the healthy control group， the characteristic indexes of tongue body in CHD group showed lower TB-R， TB-G， TB-B， TB-I， TB-L and higher TB-H， TB-b； and the characteristic indexes of tongue coating in CHD group showed lower TC-R， TC-B and higher TC-CON， TC-MEAN， TC-H， TC-b （P＜0.05 or P＜0.01）. Compared with non-combined primary hypertension group， CHD combined primary hypertension group showed higher per-All， TB-G， TB-L， and lower TB-a， TC-a （P＜0.05）； compared with the non-combined carotid atherosclerosis group， CHD combined carotid atherosclerosis group showed higher TB-CON， TB-ENT， TB-MEAN， and lower TB-ASM （P＜0.05 or P＜0.01）； compared with the non-combined type 2 diabetes mellitus group， CHD combined type 2 diabetes mellitus group showed lower per-All and higher TB-H （P＜0.05 or P＜0.01）； compared with the non-combined fatty liver group， CHD combined fatty liver group showed higher TB-CON， TB-MEAN， TB-ENT， and lower TB-ASM and TC-S （P＜0.05 or P＜0.01）； compared with the non-combined hyperlipidaemia group， CHD combined hyperlipidaemia group showed lower TB-S and TB-a （P＜0.05）； compared with non-combined heart failure group， CHD combined heart failure group showed lower TB-R， TB-G， TB-I， TB-L， and higher TB-a （P＜0.05 or P＜0.01）； compared with non-combined cerebral infarction group， CHD combined cerebral infarction group showed higher TC-CON， TC-ENT， TC-MEAN， and lower TC-ASM （P＜0.05 or P＜0.01）. ConclusionCompared to healthy individuals， patients with CHD tend to have darker tongue colours and rougher TC textures. Compared with non-comorbidity participants， those with primary hypertension tended to be lighter tongue colour and thicker tongue coating， those with carotid atherosclerosis had paler tongue body， those with type 2 diabetes mellitus had thinner tongue coating， those with fatty liver disease had paler tongue body and whiter tongue colour， those with hyperlipidaemia and heart failure had paler tongue colour， and those with cerebral infarction had rougher tongue texture.

Noninvasive Diagnostic Technique for Nonalcoholic Fatty Liver Disease Based on Features of Tongue Images / 中国结合医学杂志

OBJECTIVE@#To investigate a new noninvasive diagnostic model for nonalcoholic fatty liver disease (NAFLD) based on features of tongue images.@*METHODS@#Healthy controls and volunteers confirmed to have NAFLD by liver ultrasound were recruited from China-Japan Friendship Hospital between September 2018 and May 2019, then the anthropometric indexes and sampled tongue images were measured. The tongue images were labeled by features, based on a brief protocol, without knowing any other clinical data, after a series of corrections and data cleaning. The algorithm was trained on images using labels and several anthropometric indexes for inputs, utilizing machine learning technology. Finally, a logistic regression algorithm and a decision tree model were constructed as 2 diagnostic models for NAFLD.@*RESULTS@#A total of 720 subjects were enrolled in this study, including 432 patients with NAFLD and 288 healthy volunteers. Of them, 482 were randomly allocated into the training set and 238 into the validation set. The diagnostic model based on logistic regression exhibited excellent performance: in validation set, it achieved an accuracy of 86.98%, sensitivity of 91.43%, and specificity of 80.61%; with an area under the curve (AUC) of 0.93 [95% confidence interval (CI) 0.68-0.98]. The decision tree model achieved an accuracy of 81.09%, sensitivity of 91.43%, and specificity of 66.33%; with an AUC of 0.89 (95% CI 0.66-0.92) in validation set.@*CONCLUSIONS@#The features of tongue images were associated with NAFLD. Both the 2 diagnostic models, which would be convenient, noninvasive, lightweight, rapid, and inexpensive technical references for early screening, can accurately distinguish NAFLD and are worth further study.

Research on Tongue Color Classification in Traditional Chinese Medicine with Noisy Labels based on Regional Attention Mechanism / 世界科学技术-中医药现代化

Objective Because there are often noisy labels in tongue color labeled samples,these noise samples will lead to the low performance and poor generalization ability of tongue color classification.Mining and establishing an automatic and accurate tongue color classification model to promote the objectification of tongue diagnosis in Traditional Chinese Medicine(TCM).Methods Based on the characteristics of tongue color classification in TCM,this paper proposes a tongue color classification method with noisy labels based on regional attention mechanism.The novelty of the proposed method includes:on the one hand,according to the tongue diagnosis habit of TCM doctors,a tongue color regional attention mechanism is proposed to enhance the feature extraction capability of the network for the tongue color regions such as tip and both sides of the tongue and suppress irrelevant feature channels of other regions.On the other hand,a symmetric modified cross-entropy loss function is designed to optimize the network training,suppressing the impact of noisy labels on the classification performance.Results The classification results on the three self-established tongue color classification datasets show that the accuracy reaches 94.96%,93.36%and 93.92%respectively,the mAP reaches 94.53%,93.05%and 93.38%respectively,the Macro-F1 reaches 94.67%,93.16%and 92.43%respectively.Conclusion The proposed tongue color classification method can significantly improve the classification accuracy with low model complexity,and improve the classification robustness in the case of noisy labels.

Objective diagnosis of tongue in Kampo Medicine / 全日本鍼灸学会雑誌

Tongue diagnosis in Kampo medicine is considered to be a diagnostic method that can provide information about a patient's constitution and medical condition. We have identified the following problems in tongue diagnosis: the influence of external environmental factors such as light source, room temperature, and dryness, as well as subjective factors that depend on the knowledge and experience of medical doctors. To overcome these problems and to support Kampo diagnosis, we developed the Tongue Image Analyzing System (TIAS). Regarding color, objective numerical values L*a*b* were measured and standardization and objectification were promoted. We introduce some of the progress that has been made over the past 15 years since the development of TIAS.

Literature review and prospect on oral cognition and disease diagnosis and treatment between Han and Tang dynasties / 华西口腔医学杂志

Chinese medicine entered a significant period from foundation to maturity between Han and Tang dynasties when the Chinese traditional stomatology was a key stage. Sorting and analysis of existing literature and research outcomes have showed that current research on stomatology between Han and Tang dynasties focuses on oral physiology, pathology, diagnosis and treatment, and health care. It also involves stomatology history and explanation of termino-logies related to mouth and teeth recorded in medical books, use of simple methods, and thinking with citation and analysis of literature simply listed and reasoning preliminarily deducted. From the macro perspective, current research has not unveiled the whole picture of stomatology between the two dynasties and left a series of key issues unresolved. Thus, new methods should be developed and employed to carry out medical research on stomatology between Han and Tang dynasties given that is has a prosperous future.

Discussion on Technical Evaluation of Tongue Diagnosis Equipment of Traditional Chinese Medicine / 中国医疗器械杂志

This study briefly introduces the tongue diagnostic equipment of traditional Chinese medicine. It analyzes and discusses the key points of technical evaluation of tongue diagnostic equipment from the aspects of product name, performance parameters, image processing functions, product use methods, clinical evaluation, etc. It analyzes the safety risks and effectiveness indicators of tongue diagnostic equipment, hoping to bring some help to the gradual standardization of tongue diagnostic equipment and the registration of enterprises.

Pathological Change of Chronic Hepatitis B Patients with Different Tongue Coatings by Circular Multi-Omics Integrated Analysis / 中国结合医学杂志

OBJECTIVE@#To compare the circular pathological changes of chronic hepatitis B (CHB) patients according to the tongue diagnosis.@*METHODS@#Totally 41 CHB patients with typical white tongue coating (WTC) or yellow tongue coating (YTC) were enrolled and 14 healthy volunteers with normal tongue manifestation served as controls. The mRNA expression of peripheral leukocytes was detected by GeneChips, and 9 genes were randomly selected for expression validation. Circular metabolites were detected by gas chromatographymass spectrometry. Biological information was analyzed based on ingenuity pathways analysis or metabolomics database and the integrated networks were constructed by ClueGO.@*RESULTS@#A total of 945 and 716 differentially expressed genes were found in patients with WTC and YTC relative to healthy volunteers respectively. The biological information analysis indicated that CHB patients had obviously increased functions in cell death, apoptosis and necrosis (Z-score ⩾2, P<0.05) and decreased activation in T lymphocytes (Z-score ⩽-2, P<0.05), regardless of the tongue manifestation. Compared to patients with WTC, the YTC patients were predicted to be more active in functions related to virus replication (Z-score ⩾2, P<0.05), and the content of circular fatty acids, such as oleic acid (P=0.098) and lauric acid (P=0.035), and citric acid cycle-related metabolites were higher in the YTC patients (P<0.1). The integrated analysis based on differential genes and metabolites indicated that the most difference in the biological function network between the WTC and YTC patients was tumor necrosis factor receptor associated factor 6 mediated-nuclear factor kappa-B activation process.@*CONCLUSIONS@#CHB patients with YTC had more severe inflammation and fatty acids metabolism aberrant than patients with WTC. The results facilitate the modern pathological annotation of Chinese medicine tongue diagnosis theory and provide a reference for the interpretation of pharmacological mechanisms of Chinese medicine treatment.

Research progress of the modernization of TCM tongue diagnosis / 国际中医中药杂志

Tongue diagnosis is one of the diagnostic methods of Traditional Chinese Medicine (TCM), but its development has always been restricted by the lack of objective quantitative indicators. With the rapid development of computer technology and the advent of the algorithm era, the modernization of TCM tongue diagnosis has gradually become a hot research spot. This paper annalyses the literature and related patents of the modernization of tongue diagnosis and summarizes the R&D progress and application of tongue diagnosis as well as related instruments. It is found that domestic and foreign scholars focus on tongue diagnosis related research and attach importance to the formulation of relevant international standards. Tongue collection and analysis technology continues to develop; tongue diagnostic instruments are also gradually enriched. At present, their applications are extended to family self-use, but they are still mainly used in teaching, scientific research and other fields, involving the clinical efficacy evaluation of TCM, clinical case classification and health management, and there is still much room for development. In the future, we should strengthen the communication between multi-regional research centers, promote the communication among talents in different fields, constantly make up for the deficiencies and promote the development of tongue diagnosis research.

Boym's "De Indiciis Morborum ex Linguae Coloribus et Affectionibus": The Earliest Chinese Tongue Diagnosis Manual Published in Europe, Identification of Original Chinese Text, Peculiarities of Printed Edition and Its Impact on European Medicine / 中国结合医学杂志

Upon his untimely death, Michal Boym (1612-1659) left behind an enormous written legacy; covering a diverse range of interests in fields such as Chinese linguistics, cartography, botany, zoology, philosophy and medicine. This article attempts to examine Boym's De indiciis morborum ex linguae coloribus & affectionibus (The signs of disease on the tongue, colors and affections), a translation of a previously unidentified Chinese text. The text specifically deals with the subject of tongue diagnosis, in relation to contagious diseases that were still raging in the 17th century China. Arriving to China at the end of the Ming Dynasty (1368-1644), Boym was able to personally witness the early development of tongue examination as an independent specialty; he recognized its significance and tried to incorporate it into his ultimately unfinished Chinese medical corpus. Boym's work eventually facilitated the assimilation of tongue observation in European medicine during the 19th century.

A historical evaluation of Chinese tongue diagnosis in the treatment of septicemic plague in the pre-antibiotic era, and as a new direction for revolutionary clinical research applications / 中西医结合学报

Chinese tongue diagnosis was initially developed to quickly and efficiently diagnose and prescribe medicine, while at the same time allowing the doctor to have minimal contact with the patient. At the time of its compiling, the spread of Yersinia pestis, often causing septicaemia and gangrene of the extremities, may have discouraged doctors to come in direct contact with their patients and take the pulse. However, in recent decades, modern developments in the field of traditional Chinese medicine, as well as the spread of antibiotics in conjunction with the advancements of microbiology, have overshadowed the original purpose of this methodology. Nevertheless, the fast approaching post-antibiotic era and the development of artificial intelligence may hold new applications for tongue diagnosis. This article focuses on the historical development of what is the world's earliest tongue diagnosis monograph, and discusses the directions that such knowledge may be used in future clinical research.

Study and Application Overview of Spectroscopy Method in TCM Tongue Diagnosis / 中国中医药信息杂志

Tongue diagnosis is one of unique techniques of TCM diagnosis. Its subjective and empirical description of written words, spoken language and pictures have been used until now, however, which cannot express the complete information of tongue image comprehensively and objectively. The development of modern technology provides new ideas and methods for the study of tongue diagnosis in TCM. For example, the application of spectroscopy is of great significance for restoring tongue image information. This article briefly introduced the spectroscopy method, summarized its research and application in the field of TCM tongue diagnosis, and put forward the problems and prospects to provide references for further research.

Application of Modernized Tongue Diagnosis in Clinical Research / 中国中医药信息杂志

Traditional tongue diagnosis is a vital basis of syndrome differentiation in TCM. The development of computer technology has opened up a new path to the tongue diagnosis modernization. The purpose of applying modernized tongue diagnosis into clinical research is for providing objective basis for diagnosis, TCM syndrome differentiation, evaluation of illness condition and efficacy evaluation. This article analyzed the application of modernized tongue diagnosis in clinical research in recent years, summarized the application status and existing problems of applying tongue color, texture, shape, indentation, sublingual veins, microcirculation, and spectrum analytical techniques into the clinical research, with a purpose to provide references for further research on modernized tongue diagnosis.

Determination and Analysis of Chromatic Value in Abnormal Red Tongue Tip / 中国中医药信息杂志

Objective To measure the chromatic differences of the tongue tip and tongue side and provide quantitative evidence for tongue color diagnosis. Methods Totally 683 healthy people were recruited, and their tongue photos were taken. Then ICC specific documents were used for the correction of all tongue photos, and chromatic values (L*, a*, b*, C*and h°) of tongue tip and tongue side were obtained for further statistical analysis. CIEDE2000 was used for calculating the color differences. Results The average color difference of tongue tip and tongue side in normal pink tongue was 5.4. When pink tongue has abnormal red tongue tip, the average color difference of tongue tip and tongue side was 10.85. Compared with normal tongue tip, the average color difference of tongue tip and tongue side in abnormal color tongue with abnormal red tongue tip increased from 5.4-7.0 to 11.23. Conclusion Red tongue tip is a sensitive sign indicating abnormal heat in the body. Tongue tip quantitative diagnosis is valuable in the determination of heat sign in TCM preventive treatment of disease, and reveal the diagnosis meaning and scientific connotation of red tongue tip.

Observation and Thinking of Diseased Tongue amongShanghuo(Heatiness) People / 世界科学技术-中医药现代化

This study was aimed to discuss the diagnosis significance of the diseased tongue demonstration in Shanghuo (heatiness) people. Based on 303Shanghuo cases, the relevance of diseased tongue demonstration and inquiry data were analyzed. The results showed that 53.14%Shanghuo cases had at least more than 2Shanghuo inducing causes. The most common inducing cause combinations were pathogenic factors neither endogenous nor exogenous (unbalanced diet, overworked) and internal factors (over stressed, emotional). When there were several Shanghuo causes occurred at the same time, the probability of appearing diseased tongue demonstration increased significantly. There were 29.95%Shanghuo cases occurredShanghuo experience frequently. And in these cases, the probability of appearing diseased tongue demonstration increased significantly. It was concluded that when Shanghuo people had diseased tongue demonstration appeared, it was not merely just“is going to get ill”, but was already suffering from heat syndrome. In traditional Chinese medicine (TCM) physical examination, to effectively differentiate“is going to get ill” and“being ill” was initially important. And the diseased tongue demonstration was a crucial diagnostic basis.

Quantitative research of perception of tongue color in traditional Chinese medicine / 国际生物医学工程杂志

Objective To quantify the changes of tongue color with the development of the disease according to the characteristics of human vision.Methods Psychological scales of tongue color perception were obtained from thc psychophysical experiments.Polynomial regression and support vector regression (SVR) were used to establish the mathematical model between the physical values and the psychological scales of tongue color.Results The psychological scales exported from the model could correspond to the visual perception of tongue color change, and SVR has higher accuracy.Conclusions The psychological scale, can not only quantitatively evaluate the tongue color in the development of the disease, but also quantify the degree of disease, to assist the doctors for disease diagnosis and treatment.

<b>Standardization of Kampo Medical Findings in a Specialized Kampo Medical Service Facility </b> / 日本東洋医学雑誌

Standardizing Kampo medical findings is a significant challenge in Kampo medical circles. These findings are fundamental to Kampo diagnosis. This paper introduces our attempt to standardize these findings in a specialized Kampo medical service facility.<br>We started our project with verbal standardization. Nine medical doctors, all of whom were Kampo advisors or Kampo specialists, discussed issues such as subjective and objective findings, including those of the tongue, pulse, and abdomen, as well as the selection of target items, criteria for judgments on each item, and associated issues. When discussing the above issues, descriptions in prominent traditional Kampo texts were given most importance, and the wisdom of famous Kampo doctors since the Showa period was also given weight. In addition, we focused attention on clarifying the criteria for making judgments.<br>One hundred and twenty items were selected as subjective Kampo findings. We selected 12, 6 and 10 items as objective Kampo findings in the tongue, pulse, and abdomen, respectively, and provided criteria for judgments with each.<br>Our next challenge is to spread these standardizations in Kampo medical circles.

Current situation of tongue diagnosis in psychiatric diagnosis / 国际中医中药杂志

This paper overviewed the studies of the current situation of tongue diagnosis in psychiatric diseases (schizophrenia,depression,nervous disorders,sleep disorders and psychotropic drug-induced side-effects),summed up the importance of tongue diagnosis for the diagnosis and prognosis of mental illnesses.

Objectification of Tongue Diagnosis with a Compact Digital Camera-Photographing Standard and Repeatability- / 日本東洋医学雑誌

In order to maintain objective tongue diagnosis, we have researched a photographic standard and the repeatability of tongue photography, using a Compact Digital Camera (i. e. digital camera).<br>We photographed the tongues of subjects who held a small color chart on the end of a chopstick.<br>We were able to reduce the level of reflected camera flash when the camera was held vertically by its upper grip, in such a way that camera flash came from the subjects' upper left. We examined various focal distances, and white balance (W. B.) settings in the camera's Close-up Mode, and obtained well-adjusted photographs with minimal reflection when the focal distance was about 10cm, and the camera's W. B. was set to Flash Mode. Photographs taken under these conditions were highly consistent regardless of place, time, and who the subject or photographer were. We report this photographic standard as recommended for objective tongue photography.

Clinical observation on 213 cases of thick tongues in shape / 中华中医药杂志

Objective:Methods:To observe 213 cases of thick tongues in shape systematically by 30 kinds of thick tongues proposed in the Tongue Diagnostics and clinical observation.Results:After contrasting 213 patients with 200 cases of correlative disease,it has found that thick tongue is closely related to some syndromes and diseases,thus revealed that some diseases will cause blood stasis of superior vena cava,suffocating of the tongue lymph return-flow,increased power of the blood in the tongue tissue.Blood stasis in the tongue tissue,tissue edema and local exuded inflammatory pathological change in the tongue induced by the motion and sensory disturbance of the tongue muscle and nerve will lead to increased size and thickness of the tongue.Conclusion:The methods and data adopted in this paper provide significant reference in future study of tongue shape.