Diagnosis In Chinese Medicine
The art of diagnosis is a lifetime voyage in the interpretation of the presenting signs and symptoms of the syndrome complexes. A viable diagnosis is totally dependent on competent knowledge of TCM theory. This cannot be stressed enough. What separates a good acupuncturist from an excellent one is his understanding of TCM theory and how to apply this knowledge. On the other hand, a competent TCM theorist means nothing if they cannot interpret the data correctly.
In TCM, diagnosis of disease is the process of discriminating patterns of disharmony, or the syndrome complexes. This can be divided into two parts. The first part is to thoroughly examine the patient, like a crime scene investigator as I mentioned before. The second part of diagnosis is logically interpreting the information gathered in the examinations, or to discriminate patterns of imbalance.
Traditionally, TCM examination is divided into four parts, commonly referred to as the “Four Pillars of Diagnosis.” These are questioning the patient, observing the patient, palpating the patient, and auscultation / olfaction. Lets look at these in more detail.
It is said that if you listen to the patient, the diagnosis is rendered. This is general idea in the patient interview. When the practitioner questions the patient in TCM, I believe 80% of the time the diagnosis is correct. It is like throwing apples in a bag. The ones with the most apples is the primary diseased organ / pathway. It is there for vital to understand the presenting sign and symptoms to categorize dysfunction. In TCM this is called pattern discrimination. This is the main form of diagnosis and treatment. It is symptom based. Much of the questions reflect the five element correspondences and the primary functions of the organs. Therefore proper understanding of the functions of the internal organs and the Five Element characteristics is crucial to diagnosis.
In TCM, there are ten basic questions that lead to one hundred questions. Here are the main classic questions in TCM diagnostics:
Low energy – Indicates deficiency of Qi. If energy is lower in the end of the day Yin deficiency. If patient is more deficient in the morning Yang deficiency. If the patient is constantly tired throughout the day, indicates overall Qi deficiency.
Excess or hyperactivity can be possible excess yang heat, excess interior heat, or excess yang qi rising.
Chills indicate invasion of pathogenic cold.
Fever indicate invasion of pathogenic heat.
Chills with fever indicates exterior syndromes of wind/cold or wind/heat. Wind/Cold – symptoms include severe chills with mild fever, no sweating, general body aches, headache, pulse will feel floating and slow. Wind/Heat – symptoms include mild chills with severe fever, sweats, excess thirst, and a floating and rapid pulse.
Fever without chills with aversion to heat is do to excess heat in the interior. Symptoms include profuse sweating, severe thirst, and a surging pulse. Fever at night is mainly do to Yin deficiency.
Chills without fever indicates interior cold syndromes. Symptoms include chilled appearance, cold extremities, and a deep, slow, and weak pulse.
Alternating chills and fever indicate intermediate syndrome. Other symptoms might include bitter taste in mouth, thirst, and fullness in chest.
Absence of perspiration in exterior syndromes indicate invasion of pathogenic cold.
Presence of perspiration in exterior syndromes indicate invasion of wind or heat or both wind/heat.
Perspiration at night (night sweats), which stops upon awakening, indicates Yin deficiency with hyperactivity of Yang heat.
Frequent Perspiration that worsens with activity deficient Qi and deficient Yang Qi.
Profuse perspiration that is accompanied with high fever, mental restlessness\, thirst, preference to cold drinks, and a surging pulse indicates excess heat from excess Yang heat being expelled out by perspiring.
Poor appetite is a weakness in Spleen and Stomach Qi. Possible symptoms include prolonged illness and poor appetite, loose stools, lassitude, pale tongue, white thin coating on the tongue.
Poor appetite with chest fullness, abdominal fullness, thick and sticky coated tongue indicates stagnation of Qi of the Spleen and Stomach caused by food retention or stagnation of dampness.
Increased or excess appetite is typical with excess Stomach heat or Stomach fire.
Increased appetite without a desire to eat is typical of Yin deficiency causing internal heat.
Sweet tastes indicates Spleen Qi deficiency and / or damp / heat.
Sour tastes indicates food retention in the Stomach or lack of harmony between the Liver and Stomach.
Salty tastes are caused by Kidney Yin deficiency.
Lack of taste sensation is caused by Spleen Qi deficiency.
Pungent tastes are caused by in-balances in the Lung, usually Lung heat.
Bitter vomiting is a result of Liver and Gall Bladder heat.
Vomiting that occurs after eating is usually a result of heat pathogenic factor.
Cold syndromes, or any syndrome in which heat is not noticed causes lack of thirst. In this case the body fluids are not being consumed because of the cold.
The presence of thirst in a patient indicates heat or retention of damp phlegm in the interior preventing the body fluids from ascending.
Constipation is usually due to excess heat or excess usage of body fluids.
Loose stools indicate mainly deficiency of Spleen or dampness invading the Spleen
Watery stools with undigested foods usually means a deficiency of Yang of the Spleen and the Kidney.
Bloody stools with mucous is usually a result of damp heat in the Intestines and stagnation of Qi in the Intestines.
Dark color urine usually indicates heat syndromes.
Clear and abundant amounts of urine usually indicates cold or an absence of heat.
Turbid / Cloudy urine indicates damp heat.
Red urine usually indicates damage of a vessel due to heat.
Clear increased amounts of urine indicates weak Kidney Qi and Bladder controlling the urine.
Little volume and yellow urine with accompanied urgency and painful urination usually indicated damp heat in the Bladder.
Dribbling and felling of retention of urine usually indicates Kidney Qi deficiency, possible damp heat, and stagnation of blood or stones.
Insomnia accompanied with dizziness and palpitations is usually caused by the inability of the blood to nourish the Heart and the Spleen.
Insomnia with restlessness in the mind and a dream disturbed sleep usually indicates Heart heat or fire.
Dizziness is usually a symptom of deficiency of Qi , blood deficiency, fire, wind or phlegm.
The head is the meeting place of all the Yang pathways. The Qi of all the Zang and Fu flow to the head. If any of the external pathogenic evils attack the head or neck and damages the yang pathways, or if Qi and blood stagnates as a result of internal diseases, the head and brain lack nourishment and a headache is sure to follow.
Recent onset and short duration is usually a result of wind cold.
Gradual onset are usually of interior etiology.
Day-time headaches are usually a result of Qi deficiency or Yang deficiency.
Evening headaches are usually caused by blood deficiency or Yin deficiency.
Cervical spine headaches, especially at the nape of the neck (Greater Yang Channels) are usually caused by Kidney Qi deficiency or invasion of wind / cold.
Forehead headache Bright Yang Channels) are usually caused by Blood deficiency or Stomach heat.
Temporal headaches ( Lesser Yang Channels) are usually a result of invasion of wind / heat, wind / cold, or from interior Liver and Gall Bladder Fire rising.
Top of the head headache (Terminal Yin Channels) are usually a result of Liver blood deficiency.
Whole head headache is usually a result of invasion of wind / cold.
Heavy feeling headache is a result of either phlegm or dampness.
Headache that is inside the head is usually a result of Kidney Qi deficiency.
Throbbing headache is usually a result of Liver Yang rising.
A dull, boring headache is usually a result of blood stagnation.
Continuous and dull pain in the back is usually a result of Kidney Qi deficiency.
Recent, severe, and stiff back pain is usually a result of Blood stagnation.
Severe pain that is aggravated by cold and damp weather and is comforted by heat is usually a result of pathogenic cold and dampness invading the back.
Boring pain is usually a result of Blood stagnation.
Pain in the shoulders and upper back is usually a result of exterior conditions – wind / cold, wind / heat, etc.
Pain in the joints that moves from joint to joint is usually a result of Wind.
Fixed joint pain that is very painful is usually a result of invasion of Cold.
Fixed joint pain that is associated with swelling and numbness is usually a result of invasion of dampness
Bilateral arm and leg numbness, or hand and feet numbness is usually a result of blood deficiency.
Unilateral numbness of fingers, elbows, and arm (especially the first three digits) is usually a result of Wind and Phlegm.
A rapid, sudden onset that is associated with chills and fever is usually a result of Wind / Cold.
Pain that I felt all over with associated tiredness is usually a result of Blood deficiency.
Pain that is in al the muscles and has an associated hot sensation is usually a result of Stomach Heat.
Pain all over that is associated with a feeling of heaviness is usually a result of Invasion of dampness in the muscles.
The thorax is under the direct influence of the Lung and Heart Zang.
The sides of the body are mainly influenced by the Liver Zang and the Gall Bladder Fu.
The abdomen is influenced by the Liver, Spleen, Intestines, Kidney, and Bladder.
Pain in the chest is usually a result of Blood stagnation in the Heart that is usually caused by Yang deficiency.
Chest pain that is associated with a productive yellow cough is usually a result of Lung heat.
Abdominal distension and fullness is usually a result of Liver Qi stagnation.
Epigastric pain is usually a result of either Food retention in the Stomach or Stomach heat.
Epigastric pain that is very dull and not severe in nature is usually a result of Stomach cold deficiency.
Most all ear conditions are due to Kidneys because the Kidneys open to the ear. All the Lesser Yang pathways flow to the ear and therefore external pathogenesis of these pathways such as Heat, Dampness, and Phlegm can affect the ear.
Tinnitus – A sudden onset is usually a condition of Liver-Fire or Liver-Wind. A gradual onset is usually a condition of Deficiency of Kidneys.
A loud high pitch noise is usually a condition of Liver Yang rising, Liver Fire, or Liver Wind.
A low pitch noise is usually a condition of Kidney Qi deficiency
Deafness that is chronic in nature is usually a condition of Kidney Qi deficiency. Blood and Heart deficiency, deficiency of Qi, and Yang Qi deficiency
Pain in the eyes is usually a condition of Liver because of the relationship to the opening of that viscera.
This is the process in which the practitioner gathers information by the observation of changes in the patient’s body. The most common parts that are inspected are the tongue and the face. Changes in the appearance of the body can give the practitioner clues in the nature of disease and pathology.
Observation of the Face –
One part of the observation examination is face diagnosis. This was written in the Huang Nei Jing. In TCM the face is another landmark, like tongue, or the vital organs. Impairment of the organs can therefore reflect in the face. This can manifest in facial complexion, texture, or moisture in the corresponding area.
It was already established that the Liver opens and controls the eyes. It is said that all the organs reflect in the eyes. Different appearances of redness, moisture, and textures in parts of the eye can reflect in impairment in the corresponding areas of the eye.
Observation of the Tongue –
Along with pulse diagnosis, this is can be the deciding factor in determining patterns of disease. This diagnostic procedure is much easier to master that pulse diagnosis. The tongue is a map of the internal organs.
The tongue can be divided into three sections Upper Burner, Middle Burner, and Lower Burner. The Upper Burner consists of the Heart and Lung. The Middle Burner consists of the Liver, Spleen, Gall Bladder, and Stomach. The Lower Burner consists of the Kidneys, Bladder, and Intestines. One can simply note changes in geography of the tongue and link them to a organ. For example, a red tip indicates Heart dysfunction, specifically heat in the Heart. If there is white coating present only in the back of the tongue indicates dysfunction in the Kidneys, specifically Qi deficiency of the Kidneys. The practitioner simply has to memorize key patterns of disease and the location of the organs in the tongue to be a successful tongue diagnostician.
Close attention is paid to the tongue to determine pathology. The TCM practitioner evaluates the patients tongue color, shape, and coating. Lets look at the specific conditions that are encountered in tongue pathology.
Pale Tongue: Indicates xu (Deficient) and cold syndromes or symptoms due to yang Qi deficiency and insufficiency of Qi and blood.
Red Tongue: Indicates heat syndromes, mostly shi types (Excess) of disease caused by interior heat, or symptoms of fire preponderance due to yin deficiency.
Deep Red Tongue: Denotes the excessive heat seen in febrile disease due to invasion of exogenous pathogenic heat which as been transmitted from the exterior to the interior of the body. It also can be seen in miscellaneous diseases due to a preponderance of fire caused by yin deficiency, or seen in diseases of accumulated fire in the liver channel.
Purplish Tongue: Shows the syndrome of blood stagnation. A tongue with purplish spots or petechiae also indicates blood stagnation.
Flabby Tongue: A flabby tongue body with teeth marks on the margin and pale in color indicates a yang deficiency of the spleen and kidney leading to accumulation and obstruction of phlegm-dampness. A flabby tongue with a deep red color indicates excessive pathogenic heat attacking the heart and spleen.
Thin and Small Tongue: This indicates consumption and deficiency of blood and yin. A thin and small tongue with a pale color denotes deficiency of both qi and blood. A thin dry tongue with a deep red color is mainly due to a preponderance of fire and great exhaustion of body fluids.
Rigid Tongue: Seen in febrile diseases due to the invasion of exogenous pathogenic heat transmitted into the pericardium or due to an obstruction of pathogenic phlegm. It may also be seen in high fever leading to consumption of body fluids and preponderance of pathogenic heat. It is a prodrome of wind-stroke (cerebral stroke).
Deviated Tongue: This is a prodrome of wind-stroke.
Cracked Tongue: Cracks on the tongue with deep red color indicate excessive heat. A cracked pale tongue indicates insufficiency of yin and blood. However, a cracked tongue of long term duration without any other symptoms can be considered normal.
Thinness and Thickness: Generally, if substantial pathogenic factors such as damp, phlegm or food accumulation occur and cause obstruction, they further affect the spleen and stomach leading to the ascent of turbid qi and forming of a thick tongue coating. A white thin tongue coating is formed if nonsubstantial pathogenic factors such as wind, heat, dryness, or cold attack the body; or if the pathogenic factors stay on the body surface; or if body resistance is weak during the disease development.
Moistness and Dryness: The normal tongue coating is moist, which indicates that plenty of body fluid is flowing upward. If the tongue coating is dry, it is due to body fluids failing to moisten the tongue. A dry tongue coating may also be present in some febrile diseases where pathogenic heat consumes the body fluid. A slippery tongue coating may be due to pathogenic damp-humor floating over the tongue surface.
Sticky and Curdled Tongue Coating: A sticky coating is due to hyperactivity of endogenous pathogenic phlegm and damp rising tot he tongue, and is mostly seen in diseases caused by pathogenic damp-heat or phlegm-humor. A curdled tongue coating is the outcome of food accumulation in the stomach leading to the ascent of turbid qi to the tongue surface. It is also seen in disease caused by phlegm-damp.
Peeled Tongue Coating: Mostly due to deficiency of qi and yin. If peeled tongue is accompanied by a sticky coating, it indicates a complicated disease condition to which the body resistance is weakened.
No Tongue Coating: Changes in the tongue coating indicate fluctuation in the disease condition. For example, if a qi deficiency of the stomach is manifested by a lack of tongue coating at an early stage, the tongue coating will reappear after the stomach qi is recovered. If a disease has no tongue coating, then suddenly appears, this indicates a perverse flow of stomach qi, or excessive pathogenic heat. If a disease has a tongue coating at the beginning, which disappears abruptly, this indicates stomach yin fluid has decreased. If a thick coating gradually turns into a thin white coating, this indicates that pathogenic qi is being gradually weakened, and the disease condition is becoming milder.
Generally, an observation of the thinness and thickness of the tongue coating will indicate the depth of pathogenic qi. The tongue's moistness or dryness shows the body fluid condition. The degree of stickiness of the tongue coating indicates the dampness of the stomach and spleen. The appearance or disappearance of tongue coating signified the cure or worsening of the disease condition.
Color of Tongue Coating
White Coating: Indicates exterior-cold syndromes. A white and thin coating is seen mostly in exterior syndromes, while a white and thick coating appears in interior-cold syndromes. If there is a powder-like whitish coating covering the tongue surface, it is caused by the internal accumulation of summer-humid heat and is usually seen at the onset of pestilential diseases.
Yellow Coating: Indicates interior and heat syndromes. A light yellow tongue coating is seen in cases of slight fever. A deep yellow color indicates high fever. Brownish tongue coatings represent an accumulation of pathogenic heat.
Grayish Coating: Denotes interior-heat syndrome or interior-cold syndrome. A grayish black and slippery coating on the tongue usually indicates symptom-complex due to cold-damp in the interior. A grayish, yellow, and sticky tongue coating usually indicates the accumulation of damp-heat. Grayish and dry tongue coatings are usually due to the consumption of body fluid by excessive heat.
Black Coating: This is often seen at the serious and dangerous stage of disease, and indicates extreme heat or cold. A black, yellow, and dry coating with thorns on the tongue surface usually denotes consumption of body fluid by extreme heat. A black and slippery tongue coating shows excessive cold due to yang deficiency.
The pulse is an invaluable diagnostic procedure. If done properly, it can provide the doctor with instructions in their course of treatment. Pulse diagnosis is crucial for all aspects in acupuncture. The pulses can determine which organ and pathway is imbalanced, where the disease is located in the body, how far to insert the needles, how to manipulate the needles, how long a session should last, and the patient’s prognosis. Ultimately, with tongue diagnosis, pulse palpation can be the major determining factor and basis of treatment
The Heart is obviously noted as regulating the pulses. However, it is much more complex, or integrated than this. In TCM, the pulses are associated with the internal organs, Qi, and blood. For example, blood circulation is a cooperative effort brought on by the Heart, Lung, Liver, and Spleen Zang. The Heart controls the circulation of blood, the Spleen controls the containment of the blood in the blood vessels, the Liver stores the blood, and the Lung and Spleen contribute to the pushing of blood though out the vessels and body. The Qi and blood has almost a symbiotic relationship. It is said that the blood is the mother of Qi, and the Qi is the ruler of blood. This explains how the blood nourishes the Qi and Qi regulates, or pushes the blood in the blood vessels. Without nourishment Qi cannot function and without the Yang function of movement that the Qi provides, of blood cannot function. You can therefore see how the state of Qi and blood can influence the pulses.
There is nothing easy about mastering pulse palpation. It takes years to fully appreciate the art of feeling the Qi in the radial artery. However, with in a few years of palpating pulses, your fine touch and pulse perceptions become easier and the images will become much more clear. Initially it is encouraged to spend more time in pulse palpation. In China it is not uncommon to spend twenty to twenty-five five minutes in evaluating the pulses. Obviously, this is not time effective in a busy clinic. Five to ten minutes is sufficient enough time when learning pulse diagnosis.
When taking the pulse, clear your thoughts and focus entirely on the patients Qi. Try to zone in on the radial pulse and start to decipher the images. It is said in ancient texts that the doctor doesn’t palpate the pulse, but rather listens to the pulses. This reflects the importance of concentration and focus.
Taking the Pulse
In classic Chinese texts, the pulses should be taken under optimal conditions. Providing the proper setting assures the doctor of true and clear findings.
The pulses should always be taken in the recumbent, or sitting position. The wrist should be at the same level as the heart. Make sure the patient is comfortable. If the patient cannot sit, take the pulses standing with the elbow bent and relaxed and the wrist at the heart level.
It is important to note that the doctor must be comfortable when taking the pulse. If the doctor is uncomfortable, their concentration isn’t optimal and the pulse palpation is hurried and sloppy. Traditionally, the doctor takes the pulses sitting on a desk or table. The doctor’s arm is rested on the desk or table with their arms at 90 degrees to the patient’s. The doctor’s right hand interprets the patients left radial artery, and the doctor’s left hand interprets the patient’s right radial artery. There should be no switching of positions. After a while of taking pulses, your index finger, middle finger, and ring finger will become very sensitive and comfortable in their respected positions.
The Pulse Positions
There are many different opinions on the six pulse positions. The most popular comes from Li Shi-Zhen described in his text, “Pulse Diagnosis” written in 1564. The three pulse positions are cun – front/distal position, guan – middle position, and the chi – last/proximal position.
These positions are located at the radial artery at the styloid process of the radius on both wrists. It is believed that the patients Qi and blood in the pathways and its associated organ are felt at these positions. Therefore, the status of a patient’s health is reflected in the pulses.
Feeling the Pulses
When examining the pulse, the doctor should always use his index finger for reading the cun position, middle finger to read the guan position, and ring finger to read the chi position. This was discussed earlier in the doctor positioning. It is mentioned again because of its significance.
The Three Depths
When taking the pulses. The doctor must Asses the qi and blood in all positions as well as all three depths. The pulses can be interpreted in three depths, superficially, slightly deeper, and deep. In classic texts, these are referred to a heaven, man, and earth. The depths describe where the Qi and blood are located at, where the disease is located at, and what part of the body is affected.
Upper Body - External Influences
Middle Body - Pathway level
Lower Body - Organ level
If the pulse is predominant in the cun position, it is said that the Qi and blood is superficial, just underneath the epidermis. This is usually indicative of external evils like wind and heat or Yang excess. The cun position can diagnose disease from the diaphragm to the head.
If the pulse is located in the guan position, the Qi and blood is located in the pathways where it is supposed to be. This is located between the epidermis and the muscles. The guan position diagnoses disease from the umbilicus to the lower diaphragm.
If the pulse is felt in the chi position, the Qi and blood is at the visceral level. This means that the Qi is very weak and the organ is either involved or is diseased itself. The chi position diagnoses disease from the below the umbilicus.
The level in which the Qi and blood are manifesting determines needling depths. If the pulses are very superficial, the Qi is flowing superficially and therefore needling should be shallow. If the pulses are located in the middle position, the Qi and blood are flowing in their respected pathways and needling is deeper. If the pulses are deep, to the bone, the Qi and blood is located in the organs and needling is deep. When you look at references in acupuncture texts on needling depths, the determining factor is where the Qi and blood is located. This is rarely discussed. For example, when reviewing needling depths of Hegu (LI-4) the range is from 0.3 cun to 1.0 cun. A superficial pulse will be needled at 0.3 cun , the middle pulse is needled 0.5 cun, and the deep pulse is needled at 1.0 cun.
To determine pathological pulses, one must establish normal images (Ping Mai). The following characteristics of a normal, healthy pulse are as follows:
Harmonious pulses of the Seasons
A person’s pulses are subject to the ever changing environment. To maintain the balance between the interior and the exterior, the body changes and is reflected in the normal pulse. During the springtime the Yang Qi becomes more prominent. The pulse will be increasingly stronger and slightly wiry. During the summertime the heat will cause the pulses to be overflowing. During the autumn the Yang Qi slowly weakens and the pulses will become empty, floating, and fine. During the winter the pulses sink deep because of the cold climate and they become deep and strong.
When imbalances of body, mind, and spirit inflict the body, physical changes immediately follow. A person can suffer with pain, fatigue, and organic dysfunction. Fortunately, physical changes are also present in the pulse images. In TCM, they label these pathological changes as Bing Mai and categorize them into twenty-nine pulse images. The twenty-nine images are classified into four easily felt categories. In the Bing Hu Mai Xue, it states that there are four principles, or essential images that nearly all pulses poses. They are fast, slow, floating / superficial, and deep.
When a beginning student of TCM starts to tackle these pulse categories, it seems overwhelming and even impossible to feel all twenty-nine images. If one sticks to the four categories of pulses, pulse diagnosis can be less of a headache and more of a wonderful tool of ancient wisdom.
Lets look in more detail on some of the pathological pulses. Remember that feeling the pulses takes time. Don’t get discouraged in the beginning. Pulse palpation is an art as well as a science. With that in mind, be diligent, patient, and determined and success is sure to follow.
Pulse Image: Pulse has most strength at upper-most level, and can be only be felt on a slight touch. Li Shi Zhen describes this as feeling like a piece of wood floating on water. It is very strong at the surface and disappears on deeper palpation, like when the piece of wood is pushed under water and then reappears when light pressure is applied.
A floating pulse appears when Yang Qi is excess. This image is mostly seen in cases of Wind. This can be Wind, Wind/Cold, or Wind/Heat.
Wind/Cold – If the image is floating and tight.
Wind/Heat – If the image is floating and rapid.
If the floating pulse is also forceless and empty in deep position it is indicative of Deficiency
Cun Position: This is mainly felt in the cun (front) position. This is in the upper jiao. The Lung and Heart Zang occupy these positions. The Lung is the most vulnerable organ to the exterior. It is therefore subjective to wind, heat, and cold. If the Lung is weak, these pathogens invade the body and can yield a floating pulse. As we mentioned earlier, Lung controls the Wei Qi, or the immune system. A floating pulse in the right cun position almost always means a flu / cold is present, in progression, or ending.
Guan Position: When the Spleen is deficient and it affect the entire middle jiao, a floating pulse will appear in this position on the right arm. If the Liver Qi is over-abundant a floating pulse in the left guan position will be present.
Pulse Image: Pulse has most strength at lowest level and requires deep pressure to feel. It is said to feel like a cotton ball on sand in the superficial position and very strong and rigid in the deep position.
If the pulse is weak and deep it indicates deficiency of Qi. If the pulse is full and deep it indicates interior cold or heat.
This can be felt in all the positions.
Guan Position: A deep pulse in the guan position is indicative of cold stagnation in the middle jiao – Stomach / Spleen.
Chi Position: A deep pulse in the chi position is very common. This translates to weakness in Kidney Qi and Kidney Yuan Qi.
Pulse Image: Pulse is less than 60 beats per minute or if the pulse beats three times in a respiration.
Pathology: Cold in the interior, or severe qi deficiency.
If the pulse is slow it indicates invasion of cold. If the pulse is slow and floating it is due to invasion of wind / cold. If the pulse is slow and empty it indicates deficiency of Yang.
This can be felt in all the positions.
Guan Position: A slow pulse in the guan position is indicative of cold stagnation in the middle jiao – Stomach / Spleen and Liver which can lead to painful spasms in the muscles and tendons.
Chi Position: A slow pulse in the chi position translates to weakness due to cold retention in Kidneys.
Pulse Image: Pulse is greater than 80 beats per minute.
Pathology: Heat, either excess or deficient
This pulse image occurs when there is excess Yang Qi. If the pulse is rapid and floating it is indicative of superficial heat. If the pulse is rapid and deep it is indicative of internal heat. If the pulse is rapid and strong it indicates excess heat. If the pulse is rapid and lacks strength it indicates deficient heat, or Yin deficiency.
This can be felt in all the positions.
Cun Position: When a rapid pulse is felt in the front left position it indicates Heart heat blazing upward. If felt in the front right position it is indicative of Lung dryness.
Chi Position: A rapid pulse in the chi position translates fire blazing upward due to Kidney Yin deficiency.
5. Empty Pulse:
Pulse Image: This pulse describes the strength of pulse. Under firm pressure, the empty pulse feels soft and weak. However, an empty pulse is felt with light or heavy pressure, but feels forceless to the fingers.
An empty pulse reflects a weakness of the body and leads to a lowered state of resistant. Whether the pulse is rapid or slow, an empty pulse is always due to deficiencies. This pulse image reflects a state of deficient Qi and blood.
Cun Position: This is mainly felt in the cun (front) position. This is in the upper jiao. The Lung and Heart Zang occupy these positions. If the Heart blood is deficient leading to mal-nourishment of the Heart, this position on the left becomes empty.
Guan Position: When food stagnates and the Stomach swells because of deficiencies, the process of transformation and transportation function of the Spleen is lost. A empty pulse is then felt in this position.
6. Full Pulse:
Pulse Image: This pulse describes the strength of pulse. It is present upon deep and superficial pressure. It is felt as a full throbbing pulse. Pulse can be felt strongly on all three levels at the same time.
A full pulse reflects states of excess. This pulse image reflects the struggle of the body’s excess Qi and blood and a normal energy level.
Cun Position: A full pulse at this position reflects excess heat and wind in the upper jiao. This can lead to symptoms such as headache, fever, soar throat, and stuffiness in the chest.
Guan Position: Accumulated heat in the middle jiao – Spleen/Stomach causes a full pulse at this position. Symptoms such as stuffiness and abdominal distension.
Pulse Image: Pulse feels like pearls coursing through the pulse, with a definitive rolling quality. The pulse quickly hits each individual finger and just as quickly rolls away. It feels like slippery little balls that remain even. A slippery pulse usually occurs with a rapid pulse.
Pathology: Dampness of any variety, phlegm, pregnancy, heat.
A slippery pulse indicates a mild illness. It is a result of an abundance of Yang Qi in the body. It also can be caused by heat from the Liver or the Kidney fire that cause the blood to heat up. It is seen very often in pathologies with increased dampness and phlegm. Pregnant females very often have a slippery pulse reflecting abundant Qi and blood in the body. Healthy people that have abundant Qi and blood can also present with a slight slippery pulse.
Cun Position: A slippery pulse at this position reflects when the Qi accumulates in the chest and diaphragm, interfering with the descending function. This leads to symptoms of acid reflux, vomiting, stiff tongue, and coughing.
Guan Position: A slippery pulse at this position reflects Liver heat t and Spleen dampness. This is very common in this position on both the right and left arms.
8. Choppy Pulse:
Pulse Image: Pulse is uneven and rough. Classically defined as a knife scraping bamboo . It is fine, short, and slow. It also moves at irregular depths, like a silkworm eating at a leaf. The will not stop periodically like that of a intermittent pulse. The choppy pulse is felt in the superficial middle, and deep pulses unlike the minute pulses.
Pathology: Blood deficiency or Qi and blood stagnation.
A choppy pulse usually is indicative of deficiency of Yin blood. It can also be felt when there is invasion of cold damp that penetrates the organs and causes stagnation of blood circulation. In pregnant women, a choppy pulse reflects insufficient blood and nourishment of the fetus.
Cun Position: A choppy pulse at this position reflects damaged Heart blood that can lead to chest pain.
Guan Position: A choppy pulse at this position reflects weakness and deficiency of the Stomach / Spleen causing fullness and swelling.
Pulse Image: This pulse feels long in its beat rate. If it is long , soft, and calm it indicates health. If it is long tight, like a string it indicates disease.
Pathology: This pulse image can reflect the strong health of an individual. In diseased patients, this pulse reflects excess Yang heat in the blood, wind phlegm, or internal heat in the Stomach or Large Intestines.
Pulse Image: This pulse image feels short and its beats are strong, but it rises and falls abruptly.
Pathology: Qi and blood deficiencies
This pulse is felt when Qi becomes weak and is not able to circulate evenly.
Pulse Image: This pulse image feels taught, long, and strong in nature. It can be felt in light or heavy palpation. It is said to feel like a bow string, very firm and fixed. It can also be compared to a sting instrument, very springy and elastic in nature. It feels like a thin musical string that bounds up against the fingers evenly but with force. This is very commonly felt, especially in the Liver (Guan) position.
Pathology: Qi stagnation, especially in Liver, can also be phlegm
This is commonly found in cases of liver Qi stagnation. It can also be present if there is excess heat (fast pace) and cold (slow pace). Patients that have spasms, stiffness, and pain in the body will also yield a wiry pulse. Excess phlegm can lead to a wiry pulse. In general, if the disease is mild, the pulse is wiry and soft. If the disease is sever, the pulse is wiry and hard.
Cun Position: A wiry pulse at this position reflects accumulated phlegm in the chest and diaphragm.
Guan Position: A wiry pulse at this position reflects Liver and Gall Bladder disease, primarily Qi stagnation. Excess cold in the Stomach can also yield a wiry pulse in this position.
Pulse Image: Exactly what it says. Pulse simply feels thinner than it should. It feels like a thin string of thread. It s felt as weak, soft, and without strength.
Pathology: Blood or qi deficiency.
This is seen in cases of deficiencies and failure of Qi and blood. It can also be seen in disharmonies of the even emotions, weakness in Yang Qi, internal damage to jing, and penetration of dampness.
Cun Position: A thin pulse at this position reflects severe deficiency if Qi.
Guan Position: A thin pulse at this position reflects Spleen / Stomach deficiency.
Pulse Image: Pulse feels taught like a rope, thicker than wiry, feels as if the pulse evenly hits the fingers in different places with every beat.
Pathology: Cold, usually causing stagnation.
Cold of any nature will produce a tight pulse. Cold can attack the Liver, Lungs, Spleen/Stomach, and Kidneys.
Cun Position: A tight pulse at this position reflects cold damage. In the left position it reflects external cold. In the right position it reflects internal cold.
Guan Position: A tight pulse at this position reflects Spleen / Stomach cold damage.
Chi Position: A tight pulse at this position reflects deficiency and cold of the Kidneys.
Pulse Image: Strength of the pulse is minimal, and with more pressure cannot be felt at all.
Pathology: Qi deficiency
Cun Position: A weak pulse at this position reflects weakness in the Heart and Lungs
Guan Position: A weak pulse at this position reflects Spleen / Stomach weakness.
Chi Position: A weak pulse at this position reflects deficiency of the Kidneys.
Pulse Image: Regularly is irregular for this pulse image. Pulse seems to miss a beat and then pauses.
Pathology: Heart organ disharmony or exhaustion of the organs
It can also be felt after three months of pregnancy. Indicating deficient Qi.
Auscultation & Olfaction
Some information can be gathered from listening to the speech and respiration. If the speech is loud and robust, it indicates excess. If the voice is weak and timid, it indicates weakness and deficiencies. Weak breathing is indicative of deficient Qi. Forceful breathing indicates presence of excess heat.
Any foul odor usually indicated the presence of heat. This can be seen in the case of body odor. A foul and sour odor can be caused by food retention. Metal smells are commonly seen in Lung impairment.