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Among the most salient features of contemporary Chinese medicine tongue diagnosis is the topographic mapping of the body’s interiors upon the tongue surface. As if it is a diagram, we can look at the tongue body and coating and gather useful diagnostic criteria.
Again, two recently published tracts – one by Iannis Solos (Gold Mirrors and Tongue Reflections), include translations of two seminal texts, and another, a dissertation by Nancy Holyrode-Downing, explores the history of tongue diagnosis from the Han Dynasty to the present era. The former includes a variety of tongue images not commonly seen – both choose not to focus on the findings of a relatively recent and influential stream of knowledge from the Warm Disease (Wen Bing) current of Chinese medicine.
Two protagonists of this current of Chinese medical thought contributed much to our understanding of epidemic and febrile diseases. They are Wu Ju Tang and Ye Tian Shi – both of the Qing Dynasty. Perhaps what’s relatable here is that the Warm Disease school is associated with many of the heat conditions that we see in the warmer months, and which are particularly relevant to illnesses that occur from spring to late summer, including dermatological conditions, and dampheat lodged in the body’s interior.
Wu Ju Tong classified illness according to Three Burners – the upper respiratory, the digestive, and the urogenital. Of course, these are not their proper names for the upper, middle and lower burners.
If you look to a tongue, at quick glance you can divide the tongue body into three vertical sections, and narrow down pathology based upon what appears in those three divisions. If you notice chronic symptoms in the organs of a specific burner, you can see if you notice any changes in color or coating in one of those sections.
“Use herbs that are as light as the feathers of a bird for disease in the upper burner; use herbs to lift the Spleen qi and cause the stomach qi to descend in the middle burner, just like calibrating a scale that should always be in balance; and use heavy and cloying herbs to treat yin deficiency for the Liver and Kidney in the lower burner like adding a heavy weight to a scale to tip the balance.” – Wu Ju Tang
Ye Tian Shi offered a framework called the four levels, which reflects the impact of heat pathogens, often viral/bacterial in nature, upon the body dynamic. For those, the color of the tongue body and certain markings or presentations, alerts us to the severity of the disease transmission, and differentiating properly is a big deal as the nature of a pathogen is specified from the outset in Chinese medical diagnosis.
Actually, for quite a variety of skin conditions – such as eczema, psoriasis, dermatological presentations that involve macules, papules and blisters – this realm of diagnostic knowledge is indispensable. It’s common for a modern herbalist to view medicinals according to apparent pharmacological properties – such as antipyretic, antiviral or antimicrobial – without acknowledging how they function according to the extensive, empirical knowledge relative to, for instance, the stage of progression of such conditions.
There are very specific differentiations. A modern herbalist may lump herbs together, not knowing that herbs also harness the body’s intelligence into strategies; or paradigms of healing, perhaps. The outcome is that to the trained eye it’s like forcing break dancing to polka music.
Which brings us to consider the variety of information that these different texts and contexts have to offer.
In modern Chinese medicine, we regard the sides of the tongue as indicative of the state of the liver/gb, the tip and top 1/3 to the heart and lungs; the center to the spleen stomach and the lower 1/3 to the kidneys, large intestine, urogenital organs, etc. It’s not entirely clear when these derivations were solidified, but they have mostly been accepted.
· In addition to these significations, we look to the color – color being a main indicator of the nature of imbalance. What would red signify – heat, generally. Pale color – a lack of blood or qi. A very common color is called ‘dusky’ – often regarded as purple, or pale purple and amounts to stagnation.
· We also look at the size and shape. For example, puffy can sometimes imply dampness, or a lack of yang qi by which warmth is distributed. Sometimes the tongue body can be stiff, short, upturned, downturned, off to the side or quivering. These are all facets that we assess.
· What about under the tongue? Distended sublingual verici often denote blood stasis.
· What about the coating? Is it fresh, or perhaps dry or grey? Is the taste in the mouth sweet, sticky, bitter, or off? These are important indicators. A thin white coating is normal. Sometimes the body’s yin can be lacking and we see a geographic tongue, which is called peeled. There will be areas without coating.
I think this level of information can be had by searching the web, and can be useful.
The classics referred to in the above works hardly reflect any of these generalizations. They address specialist findings relevant to the school of Cold Damage, known as ‘Shang Han.’ Again, these translated texts were circulated around the 13th to 14th century flesh out tongue images that broaden the clinical presentations, for which pulse diagnosis and symptom/sign presentation were well-established.
What’s most relevant to these are specific stage-like presentations of acute, or chronic diseases noted in the earliest of Chinese medical lore. There is less of an emphasis upon specific organ systems, as the nomenclature and disease models are different in these contexts.
What you do find is a much more specific line of medical theory, which moreso, might indicate not that there is “dampheat in the liver/gallbladder (area}” and someone has been leaning on “food and drink,” but moreso about progression, i.e. whether a condition/individual would benefit from sweating (diaphoresis), or purgation, for example if heat is trapped in the body and can be evacuated down and out.
When speaking of external pathogenic factors – we rely on concepts of wind, cold, heat, dampness, dryness and fire – each of which have been treated from different medical models throughout the centuries.
So again, what we see in contemporary tongue diagnosis is the synoptic quality of body mapping, and we often take for granted how such images took on the interpretive significance we assume through modern, institutional learning. There’s so much wisdom packed into a generic imaging of the body that has to be astutely sifted through.
You can take things at face value, or recognize there are interpretive depths to just about anything – like routine bloodwork.
To respond to this question, what we can see from the tongue (or the pulse for that matter) can be rather nuanced, or quite generalized. Such is the beauty, or obscuring nature, of modern Chinese medical knowledge.
It all depends upon what you need to know, and how you are looking. Sometimes a quick review or glance is sufficient. Other times you are gaping at a tongue or pulse for a while, which can make some of my seniors or pediatric patients, giggle.
While tongue diagnosis is a part of the panoply of diagnostic methods, its also a window into the world of medicine, with superficial features and exteriors, as well as a rich and complex depths of inquiry and understanding.
“What do you learn from the tongue?” “What does the tongue inform you?”
I commonly receive this question amongst new or inquisitive patients, and on occasion request that they examine the tongue to begin to make connections and better understand their health status. I recall my first notable presentation – my own tongue!
One celebratory evening, a colleague of mine of native descent invited me for dinner. After over a decade of very scrupulous vegan and vegetarian diet, I was offered food prepared after a hunt he and his relatives had gone on.
I obliged. And it was a personally meaningful and powerful exchange and experience, and I had a night full of vision-filled dreams. Though, when I woke up I also had a somewhat uncommon tongue presentation. The coating was black – seemingly dark and charred, a sign that might indicate heat toxin, or a type of toxic response, from the Asian medical perspective.
In actuality, we find many interpretive depths around tongue presentations, in clinical practice, and in the literature. What may be severe or illustrative in one context, may lack such significance in others.
Recent scholarly monographs (Solos, 2013), and a dissertation (Holroyde-Downing, 2017) we’ll review for you, explore the history of tongue diagnosis from the premodern era up until the present. One of the astonishing insights they provide is the historical development and inclusion of tongue diagnosis.
Among these textual/historical findings is the tracing of key passages from canonical literature such as the Inner Classic (Nei Jing), to the inclusion of diagnostic signs in texts on Cold Damage (Shang Han). We find that the tongue is associated, for instance, with visceral systems such as the heart (xin), but also in epidemic diseases due to external contraction.
Indeed, the author of Gold Mirrors and Tongue Reflections, a key translation of two seminal texts that are foundational to tongue diagnosis, reveals how contemporary interest arose with serious epidemics – especially around 13th century, and more recently – with the SARS epidemic that arose in the early 2000’s.
That epidemic diseases was a key force contributing to the focus on this form of “looking diagnosis” reveals how tongue diagnosis is especially helpful for understanding the progression of a disease process due to an “external contraction,” which we often relate to viral pathogens, and the like.
We gain a reflection of how a disease process is progressing, affecting the “interior” of the body.
What a tongue tells is context dependent.
We can look to a tongue and examine the “shen” which refers to the spirit, the liveliness or even constitution strength of the individual. This can be revealing also for prognosis. If the spirit is strong, and there is healthy sheen, the more superficial findings of the tongue can be seen as secondary – manageable.
In future discussions, we’ll highlight some cross-disciplinary and cross-cultural observations of the tongue. As with any diagnostic method, there is a great deal of interpretive variation. One might suppose that the canonical investigations should be at the forefront, and leave aside contemporary Chinese medical frameworks. But this could be delimitating.
Contemporary models can be largely reductive – or synoptic. They may gather information from disparate contexts to assemble an integrative tongue picture. In one context, such as fertility or dermatology – a clinician may pause briefly to examine key, relevant features that are significant to their discipline. In the case of epidemic diseases, the color of the tongue body, certain markings and the state of the tongue coat will take on another level of significance.
Lastly, from the cross-cultural perspective we can appreciate the tongue as a map of the body, with specific regions of the tongue relating to different organ systems, and that the tongue coating, emerging from the fluids of the stomach and as a mirror of the digestive system – these are almost universally similar.
So if we are examining the tongue, these are some of the principal features we are looking at: the overall appearance, the shape, the constitution, regional variations, coating and the colors that arise in these features that reflect different factors of imbalance, or reflect health!
More to follow in our newsletter and upcoming posts.