Constitutional Medicine, Tongues & Pulses.

Underlying a person’s health and personality is their constitution, which can also be described as their 'nature' or 'temperament' If you are new to this subject you might want to read the general introduction here and if you have yet worked out your own constitution then you might want to first read about that here.

A living, practical understanding of the constitution and the changing nature of both the tongue and the pulse have been central to all the old traditions of medicine. For a good while now I have been sharing my own experiences and understanding of this fascinating subject via forums, seminars, webinars and articles and the following material is taken from a paper I presented to my colleagues at an international conference some years ago. I include it here with my fellow practitioners and students in mind but also for anyone who has a keen interest in this subject for their own reasons...

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These three, deep laws have been the best guides I’ve had.

1) Primum Non Nocere   
..... First, do no harm.

2) Tolle Causam    
..... Treat the cause

3) Vis Medicatrix Naturae    
..... The healing power of nature

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All things considered, Dennis Stewart and Co 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 with no land in sight!

In working out what actually works an awful lot has happened for me since that time and in very practical ways the above ‘rules’ have been profoundly useful. I have learned beyond a shadow of a doubt that it really is Nature that does the healing (as much as 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, about not interfering with Nature. The second rule is equally powerful in its usefulness on what to do. Treating the cause means you have to get involved and to treat the cause you first have to look at it, which is tricky, not because it’s so very hard to see but because there can be so much to see! People rarely have just one single origin to their troubles and each layer you look at can seem to have another one underneath!

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?

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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 and gently worked 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 and so help them to better understand themselves.

People do all kinds of injuries to themselves with their stress, their diets, their environments, their relationships... 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.

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, 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 millennia. It’s a bit of a mystery as to why we have gotten so estranged 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. (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’!)

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.  

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.

However it is crucial to understand from the outset that none of this is fixed in stone. People are organic, messy, changeable creatures. They will have a genetic, constitutional tendency to always be somewhat cooler or hotter, dryer or damper but they can and do move a great deal forwards and back from that natural tendency.

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’.

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The Tongue

Just looking at the tongue without the constitutional background is basically a really bad idea. I know this to be true because I’ve always looked at my patient's tongues and 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 sandal 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…

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If you have gone through a bit of questioning as discussed in the working it out section here, you should already have a reasonable sense of the constitutional pattern of the patient who is now sitting before you and this is where it all gets very interesting for 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 a basic constitutional understanding in place.

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 gives you the back drop; now, at this particular moment, the tongue is able to help show you where to place your treatment emphasis, it's priceless information!

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There are 5 main tongue parameters that are espcially useful; they are:
.......... 1) Colour 2) Smoothness 3) Coating 4) Moisture 5) Fullness

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 constitution 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. Cooler 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.

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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 whilst cooler temperaments go to more white coatings . A greasy coating from either type, which seems like a kind of solid ‘film’ over the tongue is telling us to go carefully and thoroughly because this well-developed layer is indicative of a long build-up of ‘encumbrance’.

Equally important in looking at the coating 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 too far.

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 Sahara 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.

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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 probable tick in the dry box but be aware that it might just be a genetically smaller tongue.

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~ 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 one other movement which is extremely revealing. A movement that can help us to much better understand a person's ‘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! Let’s start with what kind of pulses you typically feel in the different constitutions.

Cooler
A cool constitution typically has a pulse that takes more than a moment to find. A really cool 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. Cool 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 cool 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 cooler people have less ‘energy’, this is not necessarily true at all, but they do tend to keep it within more.

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Damper
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.

Tiger 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’.

Bear 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

Dryer
Dry signs in the pulse are equally telling in that they feel much shorter, more compact. 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 more space, more air, immediately before and after each beat.

An Eagle 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 Eagle 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 Elephant/Butterfly’s cool 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 an EB that has gone too cool 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.

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Hotter
The hot constitutional pulse has already been somewhat described 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 dramatically and with less warning.

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.

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Qualities of Pulses

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 cooler constitutions. 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 usefulness 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).

Slippery to Firm.
Again this is a particularly useful quality to get accustomed to feeling for in the pulse. Damp, slippery pulses are distinctly 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.

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The Impression

The Chinese say you have to listen to 10,000 pulses before you master it. I guess the point is that you have to feel a lot of pulses to get the hang of it and 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 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.

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, to not have to lead but to wisely guide the way.


____________________________

~ Tigers: Hotter & Damper

~ Eagles: Hotter & Dryer

~ Elephant/Butterfly: Cooler & Dryer

~ Bears: Cooler & Damper

~ Back to Constitutional Medicine Introduction

~ Working our your Constitution

~ Origins & Adaptations of Constitutional Medicine

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© 2011 R.J.Whelan Ltd