Immediate Significant Changes
On The Tongue As A Direct Result Of Gua Sha
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.
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.
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 bodys 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
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?
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
By Arya Nielsen, MS, MA, LAc
Appearing in Gua Sha, Eine traditioelle Technik fur die moderne Medizin,
Verlag fur Ganzheitliche Medizi, 2000 ISBN 3-927344-51-6
content of this article was first presented at the International
Acupuncture Conference in Amsterdam, Nov 1999, sponsored by the
Anglo-Dutch Institute of Oriental Medicine.
Stasis at the
Tongue and Body Surface
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.
and After Tongue
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
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.
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 Tongues
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
Changes and Their Signifigance
Moisture and Coat
dry Tongue becoming moist indicates Fluids are moved and harmonized.
drippy Tongue becoming normally moist indicates Fluids are astringed.
thick coat becoming thin indicates Dampness is resolving.
coat changing to thin coat, or a not rooted coat beginning to
root indicates the Qi and Yin of the Stomach is strengthened.
thin coat thickening indicates Damp is collecting. Check patient
regarding hydration or unresolved pathogenic factor.
coat changing on a specific area of the Tongue indicates Factors
are either resolving or deepening at the corresponding Organ,
Channel or Jiao
red Tongue becoming less red indicates Pathogenic or residual
heat has been cleared.
pale Tongue redening indicates Stagnation resolved. Qi and Blood
peachy Tongue becoming pink indicates Deficient Blood is quickened
purple area turning pink indicates Stagnant Blood is moved.
red points or petechiae disappearing indicates Stagnant blood
with heat is resolving.
swollen or thick Tongue reducing indicates Fluids deeper in the
body are astringed. Qi and Yang are tonified.
scalloped Tongue smoothing indicates Fluids are astringed, related
to Spleen, and or Shao Yang.
thin Tongue thickening or becoming more scalloped indicates Fluids
are collecting. Check
for unresolved internal deficiency.
Most Common and Valuable Change:
Heat Stasis is Cleared
not unusual in practice in the Northeast to see some form of residual
pathogenic heat (Maciocia) in a patients 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 patients residual
heat was trapped in the surface tissues. Gua Sha was able to clear
it and the underlying terrain of deficiency can be seen.
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
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.
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.
Gua Sha In Accute Disorders
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
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.
Sha and Chronic Disorders
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.
Comfortable With Change
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.
teaching Tongue observation or Gua Sha I recommend drawing the patients
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.
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.
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