Pulse Diagnosis Steps:
First distinguish floating from sinking,Second differentiate between deficiency and excess;
Third assess length and shortness, fourth calculate rapidity and slowness;
Fifth observe pulse shape, know them all.
1. First distinguish floating from sinking
What is “first distinguish floating from sinking”? The explanation is as follows:
① First, differentiate whether the pulse is floating or sinking. When palpating the pulse, the fingers gradually probe from the superficial to the deeper layers, first lightly touching the skin (i.e., “lifting”), which can reveal whether the pulse is floating; if there is no floating pulse, then apply more pressure (i.e., “searching”), at this level many pulse types can be felt; then the third force, “pressing”, checks for a sinking pulse. Therefore, “first distinguish floating from sinking” is based on the order of finger pressure to detect the position of the pulse.
② During the differentiation of floating and sinking, one can identify the types of pulses related to floating or sinking, which are:
Floating pulse types—floating pulse, soft pulse, leather pulse, hollow pulse, scattered pulse;
Sinking pulse types—sinking pulse, firm pulse, hidden pulse.
③ After distinguishing between floating and sinking pulses, it can indicate whether the condition is an exterior or interior syndrome in diagnostic assessment.
2. Second differentiate deficiency and excess
What is “second differentiate deficiency and excess”? The explanation is as follows:
① After completing the distinction between floating and sinking, knowing whether the condition is exterior or interior, it is also necessary to understand the relationship between the righteous qi and pathogenic qi (deficiency syndrome or excess syndrome), and the distinction between excess and deficiency in pulse is the difference between strong and weak pulses. Thus, the second step in pulse detection is to differentiate between deficiency and excess (strength and weakness) of the pulse.
② When differentiating the pulse as deficient or excess (i.e., strong or weak), one can also distinguish other pulse types related to deficiency and excess. Deficient pulse types—deficient pulse, faint pulse, weak pulse; excess pulse type—excess pulse.
3. Third assess length and shortness
What is “third assess length and shortness”? The explanation is as follows:
① Long and short pulses are two types of pulses with very distinct characteristics, which can be distinguished by the fingers touching the pulse vessel.
② When examining the cun, guan, and chi positions, first distinguish the pulse as long or short, and then further assess the pulses at these positions.
③ When distinguishing long and short pulses, one can also be aware of other related pulse types, such as: long pulse types—long pulse, string-like pulse, fine pulse; short pulse types—short pulse.
4. Fourth calculate rapidity and slowness
What is “fourth calculate rapidity and slowness”? The explanation is as follows:
① After determining the pulse position (the pulse position distinguishes length and string-like quality, and observes floating and sinking) and pulse quality (which also includes deficiency and excess), the next step is to address the frequency and rhythm of the pulse.
② There are 8 types of pulses related to pulse frequency and rhythm:
Pulse rate—rapid pulse, quick pulse, slow pulse, leisurely pulse
Pulse rhythm—hurried pulse, knotted pulse, intermittent pulse, scattered pulse
5. Fifth observe pulse shape
What is “fifth observe pulse shape”? The explanation is as follows:
① After completing the above four steps, one can distinguish 23 types of pulses, and the remaining are 4 types of pulses primarily characterized by their shape: surging, slippery, rough, and tight.
② Except for the unique surging pulse, slippery and rough are relative, while tight pulse and rough pulse are distinguished from each other. The surging pulse often appears in summer or in febrile diseases (yangming heat excess or the qi stage of warm diseases), or in the final stages of critical illness, which can be inferred from other information.
6. Know them all
What is “know them all”? The explanation is as follows:
① This is the final review stage. By this step, one should have a clear understanding of the pulse position (left and right, up and down), pulse quality (deficiency and excess), pulse rate (rapidity and slowness), pulse rhythm (knotted and intermittent), and pulse shape (surging, tight, slippery, rough), no longer is it “difficult to clarify under the fingers, hard to understand in the heart”.
② All information should be integrated and analyzed to draw conclusions. The methods for drawing conclusions are:
A: Filter all pulse information in the mind through the definitions of 28 pulse types, using independent pulse names where applicable; otherwise, use the combined pulse method to define the pulse.
B: Examine the degree of consistency between the obtained pulse information and the information from observation, listening, and inquiry, then determine the authenticity of the pulse and its relevance to treatment decisions.
C: Carefully differentiate the cun, guan, and chi issues: when the condition is complex, the cause is unclear, or the location is unknown, carefully examine the cun, guan, and chi; otherwise, differentiation may not be necessary.
For example:
First step floating and sinking, measured: pulse position—floating;
Second step deficiency and excess, measured: pulse quality—deficient, soft;
Third step length and shortness, measured: pulse position—cun, guan, chi all present;
Fourth step calculate rapidity and slowness, measured: pulse rhythm, pulse rate—normal;
Fifth step pulse shape, measured: pulse shape—like a silk thread;
Sixth step integration, additional information: symptoms of weakness in the limbs, pale yellow complexion, heavy head and drowsiness, bland taste in the mouth, loose stools, scanty urination, pale red tongue, thin white greasy coating;
Conclusion: Using the combined method to judge the pulse: floating fine—incorrect! Using independent naming method to judge the pulse: soft—correct.
To have this skill, the prerequisites are:
1) Truly understand the concept of each pulse type; 2) Engage in extensive clinical practice.
Pulse diagnosis is a fundamental technique in Traditional Chinese Medicine. Currently, pulse diagnosis in TCM generally refers to cun pulse diagnosis, often based on the 28 pulse types summarized by the medical sage Li Shizhen, which is also the standard in many contemporary undergraduate textbooks. This article is based on this standard. According to student requests and combined with doctors’ opinions, the following analysis is provided, and TCM colleagues are welcome to critique, correct, and discuss.
1. Basic Theory of Pulse Diagnosis
1. Significance of Pulse Diagnosis:
Pulse diagnosis is an indispensable diagnostic step and content in TCM clinical practice. The importance of pulse diagnosis lies in its ability to convey physiological and pathological information from various parts of the body, serving as a window to observe internal functional changes, providing important evidence for diagnosing diseases. In summary, it includes the following points:
① Distinguishing the location of the disease: for example, floating pulse indicates exterior syndrome, sinking pulse indicates interior syndrome.
② Distinguishing the nature of the disease: for example, slow pulse and tight pulse indicate cold, rapid pulse and slippery pulse indicate heat.
③ Distinguishing the rise and fall of pathogenic and righteous qi: for example, deficient pulse indicates deficiency of righteous qi, excess pulse indicates excess of pathogenic qi.
④ Distinguishing the progression or regression of the disease: for example, in cases of externally contracted febrile diseases, as the heat gradually recedes, the pulse becomes more moderate, indicating a sign of recovery.
2. Characteristics of TCM Pulse Diagnosis
① The elements constituting TCM pulse types include five aspects: pulse position, rate, rhythm, shape, and strength (qi strength).
② Pulse diagnosis is a profound experiential medical knowledge with many techniques; one must be familiar with the theory and then practice diligently.
③ There may be inconsistencies between pulse types and symptoms; during diagnosis, one must apply the method of prioritizing symptoms over pulse.
3. Selection and Rejection of Pulse Types (Correspondence and Prioritization of Pulse and Symptoms)
The selection and rejection of pulse types refer to discerning the correspondence between pulse and symptoms to determine the progression or regression of the disease and when to prioritize pulse or symptoms. This indicates that pulse types are one aspect of disease manifestation, not the entirety; pulse types should be considered as one aspect of information for diagnosis. A comprehensive application of the four diagnostic methods is necessary to arrive at a correct conclusion.
① Correspondence of Pulse and Symptoms
The correspondence of pulse and symptoms refers to discerning the progression of the disease based on their correspondence (progression refers to whether the disease is progressing smoothly, and the relationship between pathogenic and righteous qi), such as:
Pulse and symptoms correspond—pulse and symptoms are consistent: exterior syndrome shows floating pulse, heat syndrome shows rapid pulse, which is a correspondence.
Pulse and symptoms do not correspond—pulse and symptoms are inconsistent, such as exterior syndrome showing sinking pulse, heat syndrome showing slow pulse, which is a contradiction.
Pulse and symptoms correspond—acute or new diseases show floating, surging, rapid, and excess pulses, indicating that righteous qi is abundant and can resist pathogens. Chronic or old diseases show sinking, faint, fine, and weak pulses, indicating that the pathogen is weakening and recovery is possible.
Pulse and symptoms do not correspond—new diseases showing sinking, fine, faint, and weak pulses indicate that righteous qi has weakened. Chronic diseases showing floating, surging, and excess pulses indicate that righteous qi has weakened, and pathogenic qi has not receded.
② Prioritize Symptoms over Pulse, Prioritize Pulse over Symptoms (True Symptoms, False Pulse; False Symptoms, True Pulse)
True symptoms, false pulse—prioritize symptoms over pulse, meaning not considering the significance of pulse types, but only the significance of symptoms. For example: symptoms show abdominal distension and pain, refusal to press, dry stools, red tongue with thick yellow coating, pulse is sinking and fine—true symptoms indicate interior heat syndrome, prioritize symptoms; sinking and fine pulse is a false pulse (sinking and fine pulse indicates deficiency and cold); in this case, prioritize symptoms.
False symptoms, true pulse—prioritize pulse over symptoms, meaning not considering the significance of symptoms, but rather the significance of pulse types. For example: symptoms show cold limbs, constipation, abdominal pain and distension, pulse is slippery and rapid—false symptoms (seem to indicate cold excess syndrome), prioritize pulse; slippery and rapid pulse is true, indicating interior heat accumulation, in this case, prioritize pulse.
4. Application of the Three Positions and Nine Indicators
In difficult cases, use the left hand for heart, liver, and kidney, and the right hand for lung, spleen, and life position, generally not using the nine indicators.
5. Normal Pulse Types—Stomach, Spirit, Root
In TCM theory, normal pulse types can be summarized with the words “stomach, spirit, root”. The characteristics of normal pulse types are: pulses present in all three positions (cun, guan, chi), neither floating nor sinking, neither fast nor slow, with a rate of 4-5 beats per breath, equivalent to 72-80 beats per minute (for adults), neither large nor small, calm and gentle, with consistent rhythm, and the chi position has a certain strength when pressed, varying with physiological activities, climate, seasons, and environment.
① Having Stomach: “Having stomach” refers to the pulse feeling calm, gentle, soft, and smooth. Normal pulse types are neither floating nor sinking, neither rapid nor slow, coming and going calmly, with consistent rhythm; even in pathological pulses, regardless of floating or sinking, slow or rapid, if there is a sense of harmony, it is still considered “having stomach qi”.
② Having Spirit: “Having spirit” refers to the pulse rate being regular, gentle, and strong. Even if the pulse is weak, it should not be completely disordered and without strength; a string-like or firm pulse still feels gentle, all belonging to “having spirit qi”. Conversely, if the pulse is disordered, varying in size, rapid and slow, intermittent, or if it is overly firm or weak, it is considered “lacking spirit”.
③ Having Root: “Having root” primarily manifests as a strong chi pulse and a continuous presence when pressed. If the condition is severe, but the chi pulse can still be felt, it indicates that kidney qi is not exhausted, and there is still vitality; conversely, if the chi pulse cannot be felt, it indicates that kidney qi has failed, and the condition is critical.
6. Physiological Variations of Pulse Types
① Individual factors: gender, age, constitution, pulse position (oblique pulse, reverse guan pulse) affect pulse types.
② External factors: emotions, work-rest balance, diet, seasons, day-night cycles, geographical environment, etc., affect pulse types.
2. Pathological Pulse Analysis
1. Analysis of 28 Pulses (Independent Pulse Types)
① Pulses primarily characterized by abnormal pulse position—floating, soft, hollow, leather, sinking, hidden, firm, short, long
“Abnormal pulse position” concept: refers to changes in the position of the pulse body, such as vertical or horizontal shifts.
For example:
1) Floating pulse: pulse characteristics—easily felt with light pressure, insufficient with heavy pressure. Indicates exterior syndrome, deficiency syndrome.
2) Soft pulse: pulse characteristics—floating and fine, cannot withstand heavy pressure, not prominent with heavy pressure. Indicates deficiency syndrome, damp syndrome.
Soft pulse analysis: pulse is at a shallow position, easily felt with light pressure, insufficient with heavy pressure; pulse body is fine like a thread; pulse vessel has weak elasticity.
3) Sinking pulse: pulse characteristics—cannot be felt with light pressure, only felt with heavy pressure. Indicates interior syndrome.
Sinking pulse analysis: pulse is at a deep position, cannot be felt with light or moderate pressure, only with heavy pressure.
4) Short pulse: pulse characteristics—both ends are short, cannot fill the entire area. Indicates qi disease.
Short pulse analysis: only noticeable in the guan position, cun and chi positions are vague or not obvious.
5) Long pulse: pulse characteristics—ends are straight, exceeding the normal position. Indicates long and strong pulse indicates excess pathogenic qi. Long and gentle indicates normal pulse.
Long pulse analysis: pulse vessel position exceeds the cun, guan, chi positions, pulse body is long and straight.
6) Hollow pulse: pulse characteristics—floating, large, hollow in the middle, like pressing on a scallion tube. Indicates blood loss, yin injury.
Hollow pulse analysis: pulse is floating, easily felt with light pressure; pulse shape shows vessels on both sides but hollow in the middle.
7) Leather pulse: pulse characteristics—floating and broad, hollow in the middle but firm on the outside, like pressing on a drum skin. Indicates severe loss of essence and blood, yang qi floating outward.
Leather pulse analysis: pulse is floating, easily felt with light pressure; pulse vessel is hard on the outside but hollow in the middle, like pressing on a drum skin.
8) Hidden pulse: pulse characteristics—requires heavy pressure to feel, may not be felt at all; its position is deeper than sinking pulse. Indicates closed pathogenic factors; extreme cold; severe pain.
Hidden pulse analysis: requires heavy pressure to feel the pulse, may still be difficult to detect.
9) Firm pulse: pulse characteristics—combines characteristics of sinking, string-like, excess, large, and long pulses, firm and unyielding. Indicates internal cold and excess; hernia and masses.
Firm pulse analysis: combines the analysis of sinking, string-like, excess, and long pulses. The “large pulse” characteristic is: the pulse body (pulse vessel) is wide, but the pulse strength is not overwhelming.
② Pulses primarily characterized by abnormal pulse rate—rapid, quick, slow, leisurely
“Abnormal pulse rate” concept: refers to pulse rate exceeding or falling below normal within a minute. For example:
10) Rapid pulse: pulse characteristics—pulse rate is fast, between 90-139 beats per minute (more than 5 beats per breath), rhythm is regular. Indicates heat syndrome. (“One breath” refers to the time of a normal person’s inhalation and exhalation.)
11) Slow pulse: pulse characteristics—pulse is slow, less than 4 beats per breath, rhythm is regular. Indicates cold syndrome.
12) Quick pulse: pulse characteristics—pulse is urgent, 7-8 beats per breath (more than 140 beats per minute). Indicates yang counteracting yin, vital qi is about to escape.
13) Leisurely pulse: pulse characteristics—4 beats per breath, coming and going slowly or pulse shape is relaxed, lacking sufficient tension; pulse rate is slightly slower than normal pulse but faster than slow pulse, indicates damp syndrome; spleen and stomach deficiency; after prolonged illness and treatment, it indicates recovery of righteous qi.
③ Pulses primarily characterized by abnormal pulse rhythm—hurried, knotted, intermittent.
“Abnormal pulse rhythm” concept: refers to irregular pulse rhythm. For example:
14) Hurried pulse: pulse characteristics—rapid and irregular, with intermittent pauses. Indicates excessive yang heat.
Hurried pulse analysis: pulse rate is rapid, greater than 90 beats per minute, with irregular pauses.
15) Knotted pulse: pulse characteristics—pulse is slow with intermittent stops, with no fixed number of stops. Indicates excessive yin, qi stagnation, cold phlegm, blood stasis, masses, and food stagnation.
Knotted pulse analysis: pulse is slow with irregular pauses, pulse rate is less than or equal to 90 beats per minute, with irregular pauses.
16) Intermittent pulse: pulse characteristics—pulse stops completely for a fixed number of beats, then resumes after a long time. Indicates organ qi deficiency, pain, fright, or injury from falls.
Intermittent pulse analysis: pulse rate is normal, 60-90 beats per minute. Pulse rhythm has regular pauses.
④ Pulses primarily characterized by abnormal pulse shape—surging, fine, slippery, rough, string-like, tight
“Abnormal pulse shape” concept: refers to the pulse feeling abnormal in shape during movement, including amplitude and speed of rise and fall, surface smoothness, elasticity, volume, and area under the fingers. For example:
17) Surging pulse: pulse characteristics—pulse body is wide, like a flood, coming strong and going weak. Indicates excessive yang heat, residual yang escaping.
Surging pulse analysis: pulse body is wide; amplitude is large; speed of rise and fall is very fast, like “coming with great momentum and going with reduced momentum”; pulse movement is strong and not weak.
18) Fine pulse: pulse characteristics—pulse body is fine, like a silk thread, clearly felt under the fingers. Indicates deficiency syndrome, damp syndrome.
Fine pulse analysis: pulse movement feels fine like a silk thread under the fingers, with a fine line sensation.
19) Slippery pulse: pulse characteristics—pulse comes and goes smoothly and roundly, like beads rolling, feels smooth under the fingers. Indicates phlegm syndrome, food accumulation, excess heat syndrome (also seen in normal individuals and pregnant women).
Slippery pulse analysis: pulse movement feels smooth and flowing under the fingers, with a sense of smoothness.
20) Rough pulse: pulse characteristics—coming and going with difficulty, feels rough and lacks smoothness (opposite of slippery pulse), like “a light knife scraping bamboo”. Indicates roughness and strength for excess syndrome, blood stasis, food accumulation, phlegm obstruction; roughness and weakness for essence injury, blood deficiency.
Rough pulse analysis: pulse movement lacks smoothness, flowing with difficulty, with a surface feeling of fine serrations.
21) String-like pulse: pulse characteristics—straight and long, like pressing on a guitar string. Indicates liver and gallbladder diseases, pain, phlegm and drink, malaria.
String-like pulse analysis: pulse vessel is long and straight; under the fingers, it feels like a guitar string, with slightly higher tension.
22) Tight pulse: pulse characteristics—pulse comes tight, like a twisted rope. Indicates cold syndrome, pain syndrome, food stagnation in the gastrointestinal tract.
Tight pulse analysis: pulse body has high tension, with a feeling of rotation under the fingers during movement, pulse feels strong.
23) Moving pulse: pulse characteristics—pulse shape like a bean, slippery and rapid, short, especially prominent in the guan position. Indicates pain syndrome, fright.
Moving pulse analysis: the prominent feeling of pulse movement is mainly in one position, often seen in the guan position (i.e., short); surface is smooth, speed is fast (i.e., slippery and rapid); during movement, it feels like a bean is jumping.
⑤ Pulses primarily characterized by abnormal pulse quality—excess, deficiency, weak, faint, scattered
“Abnormal pulse quality” concept: refers to changes in the strength and power of the pulse.
24) Excess pulse: pulse characteristics—strong in cun, guan, chi positions, with a feeling of fullness. Indicates excess syndrome.
Excess pulse analysis: pulse body is long and large, with a feeling of fullness, pulse strength is strong, and pulse positions cun, guan, chi all feel strong.
25) Deficient pulse: pulse characteristics—pulse movement feels empty and weak. Indicates deficiency syndrome.
Deficient pulse analysis: pulse strength is weak, with a feeling of emptiness; lifting, pressing, and searching all feel weak.
26) Weak pulse: pulse characteristics—extremely fine, soft, and weak. Indicates deficiency of qi and blood; yang deficiency.
Weak pulse analysis: pulse movement is deep (i.e., sinking pulse), pulse movement feels fine like a silk thread (i.e., fine pulse); pulse elasticity is soft; pulse strength is extremely weak.
27) Faint pulse: pulse characteristics—pulse is small, soft, weak, almost imperceptible. Indicates severe deficiency of qi and blood; yang qi is weak.
Faint pulse analysis: pulse movement is like a fine line, lacking strength and energy, almost imperceptible.
28) Scattered pulse: pulse characteristics—floating and scattered without root, slightly pressed, it disappears, with irregular beats. Indicates floating pulse position (i.e., easily felt with light pressure), slightly pressed, no pulse can be felt; pulse beats are irregular, varying in number within different “breaths”.
2. Strange Pulses: including critical pulse types, often seen in heart disease, heart failure, arrhythmia, such as boiling pot pulse, leaking roof pulse, sparrow pecking pulse, knotting pulse, fish swimming pulse, shrimp swimming pulse, stone bouncing pulse.
3. Combined Pulses
① “Combined pulses” concept: combined pulses refer to the simultaneous presence of independently named pulse types, such as: floating tight, floating slow, floating rapid, floating slippery, sinking slow, string-like rapid, slippery rapid, surging rapid, sinking string-like, sinking rough, string-like fine, sinking slow, sinking fine, string-like slippery, etc.
② Main diseases of combined pulses: are the comprehensive symptoms of each pulse type. For example: floating rapid = floating pulse + rapid pulse, indicating exterior heat.
