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, read the general introduction 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 many years now, I've been sharing my experiences and understanding of this fascinating subject via forums, seminars, webinars and articles. The following material is taken from a paper presented to colleagues at a herbal medicine conference on the Gold Coast, Australia, it is included 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, great Australian herbalists Dennis Stewart, Andrew Pengelly, Robyn Kirby & Raymond Khoury did a pretty good job at getting ‘water-wings’ on me in the 1980s but setting up a herbal medicine clinic in conservative Christchurch in 1989 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. For example, I've 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.

The first and third rules are 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 look at it, which is tricky, not because causes are so very hard to see but because there can be so much to see. A person with a chronic problem rarely has just one origin to their troubles, furthermore each layer you look at can have another one underneath!

People are complex, so are their problems. You can throw all kinds of diagnostic darts at people and hit something important wherever it lands. Eventually it can all need a big step back, a big breath, and a pause for thought. What exactly 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 so it can be worked on in an ongoing manner.

There are as many causes as there are problems. In chronic health problems, many of them are self-inflicted. People do all kinds of injuries to themselves with their diets, with bottling up stress, with resting and sleeping inadequately, with not moving their bodies or activating their brains...

It’s naïve to think we can remove all the harm in our own life, let alone another persons' but I still 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 underlying their troubles, is their ‘nature’; variously described as their constitution, their temperament or their energy. Their nature is 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 Western Herbalists got so estranged from it whilst our Indian and Chinese cousins just kept 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 Cooler to Hotter. Cool constitutions have slower metabolisms, more gradual expenditure of calories, reduced responses to illness. They are often more introverted and introspective whereas hotter constitutions tend to have faster metabolisms, slightly higher body temperatures and have more acute or dramatic responses to illness. They are usually more extroverted, more naturally expressive.

The second, equally important spectrum in the constitution is described as Dryer to Damper. Think of this as something that overlaps the first spectrum, in other words people have a natural tendency to be cooler or hotter and, at the same time 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 can also relate to a more general depletion in the case of excess dryness and an equally apparent encumbrance in the case of excess dampness.

T
here are many permutations to all of this and there is a third spectrum, the moving ‘nervous energy’, which we only really start discussing when we get to the pulse, which greatly affects how people experience and express their basic constitutional temperaments.  

It is also 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

I highly recommend taking photographs of your patient's tongues for two reasons:

Firstly, by using a smart phone and being able to look at the photo right away, you have the immediate ability to spend longer looking at the tongue without needing them to keep hanging it out overlong. Poking out your tongue in front of someone requires no small degree of trust. It is literally showing your internal body to another person. It's very revealing, and people instinctively know this. A photo lets you read the tongue with as much time as you need to take in the impressions it is giving you whereas, at least for some people, you might stop looking too soon because you would sense their discomfort in holding it out for more than a few moments.

Secondly, it is highly useful to be able to compare before and after pictures when you see that person again. Things will change, you will get new signals from the tongue as they go through different stages and after you have gone through any kind of treatment program. Tongue photography will rapidly increase your knowledge and understanding of this ancient art.

With practice, you will see that there are almost always one or more signs that will ‘spring out’ to you. In many instances, these will be the signs you are especially meant to take notice of. Just as the body tries to talk to us through its symptoms, so the tongue tends to show us what we need to see.

The tongue goes through subtle changes all the time, it perfectly mirrors, day to day, many of the key self-regulatory functions of the vital force, the ‘body intelligence’. The constitutional picture gives you the back drop; now, at this particular moment, the tongue can help show you where the key imbalances are

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There are 5 main tongue parameters that are especially useful; they are:
.......... Colour - Smoothness - Coating - Moisture - Fullness

Before I go on and describe the kinds of constitutional tendencies, dualities and signals you can get from looking at the tongue I need to make something abundantly clear, which is that each and every person that has ever lived, and is living now, is a unique and highly complex human being.

You know this, you've heard it before, it would be easy to gloss over this point in the wish to get the answers to what the tongue can tell us; That would be a mistake. A person's individuality is not just expressed in their personality, their voice, the fingertips and their thoughts, it shows through in their tongue and how it represents the constantly changing internal environment of their body.

If you go further afield into the subject of tongue diagnosis you will soon find a plethora of books, maps and charts that set out dozens upon dozens of signposts that all emphatically say, 'this means that'.

Well, here's the thing, 'this means that' some of the time, but firstly people are very different and you would need thousands, rather than dozens, of pictures to show just how variable they can be and secondly, the tongue changes, a lot, and unless you have been studying it and know how it was before compared to now, you can badly misinterpret where those signposts are pointing.

Another thing to be aware of is that, if you study the Traditional Chinese Medicine (TCM) interpretations of the tongue, for example, and try to superimpose a Western understanding of the heart, the spleen, the liver etc, in the way TCM sees them in the tongue then you are going to completely misread the signals, Years of immersion in the philosophy and practice of TCM are necessary before you can make a clean connection between how they read the tongue to understand the body.

People naturally want answers when there is a problem. They especially want them from the practitioner they have gone to see for solutions! The great trap for anyone wishing to use the tongue to guide their understanding is to make pronouncements when they really don't know enough.

They don't know enough of the history of that person, i.e. how they were before and how things will change when a change of diet, herbal medicines etc. are bought into the picture. People are complex, there is nothing more complex than people. In learning and practicing tongue analysis, avoid the temptation to make pronouncements, rather take in impressions. This is the way to gain great insight without the ego needing to make itself heard. By the way, let me be clear that it's perfectly normal and to be expected to fall into the trap of the ego, we all do it, frequently, the greatest danger is if when we deny we do it and so have no hope of stopping it!

Our ego, our need to be right, to be clever, to have special knowledge that lets us make pronouncements on people, only gets in the way of working out what is the best way to guide a person. In practice, the patient hardly ever needs you to talk about what you are seeing when you study their tongue. If your intention to be there for Nature and for Healing is strong and pure, they will be glad to let you see their tongue, to absorb its messages, so you can be a good guide for them in their time of need.

Look closely and take in what it is telling you with a truly open mind. Later, when you have taken in the many signs, including those from their tongue, that you are there to see, hear and understand, when it comes time to make the recommendations for the right herbs, the right change of direction, those impressions will guide you well.

Colour

You will observe that cooler people tend to have paler tongues and that hotter people get noticeably redder tongues. Interspersed into the colour is the ‘hue’, how dark or bright the tongue is. Darker tongues are more common in cooler constitutions and brighter tongues are more common in hotter constitutions.

You have to look at the tongue body under the coating to get the true impression of the colour. For example, a hotter constitution with early signs of dampness might have quite a bright white coating overlaying their reddish tongue, making their tongue look paler than it really is.

Smoothness

Cooler constitutions usually 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 cooler nature, whether that is causing them some real trouble at this point in time. As people get more unwell, the tongue can get both smoother and paler at the same time. Likewise, as they get better the texture comes back and so does some of the colour.

In exactly the same way, a person with a hotter constitution going into imbalance will get a steadily rougher and ruddier looking tongue. Fissures in the tongue are usually a sign of excess heat but you need to be aware that a small percentage of people have a highly fissured ‘geographic’ tongue as part of their genetic constitution. It is the smaller fissures that come and go that are useful signs on how excess ‘heat’ may be increasing or decreasing.

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Coating

The coating is the favourite feature of everyone who looks at their own tongue or anyone else's. 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 probably going to be 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 whiter coatings. A greasy coating from either hotter or cooler types, which seems like a kind of solid ‘film’ over the tongue is generally 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! 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 dryness has gone too far.

Moisture

The current weather, the last meal, the current levels of circulating cortisol and so forth are all going to affect how dry or damp the mouth is right now. That said, there are 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 and that is by far your strongest impression, then maybe you are meant to do something about it. Likewise, if excess moisture is the key first impression, then closely look at how excess ‘dampness’ may be related to their current troubles.

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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 more or less according to the level of dampness at the time.

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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 might 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 must be very sensitive to its whisper.

Cooler 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 cooler 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 hotter 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. Hot people run into just as much trouble as anyone, they just tend to do it more dramatically and with less warning.

The hotter 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, just stay with the enquiry longer.

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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 (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 cooler constitution and faster pulses to the hotter, but this varies a lot according to numerous factors, including fitness and stress levels.

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 cooler and/or dryer constitutions.
Full pulses show up in both hotter and/or damper constitutions.

Smooth to Edgy

There is an excellent correlation between nervous tension and the ‘feel’ of the pulse. People in calm good health can have a lovely, not too soft, not too hard, fluid vitality to their pulses. 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, as soon as you feel ' edges' in the pulse, you will know exactly what I mean, they are a most helpful ‘tell’ to the observant practitioner.

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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 really get the hang of this and that I can definitely attest to. If someone approaches this subject with the modern mentality of wanting it to work as soon as it’s out of the 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 usually seen to ensue 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 seem to open our instincts into what is really going on better than anything else.

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, but if you wait with it patiently, 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 best thing any of us have going for us, ever.

Our words and medicines can be great allies to the healing power of nature but they can never replace it, that's ok, they don’t have to. Knowing this fact, this truth, not just theoretically, but in your heart and in your practice, gives an extraordinary freedom to get involved, to have compassion, and 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