Speaking of Tongues
Constitutional understanding using key questions, the tongue & the pulse
This is the exact text of a paper that I presented along with a live talk to over 300 herbalists and naturopaths in New Zealand and Australia in 2010.
1) Primum Non Nocere
First, do no harm.
2) Tolle Causam
..... Treat the cause
3) Vis Medicatrix Naturae
..... The healing power of nature
These three, deep laws have been the best guides I’ve had.
All things considered, Dennis Stewart and Company in Australia did a pretty good job at getting ‘water wings’ on to me in the 1980s but setting up a herbal medicine clinic in conservative Christchurch in February, 1989 with just a basic, physiomedicalism-based diploma was still like being thrown into the deep end of the Pacific Ocean!
In working out what actually works an awful lot has happened for me since that time and in very practical ways these ‘rules’ have been profoundly useful. I have learned beyond a shadow of a doubt that it really is Nature that heals (as much as the male ego, or the ‘therapists’ ego, might like it otherwise!)
I have also learned how we can get in the way of the healing process whilst missing how to best support it. Doing no harm is a deep subject, really deep.
The first and third rules are kind of about what not to do. The second is equally powerful in its usefullness on what to do. Treating the cause means you very much have to get involved, which frequently includes the warts, and all.
To treat the cause you first have to look at it. That’s tricky, not because it’s so hard to see but because there is so much to see. People rarely have only one single and simple origin to their troubles; each layer you look at can seem to have another one underneath!
I have personally worked with an embarassingly large number of systems of diagnosis over the years. The trouble with most of them is that they always seem to end up taking you up similar treatment alleys. We can kid ourselves all we like but the mind is always a filter and you can’t help but look at people through your personal preferences on what matters most. Analyse people’s livers and bowels enough and you can be pretty sure that is what you will end up treating. Focus primarily on allergies and you’ll get one allergic person after another. Endocrine troubles, dysbiosis, nutritional biochem… patients can partially fit through just about whatever lens you choose to look at them. In the same way, surgeons always seem to find reasons to do surgery and back-workers just keep on working that back. Counsellors never seem to have trouble finding things to talk about either (how do they do that every week, ad infinitum?). At its extreme, if the only tool in your tool box is a hammer, soon enough, everything eventually starts looking like a nail…
The trouble with people is that they have so many troubles. You can throw just about any kind of diagnostic dart at the body/mind and be pretty sure of hitting something important no matter where it lands. Eventually it all needs a big step back and an even bigger breath. What do we mean by this ‘treat the cause’ business?
I think the law is guiding us to help people to understand themselves. It is not fixing the cause; it is not removing the cause; it’s treating the cause. Giving it some room to be looked at, worked on, perhaps very gradually, and certainly very gently, to be operated on in an ongoing manner. How you might do that of course depends on many facets; from who your first teachers were to whom or what you most believe in nowadays. In many ways it actually matters much less what ‘system’ you use and rather a lot more that you can understand your patients andso help them to better understand themselves.
People do all kinds of injuries to themselves with their stress, their diets, their environments, their relationships, their obsessions to be someone and their compulsions to get somewhere. It’s naïve to think we can make such a difference as to do away with all such harm in another’s way. (It’s surely enough for us to work on that one for ourselves!). But I do think we have a golden chance in a modern clinical setting to help people get into the nitty gritty of why they are suffering. This is a profoundly healing thing to do, it changes lives.
Of course we all have to start with the symptoms no matter where we intend to head later. Symptoms are terrific guides to beginning to understand where someone is at but they do have a habit of being got rid of, or at least distorted. You can’t really blame people for taking drugs etc to stop feeling bad but I do find it imperative to get some understanding of how people actually feel, despite the various distractions. Underlying a person’s experience of their life, and certainly underlying their troubles, is their ‘nature’; variously described as their constitution, their temperament or their energy. Their nature is of course who they really are; it contains their own life-force, that which heals them. It also just so happens to demonstrate quite visible cracks along similar lines when imbalances happen, as they inevitably do.
People broadly grouped into certain types of constitution do clearly get the same kind of troubles and, very endearingly to a herbalist, seem to respond much better to certain types of treatments. All this has been carefully worked out and practiced by our herbal ancestors for millenia. It’s a bit of a mystery as to why we have gotten so alienated from it whilst our Indian and Chinese cousins have just gone about working it in deeper. But here we are. Let’s have another look.
The first concept to get a firm grasp on is that the ‘nature’, the constitution varies along several spectrums with many possible gradations. The first spectrum can be well described as Cold to Hot. Cold or Cool* constitutions have slower metabolisms, more gradual expenditure of calories, reduced responses to illness. They are often more introverted and introspective. Hotter constitutions have faster metabolisms, slightly higher body temps and have more acute or dramatic responses to illness. They are usually more extroverted, more naturally expressive. There are many permutations to all of this, for example the third spectrum, the moving ‘nervous energy’, which we only really start discussing when we get to the pulse, greatly affects how people experience and express their basic constitutional temperaments.
*By the way, I am cagey about using the word ‘cold’ too often in my language as it has so many negative connotations, (whereas nobody seems to mind being told they are ‘cool’!)
The second, equally important spectrum in the constitution is described as Dry to Damp. Think of this as something that kind of overlaps the first spectrum. In other words people have a natural tendency to be cooler or hotter and as well as that they have a tendency to be dryer or damper. Dryness and dampness are somewhat to do with just how much fluid (i.e. water and fats/oils) a person has but they also closely relate to a more general depletion in the case of excess dryness and an equally apparent encumbrance, or toxicity in the case of excess dampness. The following schematic can give some sense of how these spectrums intersect and it also re-introduces the old constitutional ‘names’ for the different temperaments.
With some understanding of how this all works you could put yourself (and other people you know well enough) somewhere within that circle; cooler or hotter, dryer or damper. The closer to the centre the more likely you are to be in balance, the further to any of the outer edges the more likely there will be problems that relate to those particular imbalances.
However it is crucial to understand from the outset that none of this is fixed in stone. People are organic, messy, changeable creatures. They might have a genetic, constitutional tendency to always be a bit cooler or hotter, dryer or damper but they can and do move a great deal forwards and back, upwards and downwards from that natural tendency. People change over the course of their lifetime, they change according to what they do and who they are with, and they very much change in the process of dealing with any kind of illness. Where the constitutional approach is incredibly useful to the practitioner is that it gives a window into understanding the most helpful things you can do to assist them with their imbalances. It can show you how to best support that natural, self-correcting ‘healing power of nature’. Where a constitutional approach is most dangerous is when you get locked into putting someone into a particular box and treating them that way, come what may! All the great constitutional systems, including TCM, Unani and Ayurveda have this inherent risk of becoming formulaic and unimaginative. People are not so obliging as to stay in whatever category you might choose to give them. There is terrific value in seeking deeper understanding of ourselves and each other through such means as these old constitutional paradigms but only up until that point that we put a full stop and assume we now ‘know’. We don’t.
In modern, Western, herbal medicine we have developed a strong ‘condition-based’ approach to our work. This does have its strengths and there are many wonderful methods and techniques to allay certain syndromes and symptoms that are seen to consistently help. It also has some glaring weaknesses. Never more evident than when a patient stubbornly refuses to get better despite your giving them the ‘right stuff!’ With some trepidation I am going to start introducing you to more detail on the constitution through the ‘filter’ of the common conditions that can come to each of the key constitutional imbalances. I am doing this because I want to give it a modern, familiar flavour however I am worried that in so doing you will lose the point of the exercise and put the ‘cart before the horse’. People’s problems do not depend on their constitution, they depend on how they have managed to do themselves harm. The constitutional tendency does however show similar patterns of illness under duress and, so long as you do not fall into the trap of looking at the problem instead of the person, these lists of common conditions will help you understand how relevant this all still is today.
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Cold, Damp, Dry & Hot Constitutions; Brief descriptions and common conditions
~ The Cold Constitution
The cold constitution is humorally described as being phlegmatic when dampness is present in excess and melancholic when dryness has dominated. These are some of the modern patterns of illness that more frequently emerge in people who have gone too far to the cold:
- Low Libido
- Low Immunity
- Chronic Fatigue
- Adrenal Exhaustion
Whilst they can be wonderfully introspective, sensitive and aware individuals, cold people’s ‘vital fires’ are seen to have burned too low when they fall into ill health. Naturally enough, key strategies to bring them back to health include the use of warming herbs and foods.
~ The Damp Constitution
Described as phlegmatic in cold people and choleric in constitutionally hot people there is a notable increase in congestion that fits many of the old concepts of toxicity & encumbrance. Cold and damp (phlegmatic) dominance can show up in such patterns as:
- Irritable Bowel
- Low Grade Infections
- PMT-C, PMT-D
- Metabolic Syndrome
Hot and damp (choleric) dominance can look a little different.
Here you might see more conditions such as:
- PMT-A, PMT-P
- Inflammatory Bowel
Both cold and hot dampness show a need to help the body with cleansing influences, but the best herbs for this may vary somewhat between whether their basic constitutional nature runs more to the cold or the hot. In theory, warming cleansing herbs are better for cold, damp phlegmatic people and cooling cleansing herbs are better for the hotter choleric. In practice herbs from both sides of the scale are seen to work and, as it takes very little for cool, wet, chronic congestion to suddenly turn hot, inflammatory and more obviously symptomatic, a good prescription might well contain elements of both. See my chart on constitutional medicine to get a more visual picture of this concept of cooling and heating cleansing herbs.
~ The Dry Constitution
This one needs some more careful thought. Described as melancholic in the cold and sanguine in the hot it looks like it might need less intervention compared to the typically more obvious signs and symptoms of excess damp. This is not the case, a close analysis of people in the modern setting shows that a great many of them have gone well over into the dry spectrum and their bodies/minds are frankly depleted, sometimes dangerously so.
These are some typical presentations when dryness has come to dominate the scene:
- Low grade Inflammation
- Chemical sensitivities
- Ageing, shrinking, withering
- Degenerative, catabolic diseases
The picture is one that lends itself readily to nutrional supplementation as a first port of call but unless the root causes of the depletion are dealt with this may only be a strategy that works for as long as you use it. Whilst hoping to address at least some of the deeper causes of depletion there are many foods and herbal tonics that have been seen to deeply nourish dry people in their typically gradual process of recovering their health.
~ The Hot constitution
The hot constitution is described as choleric when in the damp and sanguine when in the dry. Sanguine is sometimes held up as the model of the ‘best constitution’. A sanguine person is traditionally associated with a ruddy face, a courageous nature and someone who rapidly falls head over heels in love or quickly takes up arms for a worthy cause. Surely this is all to the good? Well perhaps yes if they are in good health or when they actually have a good cause. When they get out of balance sanguine people can be miserable, angry, irritable individuals that would loudly like everyone in a 2km radius to know all about their suffering. Their blood pressure quietly explodes and they don’t sleep. In fact sometimes they literally drop dead to everyone’s complete surprise because they seemed so healthy right up till then!
Choleric types seem to move in and out of ruddy good health rather more frequently. They have a tendency to hold in both heat and moisture which combine to make for some of the more dramatic of the hot constitution’s eruptions. Choleric overload symptoms typically come out in flash points in the bowel, the blood and the brain. In one sense choleric presentations are just hot constitutions that haven’t found the right vents. Help them find ways to safely let off steam and happiness and harmony may soon ensue.
Every constitutional ‘type’ has its good and bad sides. It sounds bad to be a melancholic type and I almost never use the word in practice, it has come to mean mostly just one thing. But these are the kind of people that are probably most capable of loving someone for their entire lives. Melancholics are natural introverts who plumb down deep; if they can find some sort of peace they may never cease to find inspiration in exploring the inner worlds long after the external trappings have lost their shine to everyone else… It is of course, all relative.
These are some typical ‘shows’ for heat, but there are a thousand other equally compelling things the body can do when it gets too energetically hot:
- Inflammatory Skin Things
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Working out the constitution
You have a page at the beginning of these notes that hieroglphically shows how I personally take notes on the constitutional assesment. That single page of eye-wateringly compressed notes is especially given for anyone like me, who will benefit from it all being crammed onto a page that they can carry around for a while until it all starts making sense. What follows here fills out the same process that I have described within that page in a lot more detail.
I spend just a few minutes with people asking some simple Q & A to get a sense of their constitutional tendency; it’s very quick with practice and in fact I find I have saved enormous amounts of time in consults by focusing so directly into whom they are and what is going on. The tongue helps a lot after that but I strongly recommend you resist the temptation to do it before. Yes you can often tell people a whole lot of things about themselves by seeing the tongue before they might tell you anything. It can be impressive but the problem is that once we have decided what we think then by our own natures we tend to try to make subsequent evidence fit our prior opinions. It’s always a better idea to keep an open mind and even when you think you know, remember you can always be wrong. Doubt is good, trust me.
~ The Skin
1) Dry vs Damp skin
Everyone has skin; it’s a whole diagnostic map in itself. However people’s perception on their skin is not always so helpful. Most people will say their skin is dry, even when it isn’t. Or their skin will in fact be so dry that their heels are about to crack but you might never know it by looking because they, like most people, spend much more time and money on cosmetics and skin care than they ever do on medicine… sigh.
I just feel for dryness vs dampness in the skin myself, I reach over and stick a finger onto their scalp and give it a rub, then I usually palpate a bit of arm which is unlikely to have been moisturised; no-one seems to mind.
Dampness can show quite well in terms of a palpably ‘moister’ skin. The word you might want in a really cold, damp person is ‘clammy’. The infamous cold fish handshake is a decidedly phlegmatic way to greet someone. In very poor health, cold and damp people can get a greasy kind of grey pallor that would only make an undertaker happy to behold…
The hot damp, choleric skin picture can get blown out into all kinds of eruptive spots if it gets over the top. The skin can take on an oily feel but conversely, as with any imbalance, they may be violently spurting oil in one part of their face and be completely dried out next door. Do not be confused, that is still hot dampness, just beyond the body’s ability to self correct despite its best efforts. Cooling, drying bitters really can do wonders here.
Dry people often seem to get noticeably dry skin and scalps. They are dry on the inside and they get dry on the outside. There is another downside to this; dry skin does not age well. They can make French cosmetic companies richer all they like, unless they deal with the cause it’s just money down the shower plug. I think very dry people’s brains dehydrate and shrink as they get older too; now surely that can’t be good for you…
2) Cold vs Hot skin colour
Colour and complexion of the skin can be tricky. Some people are very plainly as red as a beet or as white as a boiled potato and they do seem to be consistently hotter to colder respectively. Many people sit somewhere in between and you are just not sure, that’s ok.
Also be aware that anaemia, a long winter, a real summer tan or a fake anytime tan can mislead you into thinking them one side of the thermometer to another.
The ‘quicks’ of the nails can be a quick reference to this one as well. They are noticeably redder in the very hot and they can pale down like porcelain in the very cold. Again, many people sit somewhere in the uncertain middle; this will happen a lot, get used to it.
Consider this the first in a row of slightly vague and woolly clues about the inner workings of your patients nature’s. It’s the best we could do for millenia without machines that went ‘bing’ but it’s actually not half bad once you get the hang of it.
Do not worry that many of these ‘tells’ and clues will be indecisive. Just leave them blank, or put a question mark, and go on to the next thing. Keep an open mind, keep looking, keep thinking and you will find there always will be clear signs eventually. The body will talk!
~ The Water
What goes in and what comes out seems pretty crucial to all that life going on in between.
1) Frequency and temperature
Cooler people seem to definitely prefer warmer drinks, even to the point of shuddering at the mere mention of cold water. Hot people usually prefer cool drinks but this can be deceptive. Some hot people like to do everthing to extreme, including sipping drinks at temperatures that would melt a normal human’s lips off. Somewhat more reliable is the frequency by nature inclination (meaning what they are inclined to drink on those days that they have not told themselves to drink more). Cold constitutions are not naturally good at drinking much. Real hotties seem to have to, or their radiators burst. Dry people are weird with water; I haven’t worked that one out. You would think they would want lots but they often don’t…
This one can be very useful for getting a sense of the dry vs damp spectrum. That’s assuming you can get an honest answer from the sometimes necessarily delicate question on how easily they perspire. It can be distinctly harder to get a dry constitutional type to break out in a sweat. Damp people sometimes have oodles to spare; they can drip at the drop of a hat.
Urine was always an important diagnostic & constitutional measure. Without the dip-sticks, I can’t help but think the physicians of the time just got up a lot closer to it than we do now. We should probably all spend more time looking at our patient’s urine. They are, to be frank, often pretty hopeless about telling you anything useful about it, I can’t imagine why.
The theory runs that darker urine goes with hotter constitutions and clearer or paler urine goes to the colder. Cloudiness is purported to mean damp. Cold & damp people often seem to hold in their urine, and they get bloaty and oedematous from too much of that. I have also come across many cold & dry people who have noticeably unhappy bladders. They may get UTIs etc but they often just have dull aches and pains in their bladder region with not a leucocyte to be seen on the dip stick.
Bowel Motions (BM’s) are obviously as vital a sign as they have ever been. It is quite distinctive that hot people who run into dryness get less frequent and harder BM’s. Likewise cold people who run to dampness can sometimes get a kind of ‘congested’ constipation. The nerves clearly play a big part in it all, either through excess tension or too much laxity.
I ask patients for the frequency (twice a day is probably the human ‘norm’), and if they would say they were hard, loose or normal. Dampness may equally give loose stools as it does constipation and you see a lot of people with irritable bowels having trouble with this. Dryness will often give harder stools but again don’t be put off the trail if they say they are normal. This is all greatly affected by their diet and the state of their liver. Plus once people have lived long enough they know how to not push their limits and have learned to add a certain amount of fruit or avoid a certain type of food etc.
~ Dry throats vs stuffy noses
In the form is a space to ask the question
“Do you often get a dry itchy throat or a blocked stuffy nose?”
A lot of people will say neither and you will be none the wiser but quite a few dry types do get habitually scratchy throats and likewise damp dominance often gets to the point of plugging the breathing apparatus somewhere along the way…
~ The Weather!
The second to last question, but often the last I use before getting them to open wide and poke out their tongues, is all about the weather.
I typically just ask about heat vs coolness, “which do you feel you function better in?” is the way I usually phrase it. Only masochists say they actually like feeling cold, you need to ask in a way that bypasses some of those stereotypes about what you are ‘supposed’ to like. Many ‘hot’ people actually feel better when its cooler but will say they prefer the heat. If you are going to use weather preferences as a guide then you are going to have to be aware that many (most?) people are not particularly in tune with their own nature or the environments that actually best suit them.
Another way to ask this is to give them the four main weather types and ask which they would prefer and which they would like the least. Hot & dry (e.g. a desert). Hot & humid (e.g. tropical). Cool & damp (e.g. England). Cool and dry (e.g. Antarctica!)
It’s hard to do this in a way that keeps the question open…
If Christchurch wasn’t so damn damp I would probably have a better chance of getting more balanced answers. You may fare better in your climate.
Hot and Cool constitutions somewhat prefer a degree of their opposite in the weather. Hot people don’t need more heat than they are making already. Especially hot days can have them feeling very tense and out of sorts. Cold constitutions know they do better in the heat and they will often go to great lengths to protect themselves from the cold.
Hot people need cooling influences and cool people need heating up, this is true for the weather and it is also usually true for the herbal medicines that will serve them the best.
It is harder to get a sense of people’s preferences to dry or humid weather. They may have never been in a tropical or desert environment and if they have it may have been too strange for too shorter a time to have done anything but be confused by it. In terms of an environmental check I think it’s generally better to use the dry vs damp question in a negative construction
e.g. ‘do you notice that dry air irritates your breathing?’ = they may be dry
Or, ‘do you feel worse on muggy, damp days?’ = they might be just a little bit damp.
I recommend you certainly do ask weather questions to help gauge the constitution but I equally recommend you resist the temptation to overly weight the response. This is one of those areas where you get an answer that can make you do a double take and have doubts about your constitutional impression. Good! I hope you are a little unsure most of the time doing this. It means when you get to their tongues and pulses you will be all the more open…
Lastly I have a question about pain. This is not always appropriate to ask, but then again, it often is. People with distinctly cool constitutions are quite a lot more likely to get pain that is of a duller, deeper and ‘aching’ nature. Conversely hot people tend to get pain that burns and throbs and is perhaps subjectively more intense but also seems to be over with faster
Equally telling is what makes the pain better. Cold people instinctively know that a hot pack or some kind of heat application will assist them to some extent. Hot constitutions may flirt with the odd hot water bottle on occasion but are far more likely to want nothing - not even clothing touching the spot if it’s particularly sore. A hot constitution is also much more likely to say “a nice bit of ice will do me nicely, thank you very much.”
~ Cross Checking the Constitution
On the intake form I use you will see some neat little boxes named cool damp, cool dry etc containing a few symptoms, feelings, weather signs, food preferences etc. Proceed with caution! People are confoundingly complex and you could be as likely to be thrown off track as kept on it by using these cross-checking devices in any kind of ‘must tick the boxes’ way. I have kept them in because in the balance of things I find them more useful than not. When I do want to cross check my main impression it can only take one or two confirmations to help know I am on the right track but…
People will give you conflicting constitutional signals! They have excess heat in one part of their systems and are too cold in others. They are chock full of dampness and congestion in one place and dried out in another. Don’t give up if you get mixed feedback and feel unsure. The body/mind is always trying to get itself back into balance and it often swings back and forth in the process. The point of this kind of assesment is not to cleverly pop them in a box, it is simply to understand how to best support the healing power of nature.
~ The Tongue
The tongue is the title topic and I know it has taken one or two pages to get to it but with good reason. Just looking at the tongue without the constitutional background is basically a really bad idea. You can have detailed theories of what all the different tongue signs are supposed to mean and you can try all you like to make what you see ‘fit’ but I guarantee, if you are honest, you’ll find that approach forced, formulaic. It doesn’t give you true insight.
I know this to be true because I’ve already tried all those short cuts with the tongue and none of them ultimately led anywhere. I’ve always looked at my patients tongues, always. And I most certainly do not have a tongue fetish as one or two patients have been heard to quietly enquire in between my taking a handful of close-up photos of their tongues, I’ve just always known that I am supposed to look and that it is supposed to all mean something. To try to make it mean something I’ve diligently studied everything I could find including works from Chinese, Ayurvedic and Eclectic tongue diagnosis. They all at least have some common ground (thank goodness) and I won’t say they weren’t helpful but without using the constitutional approaches of those systems it was of very little practical help to me in relating to my patients and formulating good scripts.
I worked especially hard at trying to inculcate some of the beautifully elaborate Chinese tongue diagnosis system. Making it fit my Western herbalist’s brain was like trying to walk around with a boot on one foot and a jandal on the other. I am sure it works brilliantly for those who are versed in TCM however I think we should frankly and respectfully not try to adopt one of their key systems of diagnosis unless we are prepared to spend the necessary long apprenticeship to really understand their view of the world and the body in it…
Our Occidental European and Arabic forefathers all knew how to look at the tongue and use that information for good without having to consult their Oriental cousins first. How did they do it? Well unfortunately it’s not clearly written down anywhere I have been able to access apart from bits and pieces, here and there. What I have found on the tongue from our culture have been long lists of things such as nutritional deficiencies or corresponding body sites as shown by the tongue; frankly it’s very speculative and clinically I found it all slightly useless.
Anyway, here is my take on how to use the tongue within the constitutional inclination.
If you have gone through a bit of questioning as previously discussed, you should already have a reasonable sense of the constitutional pattern of the patient who is now sitting before you, ‘tongue still in cheeks’.
And this is where it all gets very interesting and even rather exciting to the clinician. You are now going to have a close look over a good few seconds to get your main impressions of the tongue. With practice you will see that there are almost always one or more signs that will ‘spring out’ to you, as it were. These are the signs you are meant to see and they are really not hard to interpret if you have the basic constitutional understanding of what they portend.
The tongue changes all the time, it exquisitely mirrors, day to day, many of the key self-regulatory functions of the vital force, the ‘body intelligence’.
With an underlying understanding of the constitution, the tongue is able to tell you what the main current imbalances are, right now!
The constitutional picture gave you the back drop; now, at this particular moment, the tongue is able to help show you where to place your treatment emphasis, its priceless information!
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There are 6 main tongue paramaters that I find clinically useful. They are :
.......... 1) Colour 2) Smoothness 3) Coating 4) Moisture 5) Fullness 6) Activity
1) Tongue Colour
If the main impression from looking at the tongue is simply the colour then the primary constitutional imbalance will probably also be along the cool to hot spectrum. You will observe that cold people tend to have paler tongues and hot people get noticeably redder tongues. Interspersed into the colour is the ‘hue’, how dark or light the tongue is. Dark tongues are common in cold/cool constitutions, either dry or damp.
A hot consitution with early signs of dampness can have quite a bright white coating overlaying their reddish tongue. This may make the tongue look paler than it really is. You have to see the colour of the tongue body under the coating to get the true impression.
2) Tongue Smoothness
This is a particularly useful guide. Cold constitutions really do have noticeably smoother tongues compared to their rougher, redder, hotter counterparts. You should be able to see a nice dappled texture on the tongue of anyone, from any constitution. The tongue can now quickly tell you, even if you already knew that someone had a colder nature, whether that is causing them some real trouble at this point in time. As people get further unwell into their ‘cold’ conditions, the tongue gets both smoother and paler at the same time. Likewise as they get better the texture comes back and so does some of the colour. Again, see if this is one of the main things you instinctively ‘notice’. Try to let the tongue talk to you…
In exactly the same way, a person with a hot constitution going into imbalance will get a steadily rougher and ruddier looking tongue. Fissures are said to be a sign of heat. This is one of the puzzling areas of tongue diagnosis. Some people probably just have a ‘geographic’ tongue as part of their genetic constitution and not too much should be read into something that doesn’t inherently change. Your everyday minor fissures on the other hand do come and go and are useful signs on how ‘heat’ may be getting worse or coming into balance.
3) Tongue coating
The coating is the favourite of everyone who looks at their own tongue or anyone elses. If a coating is there in abundance it is hard to really notice much of anything else! That’s ok; the coating, and what it means, is what you have to deal with first.
A thicker than ideal coating is generally a good, reliable indicator of dampness/congestion and that it’s time to reach for your favourite alteratives, hepatics, clean diet plans etc.
Hotter temperaments definitely go towards more yellow coatings and colder to more white coatings. Having said that, many people sit somewhere in between with a kind of grey coloured coating. This is still dampness and it still needs cleansing but they just may not be that strongly on one side or the other of the hot to cold spectrum. A greasy coating from either type, which seems like a kind of solid ‘film’ over the tongue, is, at least to me, telling me to go gently and very thoroughlly. This well-developed layer is indicative of quite a nice long build up of ‘encumbrance’. One person’s happy cleanse is another person’s month of misery so in practical terms that means paying attention to those old adages about getting the bowels open before doing anything too heavy with the liver, having happy kidneys before using lymphatic alteratives and making sure the circulation is working ok before doing too much heavy detoxification with the blood (or at least making sure they stay really warm during the cleansing program if they have a cold constitution)
Equally important in the look at the coat is to see that they actually have one. It’s easy to think things are fine because you can’t see it when in fact the problem is that you can’t see it! This one does take practice because of course it is much harder to see something that’s not there but people should have a fine, very faintly white coating on their tongues. If they don’t it is one of the more reliable signs that their dryness has gone to the bad. They are now too dry and something needs to be done. A healthy coating seems to gratifyingly and quickly grow back with the appropriate herbs and foods.
4) Tongue moisture
It must be said that the current weather, their last meal, their current levels of circulating cortisol and so forth are all going to affect how dry their mouth is right now. And having said that there are still people for whom it’s like opening a window into the Saraha desert, and others for whom you wonder if a fish might be about to swim on out. If the mouth and tongue are noticeably dry then you are meant to do something about it. If excess moisture is a key impression then likewise look at how ‘dampness’ may be related to their current troubles.
5) Tongue fullness
Along with visibly dry to damp tongues there is a noticeable tendency for tongues to get swollen or shrunken according to how damp (=more swollen) or how dry (=more shrunken). Where this one can be a tad deceptive is that some people are born with plainly bigger tongues than others. It is not the ‘bigness’; it is the ‘swellingness’ or ‘shrunkingness’ you are trying to pick up. A good guide for the really damp is to see what is colourfully described as ‘scalloping’ along the side edges of the tongue. These indentations are from the teeth and they do seem to get less or more according to the level of dampness on the day. Shrunken tongues are perhaps easiest to notice by their tendency to be very shy about getting much further out than the teeth, put another tentative tick in the dry box but be aware that it might just be a genetically smaller tongue.
6) Tongue Activity
Lastly the subjective impression of how wriggly vs how still the tongue is something I personally find useful. I think it means things and I’ve been connecting the dots with people I’ve seen in practice. Of everything I have said so far about the tongue, (which has of course all been entirely scientific), what follows here is probably best put into a little category of its own called ‘Richard’s musings’. Pass the salt and add as much as you feel it needs.
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Better still, form your own impressions…
‘Quiverers’ The rapid shivery tongue of the intensely emotional person who holds much of it in. They can have a kind of seething, nervous energy that may be well controlled externally.
‘Lollers’ The rolling, restless tongue of the unsettled and unsure where to put themselves
‘Puddings’ The still, motionless tongue of the very tired and uninspired.
‘Cave-dwellers’ Seriously, you sit back yourself after a chat with these brief flashers and see if you feel there are things they are just not telling you…
‘Nose-cleaners’ Alright I guess I am making that one up.
‘Just rights’ If there is such a thing then it probably includes a tongue that moves somewhat but not excessively. The tongue is a skeletal muscle and as such under close control of the central nervous system. It would have to be closely controlled otherwise it would be jolly hard to learn your ‘mother-tongue’ from such a tiny age. The tongue is also clearly able to be put on auto-pilot for most of the time. None of us have to think about swallowing or how to form words but if something happens (e.g. a stroke) they are extraordinarily difficult things to learn to re-coordinate. You should have at least some activity in the tongue, surely a little bit of nervous energy, otherwise your dead, right?
~ Rolling up the Tongue
Now for those of you who have been down some of the aforementioned tongue paths and may still be invested in the long lists of ‘this type of tongue means this type of problem’ I sympathise with any sensation you have of being rather short changed at this point. And look, if I had a bit of lingering faith that those methods would be of real clinical value to a fellow herbalist then I would gladly devote much more of the real estate of these pages to re-describing them. I’m sorry, such lists looked great in the books to me, but when real patients came in it was all just so much theory that went the way of ‘oh’ so much theory.
I have since found that other experienced practitioners also look at the tongue after they have taken the history and already developed a sense of where their patient is at. It is a wonderful guide to the inner workings but it is vital to understand that this tongue is unique to that one person in front of you. Comparing their tongue to others is fraught with danger, comparing it with what you already know about them can be full of userful meaning.
~ Constitutional State of Being
The basic four temperaments of heat, cold, dryness and damp merely set the stage for the actor to come in. The physiomedicalists added status strictus for excess tension and status laxus for too little. This is where things suddenly get a lot more complex. There is this thing called a nervous system, which includes both a brain and an even stranger phenomenon called a personality that now come into play. The expression of this aspect of being is visibly seen through movement. The movement of the body, the cadences of speech, and probably to some extent the movement of the tongue, (though I think that should be given only a very little significance within the whole picture).
On the other hand, literally, there is one other movement which is extremely revealing. A movement that can help us to much better understand a persons ‘living’ nature.
This movement is of course that constant, largely uncontrollable, most essential and original of all the signs of life, the pulse.
~ The Pulse
The pulse is the hardest of all the material herein to usefully convey. I will make an attempt by approaching it from several different angles but you will have to practice with it, a lot! Don’t pretend any special knowledge to get started, just feel their pulse, quietly. I rarely mention what I pick up from the pulse in consult. I want it to feed directly into the part of me that needs to know what they need. I don’t want to impress them, I want to help them.
~ Constitutional pulses
Let’s start with what kind of pulses you typically feel in the different constitutions.
A cool constitution typically has a pulse that takes more than a moment to find. A really cold person’s pulse can sometimes be so deep in there that you find yourself wondering if they have one! What happens eventually is that you do find it but you realise that it is a very quiet, very subdued pulse and you just have to be sensitive to its whisper. Cold pulses are also often considerably slower although of course this varies a lot according to their fitness and recent levels of activity. Compared to other constitutions a cold pulse often also feels ‘thin’. This is hard to describe but once you start feeling for it you will quickly notice how some pulses are ‘full’ and some are clearly not. It would be a mistake to infer from this that cold people have less ‘energy’, this is not necessarily true at all, but they do tend to keep it within more.
Damp signs in the pulse are particularly interesting to feel because sometimes the only word that properly describes what you are noticing is ‘slippery’. The pulse kind of rolls under your fingers and as you adjust the pressure it kind of rolls towards and away from you. It is also noticeably harder to feel the beginning or the end of the pulse, it just kind of wriggles through. ‘Slipperiness’ will make sense as soon as you feel it a few times.
Choleric people with excess damp heat will often have a flooding, full pulse that feels like it is rising out of the wrist. This pulse can have an agitated quality if they are out of balance, you might sense a kind of unhealthy ‘fullness’.
Phlegmatic people with too much cold dampness have a slippery quality that feels more subterranean, it’s fuller than a classically cold pulse but it is still well under the surface and may be small at the same time, a caper compared to a stuffed olive, so to speak
Dry signs in the pulse are equally telling in that they feel much shorter, more compact than you would think normal. Compared to the full, slippery, damp pulse the dry excess can be thought of, and felt, as a kind of deficiency. The beginning and the end of the pulse are much more easily noted, it’s like a drum beat on a dry surface, there is a bit of space, more ‘air’ immediately before and after each beat.
A sanguine person who is hot and dry can have a strident, faster or at least much fuller pulse. This is not to be confused with the slippery fullness of dampness and you might get that sense mainly through a feeling of ‘sharpness’ to the beginning and end of it. When there is imbalance in the sanguine constitution you can feel an edge, a kind of ‘hardness’ to the pulse. Instead of being pliable and accommodating you can feel that you can’t press your fingers in much further than the surface. Such tension may have a long way to go before it manifests as symptoms but the warning signs are all there in the pulse if you know what to listen for and are open to hearing them.
The melancholic’s cold dry pulse is probably the hardest of all pulses to feel. You really have to take your time, be quiet within, and let it come to you. If they are in health there is a lovely soft and quiet quality to it, but if you put a melancholic that has gone too cold together with too much deficient dryness then they may not be doing at all well. You can feel at such times how the pulse can be very weak, thready, empty and depleted.
The hot constitutional pulse has already been somewhat desribed by several comparative references above. It really does bound along like the energiser bunny. The common mistake is to just assume that ‘more’ equals ‘better’, of anything. As an example just have a look at our civilisation! Hot people run into just as much trouble as anyone but they tend to do it more drammatically and with less warning. It may be that the majority of our patients tend to the cooler end of the spectrum because when the hot ones get into serious trouble they can be down at the bottom of the cliff getting the emergency care that they all of a sudden need. Also, more chronically over-heated people can get onto the drug path with gusto, particularly heart patients; who are often hotties. Virtually every drug in Western pharmaceutical medicine is cooling in nature, many of them downright cold. ‘Anti’ this and ‘blocker’ that. Things which suppress, reduce, obstruct or basically control any natural living process tend to be quite cold temperamentally. Heating tends to add to whatever else is going on, cold things are better at subtracting.
The hot person’s pulse in ill health can get a noticeable disturbance in rhythm; it becomes uneven in its flow under your fingers. Sometimes the easiest way to pick this up is to just notice if you have ‘got’ the pulse within a few moments. Of course this needs practice but if you easily have its measure then it tends to be generally ok, there just isn’t that much going on. If on the other hand there is a sense that it is changing, moving forwards and backwards, up and down, then stay with the enquiry longer. It can only take a little nudge to get a hot person moving back into balance but left to themselves they often do nothing until it can quite literally be too late.
~ Qualities of Pulses
Much of this has now already been touched on but a slightly different perspective may be more intuitive to someone else, for example someone like me! As you will see on the assesment page at the beginning, similar to the tongue there are a several parameters that I make a mark on to help my current thought process and maybe my future memory
.. Deep to Surface.
Simply how far you need to go to feel the pulse. Deeper, harder to properly find and ‘feel out’ pulses are much more typical of the cold constitution. Pulses that are right there on the surface and are much easier to feel are usually more to the hot side of the spectrum.
.. Slow to fast
This has two levels, the first is obvious and you can count the beats per minute if you like. (Profoundly sadly; this is where conventional medicine seems to have drawn the last line on the everyday usefullness of the pulse and even then is more likely to use a machine to do it if they have one). Slow pulses are more frequent in the cold constitution and faster pulses to the hot. But this is where I disagree with the stereotype. I have felt plenty of cool or hot people’s pulses which present the opposite of what should be expected (e.g. training for a marathon or missing a night’s sleep does odd things to pulse rates).
I also think the speed of the pulse should be taken as a relative sign. Similar to how the tongue shows changes according to how someone moves in and out of balance, the pulse may feel slightly or very much sped up when someone is moving into a hot, aggravated phase of an illness and conversely feel slowed down when someone is flagging in their response to their problems. It does help to know your patients; the first visit may not be the best place to gauge such things…
.. Slippery to Firm.
Again this is a particularly useful quality to get accustomed to feeling for in the pulse. Damp, slippery pulses are dinstinctly different to dry, firm pulses. It makes a great deal of difference to the prescription to know if someone needs more cleansing or nourishing.
.. Thin to Full
Thin pulses are typical in both cold and/or dry constitutions.
Full pulses show up in both hot and/or damp constitutions.
.. Smooth to Edgy
I can give a lot of significance to this one. There is an excellent correlation between nervous tension and the ‘feel’ of the pulse.
People in calm good health have a marvellous, not too soft, not too hard, fluid vitality to their pulses; you can feel good just listening to them.
People who are depressed, defeated can get noticeably flat, lifeless pulses and people who are in tension and turmoil often get distinct ‘edges’ to theirs.
Edginess is hard to describe but if you are aware of the concept then, when you feel those slight edges in the pulse, as you often will, you will know exactly what I mean. This is a very helpful ‘tell’ to the observant practitioner. Listening to such cues helps you to understand at a gut level how the edges, the conflicts, in a patient’s lives can be affecting them right now.
~ Do you need to put a pin on the map?
I want to reinforce this point because it can make or break a practitioner’s success with the constitutional approach. Do not think your job is to put them in the right category, put a pin on the map, and that somehow this will all magically result in the right treatment outcome. People, in reality as opposed to text books, are remarkably complex creatures. It doesn’t ultimately matter what kind of label you or anyone else uses to describe them, there is no healing in that. It’s how you use the information that counts. With an understanding of a person’s nature; their constitution, the beauty and value of using the tongue and pulse is that they can give you direct lines of communication into the body to hear what are the main imbalances that it is struggling to correct by itself. Then you can lend a helping hand and wonderful things may ensue. Much of this is necessarily intuitive, it requires a willingness to temporarily step back from the harder world of words and facts. Our minds are, in a very real sense, a great hindrance to this subtle and gradual process of understanding. We instinctively want to quickly make a judgment, affix the appropriate label, and move on to the next thing, come on, time is running by and we still haven’t worked out what to give them!
Openness, sensitivity and pliability are required. It is only in retrospect that I can see how counterproductive it was of my brain to be listening to people talk about their problems and at the same time be plotting various therapeutic interventions! It is so much better to wait, to remain open, to keep deepening the understanding till the last moment. Doing that, the formulae write themselves and you just ‘know’. Don’t take my word for it, take your own time with it in your own way and try for yourself.
~ The Impression
The Chinese say you have to listen to 10,000 pulses before you master it. Well if they mean 10 thousand different people then I am sunk. Even the thought of having to to do some meaningful work with that many patients on my books would send me to the hills to try my luck as a breathetarian. But I guess the point is that you have to feel a lot of pulses to get the hang of it. That I can definitely attest to. If someone approaches this with the typical modern mentality of wanting it to work as soon as it’s out of its wrapper then I am afraid they will be wasting their clearly precious time.
Listening to the pulse is an art; it needs a lot of practice.
Getting the feel for the pulse through the constitutional window is, I think, an ideal way to start to feel the temperaments of your patients above and beyond what you can learn by listening to them or asking questions. But it doesn’t stop there. Some of you may have heard the myths of great Healers who, just from feeling the pulse, tell their profoundly impressed patient how they broke their leg at the age of 6, had a long illness to their lungs in their teens and then later sneaked some bacon into their vegeterian diet in their 20’s. Its spooky stuff and gets us into the wonderful realm of the incalculable but it does go to show how much of an access you can get to another person through feeling their pulse.
I can say that, with practice on the pulse, there is often a sense of being able to really ‘feel’ the life force, the nature of the patient. Most herbalists I have met clearly set great stock in that intuitive flash of ‘just knowing’ what is the right approach, the right herb, and how when that happens wonderful things are often seen to take place in the healing journey. Perhaps we all find our own way of getting there but I believe it is no accident the tongue and the pulse have been so integral to nearly every system of medicine; they truly do seem to open your instincts into what is really going on.
Feeling a pulse is like catching a shimmering fish. If you touch it too lightly it will whisper through your fingers like smoke. Press too deep it will wriggle and writhe until you let it go. Wait with it patiently and it will give you its body and let you feel its underwater swim.
We are back to what it is that actually heals people. One of the greatest things that this process has done for me personally is that it has grown and continues to develop a sense of ‘that’ which actually heals. And that, my dear colleagues, is the number one thing any of us have going for us, ever. Our words and our medicines can be wonderfully supportive allies to the healing power of nature but they can never replace it. And they don’t have to. Knowing this, not just theoretically, but in your heart and in your practice gives an extraordinary freedom to be involved, to have compassion, without depending on the outcomes.
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Finishing with Questions
Let’s sum it up, what have we actually done through this process? We have asked a handful of questions to get a sense of the main trends in our patient’s constitutional ‘nature’. We have looked at the tongue to see what are the most obvious ‘tells’ from the body as to where it needs help the most. We have felt the pulse to get a deeper sense of their vitality, their life force, and to deepen the impression of their current constitutional status.
All this should lead us to having a good chance of being able to usefully ask the following questions.
- Does this person need some help with warming or cooling? How much?
- Does this person need cleansing influences or a more nourishing kind of support?
- Will this person benefit more from some kind of building up or relaxing down, i.e. are they in a state of deficiency or excess?
The End ...
So, lastly we come to the practical end of all of this. Why go to the trouble to learn a patient’s constitution and to try to get a feel for their nature in the first place? Aren’t their enough protocols out there kindly provided by ‘Corporate Naturopathica’ that will ensure we get our programs right for the ‘condition’ without having to worry about learning any old skills?
This is another deep subject. Talk to young graduates and new practitioners and you will hear a common theme. They can be obsessed with ‘what’ to give. Whoever talks to them the most convincingly about ‘what to give’ gets the vote with their cheque book. And let’s face it; the world of natural medicine is replete with healthful substances, we certainly do not lack choice! Talk to older praccys and a different picture emerges. I suppose each of us has to decide for ourselves how much we think it is up to us and how much it is up to ‘Nature’ to heal whats wrong. I can only speak from my own experience on this which is to say that compared to the radical diets, vigorous protocols and intensive self-improvement programs I gave in my early years, the much subtler nudges I use today in well tuned tonics and simple suggestions usually just work better. And I’m saying this for the really rough stuff that I’m presented with now more than ever before.
On a related note there seems to be this endless and unsolveable debate within natural medicine as to whether it is primarily the ‘substance’ or the ‘energy’ of medicine that conveys the healing. A deeper analysis of the problem reveals the problem itself to be nonsensical! The substance and the energy cannot exist without the other so why make one more than the other? It’s similar to the notion that the mind is somehow more important than the body or vice versa. It doesn’t matter what is going on, people suffer, always, in both.
Like I say, it’s a deep subject. So that’s nice. Now, ummm, what do you give? Well for a start I think Herbalists are allowed to and should develop their own favourites.
However you might explain this away, whatever you feel most attuned to and whatever you have good reason to feel the most confidence in are the things that will be seen to help your patients the most. Personally I like strong, physical doses of herbs but I feel it is vital to have an appreciation of their energetic qualities at the same time. How else can you really ‘know’ which ones to use!
The chart at the beginning of your notes titled 58 Constitutional Medicines expresses more of my approach. This is all very flexible but it should go to highlight some of the broad strokes of how certain herbs can match into the constitutional patterns. You will notice many of the herbs are found in pairs on the chart. Pairing herbs is a powerful way to unleash their synergy; some of you will be familiar with this but if you aren’t I warmly encourage you to look into it more. Pairing quickly helps you to build powerful, meaningful prescriptions and is another of the old ways that has stood the test of time over many millenia…
Do we really think we are so different today?
I wish you well with it all.
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References & Acknowledgements
No text books were harmed in the preparation of the above material but I really do have to thank Simon Mills for getting me properly started on the constitution many years ago in his literally ‘Essential Book of Herbal Medicine’.
I also acknowledge with great affection all the wonderful herbalists whose talks, books, seminars, online contributions and best of all, companionship have all richly nourished the thirsty sponge of my brain. Equally I acknowledge the remarkable trust from several thousand patients who have given me the extraordinary opportunity to continue to actually practice and learn this craft.
Surely nothing of any importance that I have described above is new; the best reference I can claim to any of it is that it has all been said in one way or another, many times before.
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