Ayurveda the divine science of life -10

Ayurveda the divine science of life

  EXAMINATION

OF FAECES

The state of the faeces is universally regarded by

many systems of traditional healing including

A¯

yurveda as the most useful sign in determining

digestive function, and as a result, the health of the

patient. Ideally, the faecal material should be examined

soon after expulsion, in its entirety, and for a

period of several days. This represents some practical

obstacles in a clinical environment, and thus patients

should be instructed as to the method of collecting

data regarding their bowel movements. For certain

diagnostic procedures a small amount of the faecal

material can be collected in a vessel. In a state of

health, a bowel movement will display the following

characteristics:

1. Light brown in colour

2. Solid, well-formed, voided in its entirety without

breaking

3. Have a continuous size and shape, 2.5–4 cm in

diameter

4. Smooth, without a twisted or nodular appearance

5. Without a large degree of undigested food.

There are several criteria when examining the stool:

1. Shape and consistency: When the stool is small,

voided as many pieces, irregularly shaped and has

a marbled appearance, it is an indication of va칣a,

dehydration and a lack of both exercise and fibre

in the diet. When the stool is snake-like, having a

small diameter, it is an indication of smooth muscle

spasm, most often a combined va칣a-pitta condition.

When the stools are loose to liquid, this is

an increase in pitta, indicating gastrointestinal

irritation or excessive bile excretion. When the

stools are large, dense and mucoid, this is an indication

of kapha.

2. Colour: Blackish stools indicate bleeding in the

upper gastrointestinal tract, or can be from the

excessive consumption of iron. Dark brown stools

can either indicate blood or the presence of a칖a.

Brown stools are normal. Greenish stools indicate

pitta, from an increase in stomach acidity, gastric

irritation and excess bile. With the use of cholagogues,

however, greenish stools can also indicate

the removal of pitta from the digestive tract

through an increase in liver metabolism and bile.

Whitish stools indicate kapha disorders such as

agnima칗dya, hepatic torpor, or obstructive

jaundice. Stools are very often coloured by naturally

occurring pigments in the diet, such as the

pink anthocyanins in beets and the orange

carotenes in carrots and yams. As in mu칣ra

parı칔s

˙

a¯, anthraquinone-containing botanicals

(e.g. Rhamnus purshiana) can also colour the faeces

orange or red, and long-term usage may even

temporarily stain the bowel wall, observed on

colonoscopy.

3. Odour: Foul-smelling faeces are related to protein

putrefaction, which is a paittika disturbance, manifesting

as a septic condition of the bowel. This may

also be an indication of jaundice. Milky-smelling

bowel movements indicate the excessive consumption

of refined carbohydrates and dairy, and are

often symptomatic of candidiasis, which is usually

considered to be reflective of a kapha condition.

4. Volume and frequency: A large volume of faecal

material voided more than twice daily is indicative

of paittika tendency. A small volume of faecal

material voided less than once daily is an indication

of va칣a. One or two large bowel movements a

day that take much time to void is an indication of

kapha.

5. Symptoms: Rectal bleeding is either an indication

of hepatic portal congestion or from the passing

of excessively dry faecal material. When

concomitant with otherwise normal or liquid

bowel movements it is an indication of pitta,

whereas rectal bleeding concomitant with dry

and rough stool is an indication of va칣a. A sense

of rectal fullness and pelvic heaviness without

bleeding, but with rectal itching is an indication of

a칖a or kapha. A sense of burning or irritation is

always an indication of pitta, although va칣a is

very often involved, as in fistula-in-ano. Stool that

has been passed with an explosive force and much

flatulence is a combined va칣a-pitta disorder.

Liquid or semi-liquid bowel movements with

blood and a semen-like odour is an indication of

amoebic dysentery, and blood with pus and a fetid

odour is an indication of bacillary dysentery, both

of which are pittaja disorders.

120 PART 1: Theory and Practice of A¯ yurveda

10.8 Na칍

˙

ı?parı칔s

˙

a¯: PULSE DIAGNOSIS

Na칍

˙

ı?parı칔s

˙

a?is described as one of the eight methods

of diagnosis, but few modern college-trained

A¯

yurvedic physicians practice it with any skill, and

as a result its preservation within the framework of

A¯

yurvedic diagnostics can almost be seen as an

anomaly. Traditionally trained A¯ yurvedic physicians

such as those of the as

˙

t

˙

a?vaidya families of Kerala

A¯

yurveda, however, claim to posses this knowledge,

but because these techniques are closely guarded

family secrets they remain inaccessible. As a result of

this situation there are a number of different and

widely varying A¯yurvedic pulse techniques promulgated

by various teachers and practitioners, and it is

difficult to determine which are valid and effective.

Many A¯yurvedic physicians consider the

Na칍

˙

ı칥ij˜na칗am to be the most authentic text on pulse

diagnosis, written by Mahar

˙

s

˙

i Kanada in about the

3rd century BCE, apparently the same person who

developed the Vai큦es

˙

ika Su?tra, one of the six

dar큦anas of the Vedas.22 The Na칍

˙

ı칥ijn˜a칗am is a

highly detailed text that provides an in-depth knowledge

of the pulses, their qualities and features.

Another important text on pulse diagnosis from the

medieval period is theS큑칞an . gadhara sam

˙

hita¯, which

contains a short treatise on the pulse. More recent is

the Na칍

˙

ı칛raka큦am written by Sankara Sen around

the turn of the last century. These three works form the

primary textual link we have with what is generally

supposed to be an ancient and venerable practice in

India. Beyond these, there are several excellent texts on

pulse diagnosis, such as the Chinese Bin Hu Ma Xue by

Li Shi Zhen (c. 1518 CE; Huynh & Seifert 1981) and

the methods of pulse assessment discussed in the

fourth tantra of Tibetan rGyud bzi (c. 8th century CE;

Finckh 1988), which is stated by some sources to be

a translation of an earlier, now lost, Sanskrit text entitled

the Amr

˙

ta Hr

˙

daya As

˙

t

˙

a칗˜ga Guhyaupade큦a

Tantra (Dash 1994). Pulse diagnosis in Chinese and

Tibetan medicine appears to have a longer, continuous

history of use than in India, and as a result they can be

used to confirm and support the practice of pulse diagnosis

in A¯yurveda. Regardless of the methodology,

however, it is always an important thing to realise that

pulse diagnosis is anuma칗a, an inferential method of

assessment, and in and of itself cannot provide the

practitioner with the exact nature of the patient’s condition:

it always needs to be assessed in conjunction

with the case history (a칛topade큦a) and direct observation

(pratyaks

˙

a). This is the skill of the master

clinician – knowing what is relevant and what is

extraneous.

What is the pulse?

Before we begin to delve into the specifics of na칍

˙

ı¯

parı칔s

˙

a¯, we need to understand the nature of the

pulse. Place your index finger (not your thumb, which

has its own pulse) over any artery in your body, such as

the carotid or radial pulse. As you feel the pulse it may

occur to you that you are feeling the movement of

blood through the arteries, but in actual fact you are

feeling a peristaltic muscular contraction of the artery

that is initiated by the ventricular contraction of the

heart. The pulse wave is like a long piece of rope

stretched on the ground and flicked: the pulse wave is

the ‘flick’ that can be seen to move down the length of

the rope.

The pulse wave that is initiated in the heart functions

to move the blood to the various regions of the

body, and is thus reflective of the heart, the seat of consciousness.

By pressing down and feeling the pulse

waves you are feeling the nature of your own transient

consciousness. These impulses define who and what

you are at any given moment, and while they change

according to factors such as emotions, activity and

time of day, they also display a pattern that translates

to a more generalised state of consciousness: that

which is manifest as your mind and body. Thus when

we examine the pulse we are examining the nature of

this transient consciousness, and the patterns that are

manifest within it.

Place and time

All the texts on na칍

˙

ı?suggest that it is best examined

first thing in the morning, sometime after awakening,

and after the elimination of urine and faeces, when the

lethargy of sleep has been cast off. A reading taken

at this time will usually be the most accurate.

Practitioners are advised to avoid reading the pulse

when the patient has just exercised, eaten, been outside

in the cold or warm weather, or just taken a bath

or shower. Pulse diagnosis takes a great deal of concentration

and as a practitioner you should not be hurClinical

examination 121

ried, so take your time when examining the pulse – in

some traditions it would not be uncommon for a practitioner

to patiently observe the pulse for several minutes.

Before taking the pulse ensure that you are not

too tired or hungry, and if you are having some difficulty

concentrating make sure you are breathing

properly. In his insightful book, Secrets of the Pulse,

Vasant Lad recommends silently chanting the syllables

SO upon inhalation, and HAM upon exhalation.

The SO-HAM mantra represents the unity of consciousness

and provides for enhanced concentrative

powers.

Position and pressure

The pulse is generally examined by the index, middle

and ring fingers of the practitioner, with the index finger

positioned just below the styloid process of the

radius, the projection of bone just below the root of

the thumb. Care must be taken not to place the index

finger on the styloid process. In Chinese pulsology the

index and middle fingers are placed above and below

the styloid process, respectively, and this appears to be

another valid way of assessing the pulse – for the purposes

of this text, however, all three fingers must be

placed below the styloid process. In most people the

radial artery is on the same side of the wrist as the

thumb, and it is over this that the three fingers are

placed.

According to the Na칍

˙

ı칥ijn~a칗am, the practitioner

uses his or her right hand to assess the pulse of the

right arm of the patient, holding the patient’s hand

with his or her left hand.23 The patient’s palm faces up

and the arm is slightly bent at the elbow. To this end

the patient may rest his or her arm comfortably on

a table (Fig. 10.2A), or the practitioner may support

the weight of the patient’s arm by resting it across

their own arm (Fig. 10.2B). In the rGyud bzi it is said

that the pulse of the right artery is most accurate for

a man, whereas the left artery is more accurate for

a woman. This conforms to the yogic concept that the

pingala?(masculine) na칍

˙

ı?runs up the right side of

the body, and the ida?(feminine) na칍

˙

ı?runs up the left

side of the body. Generally speaking, one can use the

left and right pulses to assess the relative balance

between these masculine and feminine qualities in a

given individual. If the right pulse is weaker than the

left, then the flow of pra칗.a through the pingala?na칍

˙

ı¯

may be deficient, resulting in a decline in agni. If the

left pulse is weaker, then the flow of pra칗.a through

the ida?na칍

˙

ı?may be deficient, resulting in a decline in

ojas.

The palpating fingers should be spaced slightly

apart, and a gentle and uniform pressure should be

applied through the tips of the fingers until pulsation

is felt. When palpating arteries that are covered by

much fat and muscle tissue the third finger may need

to be pressed with greater effort, the second with some

force but less than the third, and the first finger

pressed with the least amount of pressure. The effort

should be made to ensure that the pressure of all three

palpating fingers extends to the same level upon the

radial artery (Fig. 10.2C).

Vega (rate)

Vega is the rate at which the pulse exerts its upward

pressure on the palpating finger, and can be broadly

classified according to each dos

˙

a. This process, like all

movements in the body, is regulated by va칣a, so an

abnormal pulse rate at either end of the spectrum, i.e.

fast or slow, can indicate a dysfunction of va칣a.

Generally speaking, four pulsations per breath cycle is

considered normal, but this may be faster for children,

a little slower for the elderly. While palpating the

patient’s artery the clinician should simultaneously

observe the patient’s breathing pattern for a few minutes.

If, on average, there are more than four pulsations

per breath cycle, this indicates pitta, suggesting heat,

fever or inflammation. An increase in the pulse rate,

however, may also indicate va칣a, such as fear, anxiety

or nervousness. The difference between pitta or va칣a

can be understood by noting the gati, or the archetype

of the pulse, described later. Less than four pulsations

may indicate kapha, suggesting heaviness, coldness

and congestion. It may, however, represent va칣a, and

a substantial diminishment of the life force (jı칥a¯). Once

again, the determination between them is made by

assessing the gati. Sometimes it is difficult to observe

the patient’s breathing pattern, and in such cases the

practitioner measures the rate of pulsation against his

or her own breathing cycle (and hence another requirement

that pulse diagnosis be a meditative exercise).

Ta칕a (rhythm)

The rhythm of the pulse, or the regularity by which

the pulse is felt under the palpating fingers, is an

122 PART 1: Theory and Practice of A¯ yurveda

assessment of pra칗

˙

a as it flows through the arteries to

enliven the body. When va칣a is normal the rhythm of

the pulse is regular. When va칣a is in an increased state

the pulse becomes irregular, due to its ‘dry’ (ru칔s

˙

a) and

‘light’ (laghu) properties, making the pulse erratic and

unstable. When the pulse is regularly irregular both

va칣a and kapha are likely involved, kapha providing

an element of ‘stability’ (sthira) to the pulse. When the

pulse is irregularly irregular both pitta and va칣a are

likely to be involved, as the ‘light’ (laghu) properties of

pitta compound this same quality in va칣a. In many

people there may be a transient increase in the heart

rate with inspiration, especially with a deep breath, and

a concomitant transient decrease in the heart rate with

exhalation. This is called sinus arrhythmia, and is found

in healthy adults and is not a sign of a dysfunction.

Figure 10.2A, B Radial pulse and position. Supporting the patient’s arm.

Continued

Clinical examination 123

Bala?(strength)

Bala?is the‘strength’ of the pulse, a measure of the

upward-moving force of the pulse wave under the

three palpating fingers when they compress the artery.

There are three basic levels to the pulse: deep, medial

and superficial. The deep pulse provides indication of

the status of soma, or ojas, the anabolic force of the

body, whereas the superficial pulse corresponds to

tejas or agni, the catabolic force of the body. The

medial pulse exists between these two levels, representing

the communication and relationship between

agni and ojas. The actual pulse wave itself is initiated

pra칗

˙

a.

One way to conceptualise the difference between

ojas and agni in the pulse is to understand their activities

in the body. Thus, while agni functions to combust

ingested food for bodily usage, its overall activity

is essentially catabolic and eliminative. In contrast,

ojas functions to utilise these nutrients to sustain and

nourish the tissues, and therefore ojas is essentially

anabolic and nutritive.

If the pulse wave is felt strongly when the artery is

palpated superficially, with a light pressure of all three

fingers, and a deep pressure must be exerted to stop

the pulse wave, then the pulse is considered to be

strong, and agni and ojas are more or less equal. In

this case the medial pulse will be similar to both the

superficial and deep pulses.

If the pulse is non-existent or barely palpable in the

superficial position but strong in the deep position,

then agni may be in a weakened state, and the patient

may be suffering from cold and congestion (i.e.

kapha). If the pulse is weak in the superficial position,

and similarly weak in the deep position, both agni and

ojas may be deficient, indicating cold and congestion

with deficiency (kapha and va칣a). When the pulse is

strong in the superficial position but disappears when

more pressure is exerted the patient may be suffering

from excess agni (pitta). When the pulse is both

superficial and weak the patient may be suffering from

heat with deficiency (pitta and va칣a).

Gati (archetype)

The movement of the pulse in na칍

˙

ı?parı칔s

˙

a?is traditionally

ascribed to certain animal archetypes, or

gati. These animal archetypes allow the practitioner

to visualise factors such as rate (vega), rhythm (ta칕a)

and strength (bala¯), along with more specific characteristics

such as the width and volume of the pulse.

Using these animal archetypes it becomes easier to

visualise what dos

˙

a may be influencing the pulse. The

radius

radial artery

Index (distal)

Middle (medial)

Ring (proximal)

styloid

process

Agni

Deep (K)

Ojas

Agni

Superficial (P)

Ojas

Agni

Weak (V)

Ojas

Agni

Deep/

Weak (VK)

Ojas

Agni

Superficial/

Weak (VP)

Ojas

Agni

Strong

Ojas

Figure 10.2C The positioning of the fingers when taking

a pulse.

Figure 10.3 Bala?: Pulse strength.

124 PART 1: Theory and Practice of A¯ yurveda

primary method to assess the gati is performed by

palpating the artery with all three fingers simultaneously,

pressing down with a medium pressure:

● The pulse of va칣a is typically described as being that

of a snake sliding along the ground: thin, subtle and

empty. The pulse volume is low and difficult to

detect, slipping and sliding beneath the palpating

fingers.

● The pulse of pitta is described as a hopping frog:

wiry, strong and abrupt. The pulse volume is high

and tense, and feels hard and wiry.

● The pulse of kapha is described as a swan swimming

through the water: wide, deep, and slippery.

The pulse volume is full, wide and soft, gently rolling

under the palpating fingers.

While there are many more animals archetypes discussed

in the Na칍

˙

ı칥ijn~a칗am, such as a leech and elephant

(some of which may even be extinct), the snake,

frog and swan serve as a basic distinction between the

influence of the different dos

˙

as upon the pulse.

Furthermore, it is important to note that these archetypes

may occur in tandem, such that a patient might

display a snake-swan pulse, indicating a combined

va칣a-kapha condition, a frog-snake pulse, indicating a

combined pitta-va칣a condition, a frog-swan pulse

indicating a combined pitta-kapha condition, or even

all three archetypes, indicating a sannipa칣a condition.

Stha칗a (location)

Each finger that is used to palpate the artery can be

correlated to a specific dos

˙

a, or more specifically, a particular

stha칗a or region of the body that is ruled by a

specific dos

˙

a (see section 2.4 Stha칗a: residence of the

dos.as). According to the fourth stanza of the

Na칍

˙

ı칥ijn~a칗am, when the practitioner places the

index finger below the thumb (granthi) on the radial

artery, followed by the middle and ring fingers, ‘first

flows va칣a, the middle is pitta, and last is kapha’.

While some commentators have interpreted it differently,

these explicit instructions appear to indicate that

it is the ring finger that ‘first’ receives the peristaltic

wave of the pulse. Thus, according to the Na칍

˙

ı칥ij˜na칗am

the ring finger indicates va칣a, the middle finger is

pitta, and the index finger is kapha.24 In my experience

the specific finger does not relate to the quality of

the pulse inasmuch as it relates to the different regions

or stha칗as ruled by each of the dos

˙

as. Thus:

● The ring finger is an assessment of va칣a stha칗a,

corresponding to the area located from the umbilicus

downwards (i.e. the colon, adrenals, kidneys,

bladder and reproductive organs).

● The middle finger is an assessment of pitta stha칗a,

corresponding to the area of the body located

between the umbilicus and the diaphragm (i.e. the

liver, gall-bladder, spleen, pancreas and stomach).

● The index finger is an assessment of kapha stha칗a,

corresponding to the area located from the

diaphragm upwards (i.e. the lungs, heart and head).

When the right radial pulse is assessed, it may

provide an indication of the health of those tissues and

organs on the right side of the body. Similarly, the left

radial pulse will give an indication of the health of

those tissues and organs on the left side of the body.

Thus the pulse on both wrists divides the body into six

basic regions:

● The va칣a (ring) pulse felt under the right radial

artery indicates the health of tissues and organs on

the lower right side of the body. Similarly, the va칣a

(ring) pulse under the left radial artery indicates the

Vata

Pitta

Kapha

Figure 10.4 Gati: Pulse archetypes

Clinical examination 125

health of tissues and organs on the left side of the

body.

● The pitta (middle) pulse under the right radial

artery indicates the health of tissues and organs on

the middle right side of the body. Similarly, the

pitta (middle) pulse under the left radial artery

indicates the health of tissues and organs on the

middle left side of the body

● The kapha (index) pulse under the right radial

artery indicates the health of tissues and organs on

the upper right side of the body. Similarly, the

kapha (index) pulse under the left radial artery

indicates the health of tissues and organs on the

upper left side of the body.

Using a moderate pressure, between palpating for

the superficial (agni) and deep (ojas) pulses, palpate

the radial artery simultaneously with all three fingers

and note if the pulsation can be felt under all three. If

the pulsation cannot be felt under any one of the fingers,

the stha칗a that corresponds with that finger

may be in a weakened state. Thus, if the right artery is

palpated equally with all three fingers and the pulsation

is weak under the index finger, this may indicate a

dysfunction in the upper part of the body, such as the

right lung or pleura. If the pulse is weak in the middle,

this may relate to a dysfunction of the liver or gallbladder.

If the ring finger pulse is weak, the dysfunction

may lie with the right adrenal, right kidney or

ascending colon. These same inferences can be made

with the left pulse as well. In each case, however, the

practitioner will have to discern what specific tissues

or organs are affected, based on an analysis of the case

history (da큦avidha parı칔s

˙

a¯) and other examination

techniques (as

˙

t

˙

a칢tha칗a parı칔s

˙

a¯).

If a weakness is noted in any of these three areas

(six locations on two wrists), or even if we want to

obtain more specific information about these areas, we

can use a single finger to palpate each location. Thus if

we want to assess the upper right side of the body, lift

off the middle and ring fingers palpating the right

artery, and simply feel the right pulse with the index

finger. Press down to a deep position with this finger

and note the strength of the pulsation. Now release

this pulse to the superficial position and note the

strength of the pulse. If the pulse is strong in both the

superficial and deep position, the health of the associated

organs and tissues is likely good. If the pulse is

weak in the superficial position then the problem may

rest with the transformative and elimination aspects

(i.e. agni) of the tissues or organ associated with that

area. Thus there may be coldness and congestion in

that part of the body, but the intrinsic health (i.e. ojas)

of the associated organs and tissues may be fine, and

simply needs to be stimulated. If the pulse is weaker in

the deep position, the problem may rest with the

actual health and nutrition of that organ (i.e. ojas),

and there may be a deficiency in that area that

requires treatment. If both the superficial and deep

pulses are weak in that particular location, then both

agni and ojas within that tissue or organ may be in a

debilitated state. If when assessing the stha칗as with

all three fingers you note a particularly powerful pulsation,

this may indicate a higher metabolic rate (i.e.

Vata

Kapha

Kapha

Pitta

Pitta

Vata

Styloid process

Figure 10.5 Sth¯ana: tridos. ic

correspondence between the pulse

and the body.

126 PART 1: Theory and Practice of A¯ yurveda

agni) in the associated tissues or organ, at worst, be

suggestive of inflammation.

We can deepen our understanding of these individual

pulse locations by applying our knowledge of gati,

the animal archetypes, to determine the origin or quality

of this dysfunction. Thus, if the pulse in that stha칗a

is that of a snake (weak, thin and subtle), this may indicate

a va칣tika dysfunction in that area. If the pulse is

a frog (wiry, tense and sharp), this may indicates a paittika

dysfunction. If the pulse is a swan (slippery, wide

and soft), this may indicate a kaphaja dysfunction.

Even with this relatively simplified rendering of the

technique there remain many features to na칍

˙

ı¯

parı칔s

˙

a¯, and the practitioner must access all of these

features and use them as a collective to accurately

determine the nature of the pulse. To attempt to synthesise

all of these aspects while learning, however,

can be overwhelming. I recommend that practitioners

first become proficient in determing the vega (rate),

ta칕a (rhythm) and bala?(strength) of the pulse. Later

on, add the component of gati (archetype), feeling for

the snake, frog and swan. Once these skills are developed,

begin to incorporate them into the concept of

stha칗a (location), determing weaknesses and

strengths in each part of the body, and the specific

characteristics of the pulse wave in each pulse location

that indicates the dos

˙

as and their activities.

10.9 Jivha?parı칔s

˙

a¯: TONGUE

DIAGNOSIS

The tongue (jivha¯) is perhaps the most useful of the

diagnostic techniques because it is relatively easy to

read, providing detailed information of the state of not

only the gastrointestinal organs, but also the assimilative,

metabolic and circulatory processes of the body.

Full daylight is the best condition in which to examine

the tongue, but otherwise adequate lighting is acceptable.

To examine the tongue properly it should be fully

extended by the patient, but remain relatively relaxed,

without using excessive force which will hide the true

shape of the tongue and make it redder. Ideally, the

tongue should be observed first thing in the morning

before eating, or on an otherwise empty stomach.

Certain foods, including artificially coloured foods,

spices and sweets will change the colour of the coating

on the tongue. Coffee and tobacco smoke will often

leave a yellowish stain on the tongue, whereas pungent

and salty foods like chilies and pickles, and even mouthwash,

will temporarily make the tongue redder.

Further, certain medications will also affect the appearance

of the tongue, such as antibiotics, and may cause

a peeling of the tongue coat or make it thicker.

As with the pulse and the eye, the tongue contains

within itself a map of the whole organism. Just as the

upper, middle and lower portions of the body contain

the function of kapha, pitta and va칣a, respectively, so

too can the tongue be divided into three portions: the

anterior representing kapha stha칗a, the middle representing

pitta stha칗a, and the posterior (or root),

representing va칣a stha칗a. As the entire function of

the tongue is controlled by uda칗a va칪u, specific problems

of the tongue, such as an inability to control

tongue movement, relate to this sub-dos

˙

a. In relation

to specific areas on the tongue, however, certain other

sub-dos

˙

as may be observed as well.

There are five aspects of tongue diagnosis: colour,

shape, location, coating and movement. The following

is an exposition of these five fundamental aspects of

jivha?parı칔s

˙

a¯:

Colour

This is the colour of the body of the tongue, rather

than its coating, which is discussed later. If the coating

on the tongue is too thick to see underneath it, then

the tongue may be curled up to examine its underside.

The clinical significance of the tongue colour relates to

the state of agni, ojas and vya칗a va칪u. Ideally, the

tongue should have a pinkish vibrancy to it, and any

deviation from this is indicative of imbalance. Once

again, by referring to the tridos

˙

a laks

˙

an

˙

as we can

understand the manifestation of va칣a, pitta or

kapha. Va칣a will be noticed as a tongue that is dark

red to purplish, bluish, blackish, orange or grey. Pitta

will be seen as a tongue that is bright red or has

a greenish hue. Kapha will be observed as a tongue

that is pale or whitish in colour. Table 10.1 lists the specific

signs to look for in the assessment of the colour of

the tongue.

Readers will note that the tongue of extreme pitta

and extreme va칣a are somewhat similar, although

with heat the tongue will be more reddish in colour,

and with cold the tongue will appear more bluish.

Failing the ability to make this distinction, rely upon

techniques such as the pulse, which will be bounding

and rapid with heat, and deep and slow with cold. The

Clinical examination 127

case history will also provide important indications

that can help the practitioner make this distinction.

Shape

This refers to the shape of the tongue, generally, but

including the sides and tip, as well as the surface.

Understanding the shape of the tongue is a differentiation

between thinness and thickness. Examination of

the surface of the tongue means looking for cracking,

furrowing, ulceration, raised papillae, deviation,

swelling, bulging or depressions. Generally, va칣tika

tongues are thin and short, and may have cracking,

furrowing, deviations, and depressions. Paittika

tongues are typically long and may have raised

papillae and some focal areas of ulceration. Kaphaja

tongues are smooth, thick, flabby and swollen. Table

10.2 differentiates the many shapes that a tongue

may take and the clinical significance of such

findings.

Shape: sides of the tongue

The sides of the tongue (Table 10.3) represent the

assimilative and transformative functions of digestion.

Assimilation is a measure of digestive efficiency, e.g.

the digestive secretions of the lower fundus of the

stomach, small intestine, liver, gall-bladder, and the

exocrine pancreas, all of which are guided by agni.

Transformation on the other hand is a measure of

how these nutrients are converted into the tissues of

the body by the liver. This process is guided by both

agni and ojas.

Shape: tip of the tongue

The very tip of the tongue (Table 10.4) relates to the

function of the heart, and the area just posterior

relates to the lungs. The heart (hr

˙

daya) was traditionally

thought of as the seat of the mind and emotions,

and thus this region refers not only to the

functional heart but also to the brain.

Tongue colour Clinical significance

Pink Normal

Pale Cold, anaemia; coating will be dry

(va칣a) or wet (kapha)

Red Heat (pitta) in the blood

Orange Chronic heat (pitta), leading to a

deficiency of blood (va칣a); pitta

aggravating va칣a

Dark red or Extreme heat (pitta) and circulatory

reddish-purple stagnation (va칣a)

Blue or bluish- Extreme cold (va칣a) with circulatory

purple stagnation

TABLE 10.1 Clinical significance of tongue colour.

Vata

Vata

Kapha

Kapha

Pitta Pitta

Figure 10.6 Sth¯ana: correspondence

between the tongue and the body.

128 PART 1: Theory and Practice of A¯ yurveda

Shape: central axis of tongue

The central axis of the tongue represents the flow of

pra칗

˙

a in the subtle body, along the same axis as the

spinal column. Pra칗

˙

a is the animating force in the

body and underlies the function of the central nervous

system. Where a generalised furrow of the tongue can

be seen this may indicate a generalised pra칗

˙

ic deficiency.

Where the furrow is deviated along the midline

of the tongue, this may indicate a spinal misalignment

or stress in the area of the spine that corresponds with

the region on the tongue (e.g. a cranial, thoracic, lumbar

or sacral misalignment). Where there is a partial

furrow, this may indicate a pra칗

˙

ic deficiency in the

region of the body that corresponds with the same

region, or stha칗a of the tongue.

Shape: surface of the tongue

The tongue is a skeletal muscle covered by a mucous

membrane. The projections on the tongue surface are

called papillae. The majority of the papillae on the

observable tongue are tightly knit filiform papillae,

periodically interspersed with larger fungiform papillae

that contain the taste buds. On the posterior tongue

there is a v-shaped arrangement of circumvallate

papillae that promote the gag-reflex when bitter,

potentially poisonous substances are consumed.

Generally speaking the surface of the tongue represents

the bodily tissues or dha칣us.

Location

Location refers to specific areas on the body of the

tongue that can be correlated with certain organ systems.

Tongue shape Clinical significance

Short, thin Va칣a prakr. ti

Long, narrow Pitta prakr. ti

Large, thick Kapha prakr. ti

Furrows and fissures Dryness (va칣a)

Swollen Congestion (kapha)

Swelling and redness Heat (pitta)

Hemispheric swelling Right side: external

congestion (pingala?na칍.ı¯)

Left side: internal congestion

(ida na칍.ı¯)

Swollen along central axis Nervous tension (va칣a,

pitta)

Hammer-shaped tip Pra칗.ic deficiency

Ulcerated, sore-covered Pitta sa칖a

TABLE 10.2 Clinical significance of tongue shape.

Tongue shape on sides Clinical significance

Scalloped25 Malabsorption, nervous stress, anxiety (va칣a), decreased ojas

Fissured Dryness (va칣a), decreased ojas

Swollen Cold and congestion (kapha)

Swollen and Red Heat (pitta)

TABLE 10.3 Clinical significance of the sides of the tongue.

Tongue shape on tip Clinical significance

Swollen tip Normal colour: heart congestion, dyspnoea, worry, grief (kapha)

With redness: heart irritation, hypertension, anger (pitta)

Swollen between tip and Normal colour: lung congestion (kapha)

center of tongue With redness: lung inflammation (pitta)

Depression behind tip Anxiety, emotional trauma, mental exhaustion

TABLE 10.4 Clinical significance of the tip of the tongue.

Clinical examination 129

Signs such as colour, shape, moisture and coating

observed within these locations provide clues as to

how an organ system may be affected by va칣a, pitta or

kapha.

Coating

The coating refers to the tongue covering, also called

the ‘fur’, and relates specifically to the function of agni

(pa칌aka pitta). In association with location, however,

the tongue coating will indicate the metabolic function

of that organ system. Tongue coatings are identified by

their color (white, whitish-yellow, yellow, dark yellow,

orange, grey, brown, black), their quality (thin or

thick), and their texture (dry, moist or greasy).

Generally it is better to have a moist tongue than a dry

tongue, and a tongue which changes from moist to dry

indicates a worsening of the condition, while a coating

which changes from dry to moist indicates improvement.

A tongue that changes from a white to yellow

coating indicates that the condition is being driven

from a superficial condition deeper, from congestion

(kapha) to inflammation (pitta), while the reverse

indicates an improving condition, from deeper tissues

to superficial areas for elimination. A coating that

Figure 10.7 Central furrow.

Figure 10.8 Deviated furrow.

Figure 10.9 Partial furrow.

130 PART 1: Theory and Practice of A¯ yurveda

becomes thicker over time indicates a worsening of the

condition, while the reverse indicates improvement.

Table 10.6 provides the clinical significance of each

kind of tongue coating.

Movement

Movement refers to the movement of the tongue when

extended for examination. As the impetus for movement

is primarily va칣a any dysfunctional movement is

va칣tika in origin. Problems with movement include

a shaking or vibrating tongue, a wagging tongue that

moves back and forth, and the inability to extend the

tongue for examination. In this latter case, sometimes

the issue relates to the patient’s discomfort with allowing

their tongue to be examined, and gentle encouragement

may be required. In some cases where the

tongue seems to protrude, this is an indication of

extreme heat (pitta kopa).

Spleen

(Palantine tonsils)

Spleen

(Palantine tonsils)

Colon

Right kidney Left kidney

Liver - small

intestine - pancreas

(sides of tongue)

Stomach

Lungs

Spinal column and CNS Heart

Surface of tongue Clinical significance

Smooth, regular Normal

Spots Pale red: congestion with heat (kapha aggravating pitta)

Red spots: heat (pitta)

White: cold and damp (kapha)

Purple: heat and stasis (pitta aggravating va칣a)

Black: stasis and dryness (va칣a)

Concave: cold (va칣a)

Convex: heat (pitta)

On tip: anxiety, stress, grief

On sides: anger, irritability

Fissures Dryness (va칣a)

TABLE 10.5 Clinical significance of the surface of the tongue.

Figure 10.10 A¯ yurvedic tongue chart,

anatomical position.

Clinical examination 131

ENDNOTES

21 Beverages such as tea, coffee and alcohol, however, can promote

frequency, as will prescription diuretics.

22 There is some scholarly scepticism that the author of the

Na칍

˙

ı칥ijn~a칗am is one and the same as the author of the

Vai큦es

˙

ika Su칣ra. It was not uncommon for medieval writers to

use the name of the great sages to add weight and significance

to their own work, and as a result the Na칍

˙

ı칥ijn~a칗am may be

a comparatively more recent text.

23 The rGyud bzi states that the practitioner’s left hand is used to

assess the patient’s right radial artery, in contradiction to what

the Na칍

˙

ı칥ijn~a칗am states. Further, some practitioners strongly

suggest that the hand not taking the pulse should not touch the

patient at all, because it will create an electrical circuit which

will lead to an incorrect assessment.

24 This model places the scheme of na칍

˙

ı?parı칔s

˙

a?more or less in

line with both Tibetan and Chinese pulsology. Using this model,

it is now possible to understand the correspondences between

the Chinese concept of the san jiao or ‘triple burner’, and the

three stha칗as represented by va칣a (lower jiao), pitta (middle

jiao) and kapha (upper jiao).

25 It is obvious that the scalloped tongue occurs because the

tongue is either swollen (which indicates kapha, and therefore

manda칐ni), or because the patient unconsciously pushes his or

her tongue against the teeth, causing indentation. This latter

event I believe is an adaptive response to chronic stressors, and

is reflective of vattika conditions. Interestingly, the palate is

considered to be intimately linked to the function of the pancreas

according to A¯yurveda. I have come to suspect that this

thrusting of the tongue upwards against the palate and the

teeth occurs with hypoglycaemic patterns, associated with fight

or flight mechanisms, increased va칣a and decreased ojas.

Tongue coating Clinical significance

Clear or white, slightly moist Normal, absence of imbalance

Absent, dry Dryness (va칣a)

Clear, very moist Coldness (kapha)

Clear or white, thin, dry Dryness (va칣a)

White, thick, moist Congestion and coldness (kapha)

White, thick, dry Congestion (ka칛ha) and heat (pitta)

White, thick, greasy Congestion (kapha) and a칖a

White and powdery Congestion (kapha) and heat (pitta); kapha aggravating

pitta

White and mouldy Dryness (va칣a), heat (pitta), congestion (kapha), and a칖a

(poor prognosis)

Pale yellow Congestion (kapha) with heat (pitta); kapha aggravating

pitta

Yellow Heat (pitta)

Yellow and greasy Heat (pitta) with a칖a

Yellow and dry Heat (pitta) with dryness (va칣a)

Pitta aggravating va칣a

Dirty yellow, brown Heat (pitta) with a칖a

TABLE 10.6 Tongue coating and clinical significance.

 

Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to   Sreeman Todd Caldecott, Elsevier’s Health Sciences and others other eminent medical scholars and doctors   for the collection)