Introduction to Tongue Assessment for the Western Herbalist

Many healing systems recognize the tongue as reflecting something about the health of a person, both patterns of overall health or imbalance and the state of particular organs and tissues.

This is one of the most valuable tools available to us herbalists. It’s an accessible, time honored and low-tech skill.  Through the interview the herbalist generates a list of problems and symptoms with many possible interpretations and possible remedies. The tongue is a powerful tool for refining our understanding of the individual and moving us toward an effective remedy.  I also appreciate that looking at the tongue lends itself easily to sharing observations and insights with whomever I am working, bringing them into the conversation more fully and helping them make sense of their own bodies.

Tongue signs can be used by those practicing from an Ayurvedic model, Traditional Western Herbalism or Traditional Chinese Medicine. I will speak mostly about tongue signs as they fit into the six tissue states model described by Matthew Wood. I find this model to be elegant, flexible and useful.  It’s simple enough to learn as an herbal student who is just beginning to think about patterns of health and illness (energetics) yet sophisticated enough to offer a lifetime of deepening refinement for the practitioner.  TCM describes many tongue signs that are beyond the scope of this article. These tongue signs play a part in specific TCM diagnoses and may be difficult for the non-TCM practitioner to translate into a Western practice. I encourage you to investigate the resources listed if you are interested in diving more deeply into this subject.

 Let’s get started!

Try to look at the tongue in natural, bright light. Move to the window area if you need to. Blood pools in the tongue as it is extended for any length of time making the client’s tongue appear darker and more purple the longer the tongue remains out of the mouth therefore you don’t want the client to hold the tongue out for an extended period of time.  If you are new to tongue assessment, don’t be afraid to ask the client to stick it out more than once.

I find that coat (color and quality/quantity), color of tongue body, level of wetness and the the absence or presence of shaking or trembling to be the indications that are the most important to observe.  These four signs give us a lot of insight into the patterns of imbalance experienced by the client. They can help determine if the client is experiencing hot, cold, flowing damp,  damp -stagnant, dry or tense and conditions.   I also keep alert for a few helpful miscellaneous indications, particularly the shape of the tongue body and the presence of inflamed papillae.

When teaching students to assess the tongue I find it’s helpful for students to look at several tongues in succession focusing on one aspect at a time, such as coat, tongue body or wetness level.  This is easier for beginners than trying to make sense of the whole tongue at one time.  Memorize and internalize these four questions and ask them each time you look at a tongue: How wet is the tongue? What is the coat like? What is the color of the tongue body? Does the tongue tremble or shake?  Make a small diagram of the tongue in your notes. This will help you remember what you saw when you review your notes and allow you make note of tongue changes over time from meeting to meeting.

Coat

Everyone has coating on their tongue. Normal coat is thin and white. It is often thicker in the posterior third of the tongue and is often more prominent in the center of the tongue as opposed to the edges or tip. The herbalist should assess the coat for color (usually white or yellow), quantity (thickness) and quality (dry or creamy and greasy).

Bear in mind that coating is the tongue sign that most reflects acute illness. Someone who sees you while they have an upper respiratory infection may have a tongue coating that is quite different than usual. A coat that is thicker, drier, whiter or more yellow are common changes when a person is ill. These signs can help you treat the infection more effectively with warming or cooling remedies for example.  Tongue coating can be observed over the course of illness and can change quickly and dramatically.

Tongue coats indicate what I like to call “buildup.”  Different healing traditions use a variety of words and concepts to discuss buildup. Toxins, ama,and phlegm are words or concepts you may be familiar with.  Too much buildup indicates that a person is bogged down with waste products, function is impeded by stagnation.  As mentioned above, a thin white coating is completely normal. Thicker coats indicate greater buildup and the need to disperse the stagnation or cleanse the tissues, allowing the body to throw off the extra burden. Whether the coat is dry or creamy reveals to us the extent to which the person is also dealing a dry or damp imbalance respectively. And the color of the coat white or yellow reveals whether the imbalance is cold or hot, with white generally indicating cold and yellow generally indicating heat.

Tongue Coat:  Note the  thick, creamy, white coat with peeling patches in the center.
Tongue Coat: Note the thick, creamy, white coat with peeling patches in the center.

Put it all together. It’s easy.  A yellow dry coat is dry heat.  A yellow, thick, creamy or greasy coat is damp heat. An extremely yellow tongue coat can begin to look somewhat brown. Likewise, thick, creamy or greasy white coat is damp cold and a white dry coat is dry cold.  Western herbalism offers such a full, rich materia medica of alteratives that can cleanse every type of constitution from the damp and hot or damp and cold to the cold and dry or cold damp.

Tongue Coat:  The coat is primarily thin but is somewhat yellow towards the center/back.
Tongue Coat: The coat is primarily thin but is somewhat yellow towards the center/back.

I’ve never seen a black coat in practice but authors on the subject agree that a black tongue coating is seen in cases of serious illness. In Leslie Tierra’s book, “HealingWith the Herbs of Life” she writes that a grey/black coat when” wet indicates extreme Cold; and dry designates extreme Excess Heat”.

The lack of coat is well described in TCM which views a lack of tongue coat as a sign of Yin Deficiency.  In our terms we might understand this as an extremely dry and deficient imbalance and weakened condition likely with secondary heat from a lack of fluidsUsually the tongue body is also quite red and often the withered in appearance.  You see this tongue more frequently in thin people with some nervous system/emotional issues, issues of dryness and weakness. Treat with moistening remedies for the atrophic tissue state.

Body Color

Normal color is pale red.  Tongue body color is one of the more challenging tongue signs to read.  The experience of color is somewhat subjective. In addition, a thick tongue coat may obscure the color in the center (learn to try to look beneath it and around it). Tongue color is rarely uniform throughout the individual tongue. While experts maintain that redness at the tip is a sign of imbalance, in practice this is a very, very common tongue sign and a person may not have any complaints that seem related to this heat.

A deep or bright red tongue body calls for cooling remedies.  Many herbs may have a cooling effect. (See Illustration tongues 1, 3, and 4). When assessing for heat is important to also assess for dryness.  Some people have heat that may be secondary to a dry condition.

A pale tongue body is a sign of cold and calls for warming remedies. I have noticed that very pale tongues are also often wet, damp tongues that may be fat or flabby.  These bodies are calling out for the warming astringents.

A purple cast is sometimes seen in the center of the tongue (See illustration tongues 5 and 6).  This spot may be quite small or take up a large proportion of the central tongue body.   This as a sign of stagnant blood that calls for dispersing via circulatory stimulants. Purple in the lung area of the tongue may indicate poor circulation and stagnation in the respiratory tract. Many women show purple in the center to back half of the tongue that seems to correlate with stagnant conditions in the pelvic and reproductive organs.

Blue coloration in the tongue is uncommon.   This is a tongue sign I find a bit worrisome when I see it.  Blue is a more extreme form of blood stagnation than the purple sign. This tongue state calls for warming remedies and powerful blood movers.  Every herbalist will have personal favorites.  I find Yarrow tests well for these folks and can provide nice results.

Wetness

Wetness is a relatively easy sign to read. Occasionally, you will notice a client attempt scrape all the saliva off their tongue and swallow it before sticking out his or her tongue. Explain that you want to observe the normal wetness of the tongue. Ask her to put the tongue back in the mouth for a few moments and try again this time allowing the saliva to remain on the tongue. A normal level of wetness is moist, but the tongue is not dripping with saliva. There’s no frothy saliva and no streamers of saliva.

Wet tongues with lots of saliva or streamers of saliva indicate a damp condition.  Seeing a wet and damp tongue should lead you to consider your favorite astringents, tightening and toning remedies.  A dry tongue is easy to spot and should lead you to consider your favorite moistening remedies. These might be mucilage rich emollients/demulcent remedies, but they may also be nutritive, tonic, building or lubricating herbs that increase the flow, retention or absorption of fats, oils and fluids.

Trembling or deviated

The nervous system can be reflected in the tongue as well. When the person sticks out his tongue does it tremble?   You might see a delicate little tremble or big jerky movements. Trembling is a sign of tension, also called wind or constriction.  This is literal tension not just psychological tension. Many people who are suffering emotionally or psychologically may benefit from nervines but may not have physical spasm or tension like this. In other words, nervines come in quite handy even in the absence of tongue signs that indication tension.   However, the person with the trembling tongue will very likely respond especially well to nervines with antispasmodic qualities.

The apparently strange shape of this tongue is an effect of the camera capturing the tongue trembling and jerking. He was unable to hold his tongue out with stillness.
The apparently strange shape of this tongue is an effect of the camera capturing the tongue trembling and jerking. He was unable to hold his tongue out with stillness.
This is the tongue of the same child above. The apparently strange shape of this tongue is an effect of the camera capturing the tongue trembling and jerking. He was unable to hold his tongue out with stillness.
This is the tongue of the same child above. The apparently strange shape of this tongue is an effect of the camera capturing the tongue trembling and jerking. He was unable to hold his tongue out with stillness.

Pappilae

The lymphatic system is reflected in the pappilae. I view anything abnormal about the pappilae including red or prominent papillae as a signal to test my lymphatic remedies. If I hadn’t considered a lymphatic imbalance during the interview I will now think a little differently about the client’s condition and perhaps ask a few follow up questions. (See illustration tongues 3 and 4).

Tongue 3: The most prominent feature of this tongue is heat throughout the tongue and inflamed papillae across the surface of the tongue.
Tongue 3: The most prominent feature of this tongue is heat throughout the tongue and inflamed papillae across the surface of the tongue.

Organ Mapping

Tongue assessment is part of both TCM and Ayurvedic medicine. There is a reasonable congruence between Ayurvedic tongue assessment and TCM regarding the map of the organs on the tongue. Within TCM there are a couple of different schools of thought with regards to where to map different organs on the tongue.

The tongue can roughly be divided into three segments anterior (tip), middle and posterior (root).

Tip/Front third is upper organs, or in TCM vocabulary, the Upper Warmer, including the heart at the tip.  Think broadly about the heart, not just the physical heart and vasculature but the metaphysical heart as well—the spirit and the mind.  Thus a very red tip or redness at the tip that extends further into the tongue body can correlate with psychological problems, or duress especially panic, anxiety and  hyperacitivity in children.  The lungs are also reflected in the anterior third of the tongue.

The middle third includes the stomach and the Chinese Spleen (largely a digestive organ in TCM) as well as the liver and gallbladder.

Liver and Gallbladder are mapped on the sides of the tongue.  In some models the liver is on one side and the gallbladder on the other.  While in other models the liver and gallbladder are treated as one unit and are reflected on both sides of the tongue

The root, or posterior third, includes the kidneys and bladder. The intestines are sometimes mapped onto the posterior third with the kidneys and bladder. Sometimes the small intestines are given one side and the large intestines are given the other side.

I find many of these refinements to be unnecessary for my level of practice, and may simply add a confusing element for beginners.  For my purposes I remind myself that heart/mind/spirit and respiration are reflected in tip and front of the tongue.  The organs of digestion in the middle third and kidneys and urinary tract in the posterior third. Personally, I find organ mapping to be less clinically useful than the practice of attempting to ascertain the tissue state(s) of the person.

Obviously not all the organs are mapped on the tongue using this method, including most of the endocrine glands, the pancreas, the uterus, lymphatic vessels, the skin, the muscles and skeleton.  Don’t worry about it. The client describes to you his swollen glands, his psoriasis, or her menstrual cramps; she knows that her thyroid is low. We don’t need organ mapping on the tongue to tell us these things.  The tongue will, however, reflect tissue state imbalances that can lead you to effective treatment, whatever the affected organs may be.

Body Shape

Body shape is easy to observe and describe. Body shape and the corresponding imbalance is well developed in TCM but not so much in Traditional Western Herbalism. The following are a few indications I find helpful. A flame like tongue is a sign of heat.  (See tongue 1 in the illustrations for a perfect example).  Because this is the actual morphology of a muscle and not just the color, I tend to believe that the flame like tongue indicates a true constitutional propensity to heat and not just a more transient imbalance.

Tongue Body Shape:  Note the flame shape and the brighter red anterior third, both signs of heat.
Tongue Body Shape: Note the flame shape and the brighter red anterior third, both signs of heat.

The thin and withered tongue is also often dry. This tongue body reflects the atrophic tissue state.  The person is malnourished possibly from poor digestion and assimilation and is often, thin, dry and nervous.

You may also see tongues that are thick, puffy and flabby. These folks may be damp either a a relaxed damp state where fluids flow out freely damp stagnant condition where fluids and other waste products are building up and causing a toxic type condition. Scalloped edges are also a sign of dampness.  (See tongue 6 for an example of puffy tongue with moderate scalloping).

Tongue Body:  Note the  scalloping on the sides of the tongue body, the tongue has a slightly swollen appearance, with one side more prominently swollen than the other.   These are signs of dampness.
Tongue Body: Note the scalloping on the sides of the tongue body, the tongue has a slightly swollen appearance, with one side more prominently swollen than the other. These are signs of dampness.

Putting it all together

Sometimes a person sticks out their tongue and the tissue state perfectly matches what you were thinking.  They have allergies, anxiety with heart palpitations and sure enough—the tongue is bright red!  Easy. You give them cooling remedies like Lemon Balm, Hawthorn or Wild Cherry Bark and enjoy watching them feel better. But very often the tongue doesn’t quite match what you were thinking. It’s ok. Let the client’s body lead the way. Be prepared to revise what you were thinking about what’s going on. Be ok with switching gears. Sure, perhaps you still want to pulse test “the perfect herb” that you were thinking of, but consider that herbs suited for the tissue state may help them more than “the perfect herb” that is famous for the condition in question.

What if the tongue has two, three or even four tissue states manifesting? This happens all the time. It’s frustrating for beginners (and experienced practitioners too)!  Bodies can manifest different and contradictory tissue states such as heat and cold or damp and dry.   One part of the body experiences one type of stress or imbalance while a different part has another imbalance. Sometimes you may find yourself trying to tease out complicated patterns like heat that rises out of cold or heat that is secondary to dryness.  This can be a fascinating area of study, reflection and discussion with other herbalists, but in the context of the consultation it can be overwhelming and you may not want to fall down that rabbit hole.  I recommend you stay focused on the practical and ask yourself what can you do for this person sitting in front of you right now? What does he or she need most? You have information from the client about what it feels like to live in their body. You have the tongue signs; you have a wealth of information about different herbs, indications, affinity to organs, energetics, chemistry and taste.

Allow your intuition some say as well and then allow the pulse testing to reveal the necessary remedies. Puzzle it out at your leisure and be prepared to reassess and refine your treatment aims during follow up.

The good news is that herbs are perfectly suited to deal with the complexity of human bodies. Plants with their complicated chemical soup and amazing  and diverse healing energies often easily treat multiple tissue states and sometimes even opposite tissue states, taking the people at both ends of the continuum and bringing them to a balanced middle place.  Yarrow, Elderblossoms and Sage are fine examples of plants that defy our attempts to fit them into little boxes and work on a variety of contradictory states.

What about the person who presents with bothersome symptoms but whose tongue shows little imbalance?  I don’t know what to tell you. It happens sometimes. Be prepared to use your knowledge of the materia medica to help you select remedies and plan on pulse testing more broadly.

What can you expect with treatment?  Tongue coat changes rapidly.  You may see a big change in the tongue coat of a client very shortly after effective treatment.  Over time, you may see changes in the level of moisture. Papillae my return to normal.  Dark spaces that appear purple or bluish may return to a more normal pinkish red. In my experience tongue body color may change subtly.  Cracks and furrows are unlikely to change dramatically. The basic shape of the tongue does not change much if at all in my experience.

Sometimes clients experience positive changes in their health after treatment but tongue signs indicating imbalance persist.  Don’t worry about this.  If your herbal treatment worked, then it worked. Is your client happy? Has your client experienced healing? That’s what really matters.  Some imbalances are superficial and easily lifted away from us, others are a part of our deep- seated, innate constitutions.  We may help people bring themselves into better balance but we cannot be “rescued” from who we are on a fundamental physical level. We all have a tendency to go out of balance in one direction or the other. Help clients understand and accept their constitutions. Help them learn to manage their unique tendencies in order to feel as good as possible.

This article originally appeared in Plant Healer (Vol III, Issue III).  Check out this fine publication for herbalists where you can read many fine articles on all aspects of herbal medicine from diverse voices in herbal medicine.

Photo credit:   Alison Kuznia Photography

Resources for Further Exploration

Flint, Margi.  The Practicing Herbalist: Thoughts for Meeting with Clients.  Marblehead, MA: EarthSong, 2005.  Print.

Kirschbaum, Barbara.  The Atlas of Chinese Tongue Diagnosis Vol. 1 Seattle: Eastland Press, 2000. Print.

Lad, Vasant, and David Frawley. The Yoga of Herbs: An Ayurvedic Guide to Herbal Medicine. 2nd Ed. Santa Fe, NM: Lotus, 2001. Print

Light, Phyllis. Ayurvedic Tongue Assessment. Workshop handout. 2001. Print.

Tierra, Lesley. Healing with the Herbs of Life. Berkely, CA: Crossing  2003. Print.

Tierra, Michael. “Tongue Diagnosis.” Proc. of Mid America Herbal Symposium, Winona. n.p., 2008. Print.

Wood, Matthew. The Practice of Traditional Western Herbalism: Basic Doctrine, Energetics, and Classification. Berkeley, CA: North Atlantic, 2004. Print.

One Comment

  1. Love how this article brings together a good tongue assessment. I am not a practitioner and I have always wanted to find all this info in just one place. the pictures are great!
    When my kids were little every morning I would ask them to show me their tongues and then I would choose the approach for the day in terms of what herbs, supplements, activity and foods to have. Now that they have grown up, I still ask them to stick out their tongue at the first sign of any symptom. This has helped us use preventive medicine so well that we have been antibiotic-free for 25 years! Thanks God!

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