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10 the Fine Art of the Tongue

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10 the Fine Art of the Tongue 10 TheFineArtoftheTongue Nancy Holroyde-Downing In 1341 during the Yuan Dynasty, a medical text appeared Nanjing 難經 (Classic of Difficult Issues).2 The Mawangdui which contained 36 drawn representations of a variety of tomb texts, reflecting the newly emerging physiological tongues. Each was accompanied by an explanation of what medicine of the Warring States and early Han, present early the individual tongue image depicted in terms of illness, concepts of the body’s vessel system. In these texts also, and a directive as to what prescription was necessary diseased bodies begin to be ascribed to a slow breakdown to treat that illness. The title of the text was the Aoshi of a state of internal harmony, rather than to attacks by shanghan jinjing lu 敖氏傷寒金鏡錄 (Scholar Ao’s Golden a displeased ancestor or spirit. Evidence of connection Mirror of Cold Damage Disorders), and the provenance of between the tongue and the body’s organs is found in these tongue images weaves a fascinating story. vessel descriptions such as: ‘attached to the kidney, and The inspection of the tongue is now a pervasive aspect presses laterally on the tongue’,3 or ‘emerges at the liver, of a diagnosis, and it is a fundamental part of the curric- enters the upper side, and is attached to the tongue’.4 ulum in most colleges of Chinese medicine worldwide. The tongue also features in Yin yang mai sihou 隂陽脈死 It is discussed in diagrammatic and theoretical detail in 侯 (Death Signs of the Yin and Yang Vessels), a text from contemporary Chinese medical textbooks and is a feature Mawangdui concerned with the prognosis of death, which of the ‘signs and symptoms’ used in planning or discussing states: ‘when the tongue binds and the testicles curl up, acupuncture and herbal medicine treatment. There are muscle has died first’.5 myriad tongue diagnosis teaching texts, most recently By the time of the ‘Jingmai’ 經脈 treatise of the Lingshu with photographic images of tongues in vast quantities recension of the Huangdi neijing, the anatomical planes showing great varieties of qualities. Tongue diagnosis is of the vessels link clearly with organs and there is an usually presented together with pulse diagnosis as systems elaborate system of correspondences in place that begins having comparable antiquity and joint primacy in the to systematise pulse and complexion diagnosis. Yet the clinical encounter. And yet, even a cursory look at classical Huangdi neijing corpus contains only a handful of referenc- texts, case histories and formularies from the Han (206 es to the tongue within the vessel/organ framework, and bce–220 ce) to the Qing (1644–1912) dynasty suggests it only scattered mentions of the tongue’s colour or dryness. has not always enjoyed its current status. The foundations of classical medicine were set out by the end of the Han dynasty. The Nanjing, often considered the work that represents ‘the apex, and also the conclusion, of ABriefTextualHistory the developmental phase of the conceptual system known as the medicine of systematic correspondence’,6 only makes It is, of course, impossible in this chapter to exhaustively passing references to the tongue. In it, we learn that the address all the received texts of Chinese medicine that refer tongue weighs 283g, and has a length of 17.8cm and a width to the tongue. However, even a brief glance at a selection of 6.4cm; that when cold and heat have affected the flesh, of references to the tongue from the Han through the Song the lips and the tongue will dry out; that the influences of Dynasties reveals two interesting facts. These references the heart pass through the tongue; that when the tongue is are neither expressions of a diagnostic system, nor are they at ease, one knows the difference between the five tastes; conveyed as images. and that when the Foot-Ceasing-Yin vessel is compromised, Texts from the Mawangdui 馬王堆 burial site (closed the testicles draw in and the tongue rolls back.7 168 bce) are thought to pre-date the classical compilations of Chinese acupuncture theory found in the Huangdi nei- jing 黄帝内經 (Yellow Emperor’s Inner Classic),1 and the of traditional Chinese medicine. 2 Probably compiled in the 1st or 2nd century ce. 1 The Huangdi neijing corpus consists of two treatises: Suwen 素 3 Harper 1997, p. 210. 問 (Fundamental Questions) and Lingshu靈樞 (The Numinous 4 Ibid., p. 197. Pivot), written down c. 2nd century bce, plus the c. 7th-century 5 Ibid., p. 220. ce Taisu太素 (Great Basis) recension, which overlaps with both. 6 Unschuld, 1986, p. 3. These texts are generally considered to contain the core theory 7 Unschuld, 1986, pp. 301, 387, 418, 516. 168 holroyde-downing Wang Shuhe 王叔和 (180–c. 270 ce) is the author of epidemic illnesses were too often unsuccessful, and the the Mai jing 脈經 (Pulse Classic), 2nd century ce. In this Imperial government was anxious to find ways to expand work, he echoes the tongue presentation in the Yin yang the scope of medical literature in the search for effective mai sihou, when he writes: ‘A sick person with a curled remedies. tongue and retracted testicles is bound to die’.8 Wang uses It established a new bureau, Jiaozheng yishu ju 校正醫 the tongue presentation simply as a portent of impend- 書局 (Bureau for Revising Medical Texts), which it charged ing death, indicating nothing about the type of illness with searching out, revising and publishing a selection of contracted or organs involved in the demise. Against the ancient and previously neglected classics that might prove copious writings on information discoverable about the useful in combating epidemic illnesses. One of these re- inner body through the palpation of the pulse, we can habilitated texts was the Shanghan lun 傷寒論,13 written see that tongue inspection was incidental in scholarly by Zhang Zhongjing 張仲景 (style name Zhang Ji 張機 fl. medicine of that time. The presentation of the tongue was late 2nd century ce). Zhang is known to have compiled noted with certain illnesses, certain vessel trajectories and this text after an epidemic swept through his hometown certain prognosticatory patterns, but not as an indicator of Changsha (in present-day Hunan province), killing of problems within particular organs, and certainly not as numerous family members and decimating the general a paramount piece of diagnostic information. population. Over the next two centuries it became one The Suwen recension of the Huangdi neijing states that of the most highly regarded and popularly disseminated the physician who diagnoses using both the pulse and the medical texts. Its particular genius was to pay attention to complexion achieves perfection.9 While the physician’s the individual and evolving condition of each patient during gaze was clearly valued during the Han, its focus was on a rapidly changing illness, not just to the fixed disease.14 complexion and the tongue hardly receives a mention. While the Shanghan lun was revolutionary in its strate- The medical case history is a marvellous window into gies for treatment with herbal prescriptions, it offers only the actual practice of a physician at a given point in time. It scattered mentions of tongue presentation, and no tongue offers the individual records of the diagnosis and treatment illustrations. One of these few mentions is in line 230 of of a single patient by a single physician, though the content, the text. Under the rubric of ‘Yangming illness’, it lists a context, and application of information may vary.10 One of white tongue fur among indications for the use of the pre- the earliest examples of the case history can be found in scription Xiao chaihu tang 小柴胡湯 (Minor Bupleurum the Shiji 史記 (Records of the [Grand] Historian) by Sima Decoction). Yet despite the paucity of tongue information in Qian 司馬遷, 2nd century bce. A physician, Chunyu Yi 淳 the text, this increased Song focus on treatments for febrile 于意, was summoned by imperial order to give an account illnesses led to innovations during the following Jin-Yuan of his practice. Offering 25 case histories in defence of his period (1115–1368 ce) which had major implications for the standing as a worthy physician, he writes that ‘in every development of tongue diagnosis. case where your vassal has conducted a medical consul- tation, he has always made a consultation record zhenji 針劑’.11 A common turn of phrase is, ‘when I examined TongueInspectionEmergesasanIllustrated the mai [pulse]…’.12 Nowhere in these records do we find DiagnosticSystem the comparable phrase, ‘when I inspected the tongue’. Certainly, to Chunyu Yi, the tongue did not hold vital The Jin-Yuan period saw the consolidation of power in diagnostic information. the North of China, with concomitant cultural changes, such as the development of neo-Confucianism, in which old ideas were reworked. The current of widespread gov- EpidemicsandtheSearchforEffectiveTreatment ernmental, cultural and philosophical changes impacted upon medical thinking as well. One of four major medical During the Song Dynasty (960–1279), an onslaught of innovators of the period was Liu Wansu 劉完素 (1110–1209). epidemics ravaged southern China. Treatments for these He put forward the hypothesis that the six pathogenic influences presented in the Suwen all ultimately manifest in a patient as fire. The prescriptions he developed and 8 Yang 1995, p. 65. 9 Kuriyama 1999, p. 10. 10 Cullen in Hsu (ed.) 2001, p. 297. 13 See Goldschmidt 2009 for a discussion of the Song government’s 11 Ibid., p. 305. revision and promulgation of earlier medical texts. 12 See Hsu, in Hsu (ed.) 2001, p. 57. 14 Miyashita 1986, p. 112..
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