Immediate Significant Changes On The Tongue As A Direct Result Of Gua Sha

One of the unique characteristics of the Chinese medicine clinical encounter is that the four examinations, looking, listening, asking and palpating, are continually updated, even within the session. After applying needles and or techniques like Gua Sha, Tui Na, Plum Blossom, or moxibustion, an area of the body may be palpated again, asking and feeling if its temperature, texture, tightness or tenderness has changed. The practitioner may feel the pulse two or three times to note any changes. Rather than securing oneself to a firm diagnosis, the practitioner uses what Judith Farquhar calls ‘knowing practice’, and Volker Scheid calls ‘knowing doing’. In other words, the clinical encounter is a circular interactive loop where the next move is guided by the changing terrain. Evaluation becomes treatment and the treatment becomes evaluation. (Finando, Nielsen 1999) Because we are able to understand a phenomenon only by changing it (Mies) then more important than the diagnosis itself, is where it yields, and becomes something else.

Tongue ‘looking’, however, is typically done only once or twice at the beginning of the session because ‘diagnostic’ features of the Tongue are not expected to change during the session of treatment. To quote a respected text on Tongue diagnosis: ‘Tongue body and coating colors are relatively unaffected by short term events or recent changes’ (Maciocia 1995) Indeed, Tongue changes are expected to happen over time, days, weeks, even months, reflecting the gradual healing that takes place deep in the body as errant, excess or deficient substances reconcile.

Indeed, most practitioners adept in Tongue observation would agree that the flesh color, the shape of the Tongue as well as the presence of petechiae, are substantial indicators that do not readily change. The moisture and coat may change more easily, reflecting the waxing or waning of acute illness. For example, when wind cold lodges at the Tai Yang level, or outer surface tissues, the patient may feel achy and sniffly but the Tongue can still have a normal coat. As the wind cold factors deepen and the body’s orthopathic Qi responds, the terrain transforms to a wind heat presentation. The Tongue becomes more moist, the presence of fluid reflecting the obstruction of channels and collaterals in the superficial tissue of the upper jiao. As the wind heat response continues as fever, the Tongue reddens, its wetness dries, the coat may become sticky, thicken, or yellow slightly. These changes are expected over hours or days.

That is, unless you are using Gua Sha. As a direct result of Gua Sha I have seen and recorded changes in the Tongue that are not supposed to happen in the short term, changes that altered my working ‘diagnosis’, initial herbal formula and subsequent intervention approach. Remember, Gua Sha moves stagnant Blood at the surface, liberating the exterior, moving fluids and clearing obstruction of the channels be it associated with a cold, hot, excess or deficient condition. When the channels and collaterals have been irrigated the affect is not only at the surface but also deep in the body. How deep is the treatment able to penetrate? Does the Tongue change?

Immediate Tongue changes have been observed in the clinics setting with patients and in teaching seminars. And the Tongue changes accompany immediate changes in symptomology. The Tongue changes because the terrain changes.

Consider that stasis of body substances shows on the Tongue as variations in color, coat, fur, and shape. Areas of increased redness indicate heat stasis, for example, accompanied by pain or stiffness. Pressing at the surface of the tissue will confirm if the stasis is associated with sha. The following before and after slides demonstrate the changing nature of the Tongue as a result of Gua Sha.

Figure 1 shows the before Tongue.

Figure 2 shows the after Tongue.

Figure 3 shows the Sha associated with the Tongue changes.

Figure 4 shows sha at neck and scalp

These Tongue changes represent a clearing of heat and harmonizing Qi and Blood in the Upper Jiao. The patient experienced immediate relief of pain at her head, neck and back. Tongue paleness can indicate Blood or Qi deficiency, but may be masked by the redness of pathogenic heat in the surface tissues as in this case.

Tongue changes from Gua Sha verify that moving Blood stasis at the surface can also transform the deeper tissues of the body. How deep the affect will show on the Tongue. Even the smallest shift can clarify the depth, direction or range of a pathology or pattern. In general, I have seen the most profound Tongue changes occur after applying Gua Sha to the upper back, neck, and shoulders confirming the Tongue’s direct correspondence with the Upper Jiao and indirect correspondence with the Middle and Lower Jiao.

Figure 1 - The tongue before gua sha is red. The sides of the Tongue are scalloped. The Tongue is wet, shiny, with a near absence of coating.

Figure 2 - After applying Gua Sha the Tongue has paled , and there is an increase in a thin white coat.

Figure 3 - The Sha that caused the tongue changes

Figure 4 - Sha at the neck and scalp

Tongue Moisture and Coat

• A dry Tongue becoming moist indicates Fluids are moved and harmonized.
• A drippy Tongue becoming normally moist indicates Fluids are astringed.
• A thick coat becoming thin indicates Dampness is resolving.
• No coat changing to thin coat, or a not rooted coat beginning to root indicates the Qi and Yin of the Stomach is strengthened.
• A thin coat thickening indicates Damp is collecting. Check patient regarding hydration or unresolved pathogenic factor.
• The coat changing on a specific area of the Tongue indicates Factors are either resolving or deepening at the corresponding Organ, Channel or Jiao

Tongue Flesh Color

• A red Tongue becoming less red indicates Pathogenic or residual heat has been cleared.
• A pale Tongue redening indicates Stagnation resolved. Qi and Blood quickened.
• A peachy Tongue becoming pink indicates Deficient Blood is quickened and nourished.
• A purple area turning pink indicates Stagnant Blood is moved.
• Some red points or petechiae disappearing indicates Stagnant blood with heat is resolving.

Tongue Shape

• A swollen or thick Tongue reducing indicates Fluids deeper in the body are astringed. Qi and Yang are tonified.
• A scalloped Tongue smoothing indicates Fluids are astringed, related to Spleen, and or Shao Yang.
• A thin Tongue thickening or becoming more scalloped indicates Fluids are collecting. Check for unresolved internal deficiency.

It is not unusual in practice in the Northeast to see some form of residual pathogenic heat (Maciocia) in a patient’s lingering symptoms. Correspondingly their Tongue will have reddened areas with or without red raised points that appear often at front end of the Tongue. Heat clearing herbs come immediately to mind as an internal medicine response seems indicated. But after applying Gua Sha, the redness may decline substantially, and the red points disappear by half. Now the Tongue can actually look pale, and I adjust my herbal prescription accordingly. These changes indicate this patient’s residual heat was trapped in the surface tissues. Gua Sha was able to clear it and the underlying terrain of deficiency can be seen.

Or the reverse can happen, but less often. Let say Gua Sha reddens the Tongue when the Tongue began as pale. This is an excellent sign as the Qi and Blood have been quickened. But if the Tongue began as red, and becomes redder, then it is possible a greater internal heat is expressing. Make sure that the patient is well hydrated, continue treatment and check the Tongue again at the end of the session. If the Tongue still remains red, then heat clearing herbs and heat reducing foods and behaviors are justified

While teaching a Gua Sha seminar in Amsterdam, it was noticed that one of the students had a dark purple area on the lateral aspect of the right front third of the Tongue. It corresponded to a right shoulder injury. The student received Gua Sha on her upper back, neck, and top of her shoulders. A re examination of the tongue revealed that the purple area had changed. Gua Sha was further applied to the right scapula area, corresponding to SI 11, 10 and 9. A lot of very dark sha appeared at this sight. A re examination of the Tongue revealed the purple area was now completely gone.

I have confirmed with many patients since, that this area of the upper back and arm (SI 11, 10, 9) can correspond to the front lateral aspect of the Tongue. While visiting a Vietnamese Zen monastery, where Gua Sha or Cao Yio, is a common daily practice, I was informed by the nuns that in Vietnamese medicine this area of the body is thought to store pathogenic heat. Clearing it with CaoYio has a very deep affect, which you can see immediately on the Tongue.

If an acute disorder is of recent onset, Gua Sha can extricate the surface stasis and pathogen with comfortable easing of symptoms. If the onset is less recent with more severe stasis, Gua Sha may create a crisis; that is a temporary worsening of symptoms as the lingering illness is resolved by the body, facilitated by Gua Sha. (Nielsen, 1996). Changing Tongue signs will correspond with the trajectory of healing.

For example, applying Gua Sha at the very beginning of a cold or flu, may prevent any further cold signs. If the intervention occurs somewhere in the middle of the illness, fever or pain may actually intensify, and then decline in 24 hours. If the intervention is given after some days where there is no longer fever, but palpation (press and blanche technique) and Tongue examination (red with red points) reveal residual pathogenic heat and Sha, then Gua Sha essentially clears what is left, preventing a relapse.

The expectation is that chronic disorders are slow to change, the patients presenting complaints as well as indicators such as Tongue. But my experience is that even in chronic disorders it is important to use Gua Sha and note the corresponding changes in symptoms and Tongue. Most chronic disorders have a component of stasis. In what way does the stasis yield to Gua Sha, and how deeply does that movement reach into the interior can enlighten prognosis. How much a terrain can be potentiated to change can often be told in the first treatment.

Practitioners steeped in Chinese medicine are shocked and challenged by what they see unfold on the Tongue after applying Gua Sha. As one of my students incredulously stated: ‘What do you mean the Tongue changes, I thought you could rely on the Tongue’. Indeed, you can rely on the Tongue precisely because it does change. And how it changes during the session of treatment helps the practitioner determine the depth and direction of a disorder.

When teaching Tongue observation or Gua Sha I recommend drawing the patient’s Tongue at the beginning of the session. After applying Gua Sha, view the Tongue again, and then again at the very end of the session. Record the changes. This practice not only develops an eye for Tongue changes, but also records the results for future sessions.

I urge all those who use East Asian medicine, whether in professional practice or informal care taking, to look to the changing landscape of the Tongue to guide your way.

Chen Z, Chen M 1989 The essence and scientific background of tongue diagnosis. Oriental Healing Arts, Long Beach, CA.

Farquhar J 1994, Knowing practice, the clinical encounter of Chinese medicine. Westview Press. Boulder CO

Finando S, Finando D 2000, Informed touch, a clinicians guide to evaluation and treatment of myofascial disorders. Healing Arts Press, Rochester, VT

Maciocia G 1987 1995 Tongue diagnosis in Chinese medicine. Eastland Press. Seattle, WA.

Mies M 1991 "Women’s research or feminist research? The debate surrounding feminist science and methodology". Trans. Andy Spencer in Beyond methodology: feminist scholarship as lived research. ed. M Fonow, J Cook Indiana University Press.

Nielsen A 1996 Gua sha as counteraction. The crisis is the cure. The Journal of Chinese Medicine Jan. #50

Nielsen A 1995 Gua sha, a traditional technique for modern practice. Churchill Livingstone, Edinburgh

Nielsen A 2000 Gua sha, eine traditionelle technik fur die modern medizin. trans Marcus Schmid and Suzanne Volcker. Verlag fur Ganzheitliche Medizin, Koetzting Germany

Nielsen A "Why we don’t diagnose in Chinese Medicine". The Anglo-Dutch Institute of Oriental Medicine Magazine Spring 1999-7

Scheid V, Interview by Velia Wortman , The Anglo-Dutch Institute of Oriental Medicine Magazine, Spring 1998 .

Song TB 1981, Atlas of tongues and lingual coatings in Chinese medicine. Peoples Medical Publishing House, Beijing.