TCM Diagnostics

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.

Inquiring Questioning the Patient

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:

Energy Level
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 & Fever

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.

Perspiration
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.

Appetite
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.

Tastes

Heat will produce a bitter taste in the Liver or the Heart. In

Liver fire, the bitter taste isnt constant. Heart fire produces
a bitter taste in the morning after a sleepless night and Heart
fire is always accompanied with insomnia.

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.

Vomit
Vomiting is usually caused by a form of heat.

Sour vomiting is a result of Liver insulting the Stomach..

Bitter vomiting is a result of Liver and Gall Bladder heat.
Vomiting that occurs after eating is usually a result of heat
pathogenic factor.

Thirst
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.

Stools
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.

Urination
Dark color urine usually indicates heat syndromes.
Clear and abundant amounts of urine usually indicates coldor 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.

Sleep
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
Dizziness is usually a symptom of deficiency of Qi , blood deficiency,
fire, wind or phlegm.

Pain

Headache
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.

Back pain

Continuous and dull

deficiency.

pain in the back is usually a result of Kidney Qi

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

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

Numbness
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.

Pain in the entire body

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.

Thorax and Abdomen

The thorax is under the direct influence of the Lung and Heart Zang.
The sides of the body are
Gall Bladder Fu.

mainly influenced by the Liver Zang and the

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.

Ears
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 Fire, or Liver Wind.

Liver Yang rising,

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

Eyes
Pain in the eyes is usually a condition of Liver because of the
relationship to the opening of that viscera.

Observation
This is the process in which the practitioner gathers information by the
observation of changes in the patients 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.

Observation of the Eyes

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.

Tongue Proper
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.

Tongue Appearance
Flabby Tongue: A flabby tongue body with teeth marks on the
pale in color indicates a yang deficiency of the spleen and
leading to accumulation and obstruction of phlegm-dampness.
tongue with a deep red color indicates excessive pathogenic
attacking the heart and spleen.

margin and
kidney
A flabby
heat

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:
excessive heat.
blood. However,
symptoms can be

Cracks on the tongue with deep red color indicate

A cracked pale tongue indicates insufficiency of yin and
a cracked tongue of long term duration without any other
considered normal.

Tongue Coating
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.

Palpation

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 patients
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 doesnt
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.

Patient Position
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.

Doctor Position
It is important to note that the doctor must be comfortable when taking
the pulse. If the doctor is uncomfortable, their concentration isnt
optimal and the pulse palpation is hurried and sloppy. Traditionally,
the doctor takes the pulses sitting on a desk or table. The doctors
arm is rested on the desk or table with their arms at 90 degrees to the
patients. The doctors right hand interprets the patients left
radial artery, and the doctors left hand interprets the patients
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.

Lung

Right Arm
Guan
Chi
Spleen/Stomac
h
Kidney Yin

Cun
Heart

Left Arm
Guan
Liver

Cun

Chi
Kidney Yang

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 patients 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.

Superficial
Middle
Deep

Pulse Depths
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.

Normal Pulses
To determine pathological pulses, one must establish normal images (Ping
Mai). The following characteristics of a normal, healthy pulse are as
follows:

Spirited (You Shen): This means if the pulse is strong and

patterns of its beat is distinct. If the can be felt coming and
going with good force, it has spirit. If it is faint, irregular,

choppy, or once and a while ceases, it is said that the pulse is

without spirit.
Rooted (You Gen):
If the pulses at the last, Chi position and
it is felt all the way to the radial bone, it is said to be strongly
rooted. In classics it states that if the pulses are rooted, the
patients health is good. Just as the roots of a tree that deeply
plants and anchors deep in the ground, the patients health is
deeply anchored.
It has Stomach (You Wei):
The pulses should posses some
slippery quality. When one feels comfortable in feeling all the
pulse images, identifying this slightly slippery quality will be
appreciated. If the pulses feel tense or large and not slightly
slippery, it looses its harmony, and is said to lack Stomach Qi.

Harmonious pulses of the Seasons

A persons 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.

Pathological Pulses
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. Dont 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.

Bing Mai, Pathological Pulse Images

Floating / Superficial Pulse (Fu Mai) :

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.

Pathology: External pathogen or

deficiency
External Pathogen
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.

Deficiency
If the floating pulse is also forceless and empty in deep position it is
indicative of Deficiency

Positions Felt:

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.

Chi Position: A floating pulse isnt

felt much in the Chi position. When
it is present, it reflects lower jiao
dysfunction and can lead to urination
and stool problems.

2.

Deep / Sinking Pulse (Chen Mai) :

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.

Pathology:

Internal organ deficiency

If the pulse is weak and deep it indicates deficiency of Qi.

pulse is full and deep it indicates interior cold or heat.

If the

Positions Felt:
This can be felt in all the positions.

Cun Position: When a deep pulse id

felt in the front position it means

there is some water retention or

phlegm stuck in the upper jiao
especially the Lungs.
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.

3.

Slow (Chi Mai) :

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.

Positions Felt:
This can be felt in all the positions.

Cun Position: When a slow pulse is

felt in the front left position it
indicates cold accumulation in Heart
and chest area. If felt in the front
right position it is indicative
invasion of wind cold or cold.
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.

4.

Rapid (Shu Mai) :

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.

Positions Felt:
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.

Guan Position: A rapid pulse in the

left guan position is indicative of
Liver fire blazing upward.
If the
right guan position is rapid it
usually is due to Stomach fire.
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.

Pathology:

Deficient Qi and blood

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.

Positions Felt:
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.

Chi Position: When the Jing and blood

is damages causing low back pain and
numbness, the pulse in this position
becomes empty.
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.

Pathology:

Heat, excess or both.

A full pulse reflects states of excess.

This pulse image reflects the
struggle of the bodys excess Qi and blood and a normal energy level.

Positions Felt:
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.

Chi Position: Excess heat in the lower

jiao leads yields a full pulse and can
lead to lumbar pain, abdominal
distension, and constipation.

7.

Slippery Pulse:

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.

Positions Felt:
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.

Chi Position: Excess damp heat in the

Kidney and Bladder leads to a slippery
pulse and can lead to lumbar pain,
abdominal distension, dysentery,
dysuria, and constipation.
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.

Positions Felt:
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.

Chi Position: A choppy pulse at this

position reflects damaged jing and
blood in the Lower Jiao resulting in

constipation, and dribbling of urine.

9.

Long Pulse:

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.

10.

Short Pulse:

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.

11.

Wiry Pulse:

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.

Positions Felt:
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.

Chi Position: A wiry pulse at this

position reflects deficiency and cold
of the Kidneys.
12.

Thin Pulse:

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.

Positions Felt:
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.

Chi Position: A thin pulse at this

position reflects deficiency and cold
of the Kidneys.
13.

Tight Pulse:

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.
Liver, Lungs, Spleen/Stomach, and Kidneys.

Cold can attack the

Positions Felt:
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.

14.

Weak:

Pulse Image: Strength of the pulse is minimal, and with more pressure
cannot be felt at all.

Pathology: Qi deficiency

Positions Felt:
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.

15.

Intermittent Pulse:

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

Sounds
Some information can be gathered from listening to the speech and
respiration. If the speech is loud and robust, it indicates excess.
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.

Smells

If

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.