Traditional Chinese Medicine

TCM practitioners feel the pulse, note & the rate. They discern width or amplitude, length, how close it is to the surface, how deep & close to the bone, the strength & the quality

Factors Influencing Pulse

• Palpation
• Divisions of the Pulse
• Location of the Radial Pulses
• The Method of Pulse Diagnosis

Pulse diagnosis gives information on:

• The state of balance of the body as a whole, i.e. the state of the Qi, Blood, Yin and Yang
• The state of individual Organs (esp. Yin Organs)

TCM practitioners feel the pulse and note the rate.

They discern width or amplitude, length, how close it is to the surface, how deep and close to the bone, the strength and the quality.

Three area of the Pulse:

1.    Inch or Cun: Distal or Front (at wrist crease)

2.    Bar or Guan: Middle (just medial to radial styloid process)

3.    Cubit or Chi: Proximal or Rear

Three Levels of the Pulse

Superficial: State of Qi and Yang Organs in general

Middle: State of Blood

Deep: State of Yin and Yin Organs

OR

Superficial: Condition of the Exterior or of the Upper Burner

Middle: Stomach and Spleen diseases

Deep: Interior diseases, esp. Liver and Kidneys

Location of the Radial Pulses

Three positions at each wrist, along the radial artery.

Most texts agree on the following;

The pulse essentially reflects the state of Qi in the different burners of the San Jiao (triple burner).

Cun / Distal: Upper Burner

Guan / Middle: Middle Burner

Chi / Proximal: Lower Burner

The pulse positions mainly give information regarding the Yin Organs. It is more difficult to assess the Yang Organs at individual positions (we tend to assess the Intestines in the Lower Burner position)

Pulse Classic

Chinese View

Clinical significance of the pulse at varying levels. The pulses are palpated at three positions, superficial, middle and deep.

• Superficial (skin level): Generally shows exogenous pathogens
• Middle: Generally shows state of ST/SP Qi
• Deep (bone level): Generally shows internal conditions

Assessment of the Pulse

In pulse diagnosis, most important thing is to assess;

• The health of the Qi in general
• Relationship of Yin and Yang on the pulse
• Relative states of Deficiency and Excess
• Whether an exterior pathogen is present

Each pulse position can reflect different phenomena in different situations.

For example;

The Lung pulse full can occur as a result of emotional problem (grief) affecting Lungs or from Phlegm in Lungs or from an Excess in Large Intestine channel, such as a tooth abscess.

The Method of Pulse Diagnosis

• Feel pulses with the pads of the fingers (most sensitive part)
• The hand must be relaxed - neither tense nor flaccid, but flexible and maintained in the pulse-taking position with the minimum of effort.

Exercise

Tense the hand as much as possible. Then relax and let the hand droop. Then gradually, with as much attention as possible, put just enough energy into your hand to lift the fingers. Imagine your fingers are like the leaves of a tree; if you waved your arm your hand and fingers would float gently after your arm. This is the optimum condition of the hand for pulse taking, relaxed, flexible but responsive.

Place the third (middle) finger pad on the radial artery just medial to the styloid process. The index finger is then placed in the distal position at the wrist crease and the ring finger in the proximal position.

NOTE: on a small person, the fingers will have to be squeezed close together but on a large person they may need to be spread out.

Try to feel the radial artery pulse with all three fingers. Use equal pressure on all three fingers and then release the pressure on the middle finger slightly to compensate for the styloid process. (The pressure of the radial artery on the styloid can produce an artificial pulse reading if the same amount of pressure is exerted there. The pulse would then appear to be excessive in the middle position.)

When you can just feel the radial artery and have adjusted the pressure of your fingertips, release the pressure equally until you can JUST feel the pulse. This is the superficial position.

Then press as deeply as possible (maintaining the relative pressure levels as before) until you cut off the pulse altogether. Release the pressure until the pulse just returns. This is the deep position.

Timing

Optimum time is early morning when Yin is calm and Yang has not yet arisen.

Position

Patient's arm should be horizontal and not higher than the level of the heart. Most practitioners use a table and place a patient's wrists on a small pulse cushion.

Finger Placement

Best to keep all fingers in place as described above, and only lift fingers slightly to feel different levels.

Breathing

The practitioner must regulate his/her breathing in order to be more receptive.

Patient's pulse is traditionally correlated with the Practitioner's

Breathing Cycle in order to determine if the patient's pulse is slow or rapid. (This was misinterpreted for a long time in the West).

Normal Pulse

4-5 beats per practitioner's breath.

Slow Pulse

Three beats or less

Rapid Pulse

More than five beats

Also pulse can be counted using a watch according to the following table;

Factors Influencing a Pulse Reading

Seasonal influences

Spring - wirier

Summer - stronger

Winter - deeper

Gender

Men's pulses are naturally a little stronger. In men, the left pulse is slightly stronger and in women, the right pulse is slightly stronger.

Occupation

• Those doing heavy physical work should have a stronger pulse.
• The patient should not have just eaten a large meal (1 hr. before OK). Otherwise, Stomach pulse will read very high and other Organ readings may be depleted.
• Allow the patient to rest after arrival at the office.
• Allow 15 minutes after urination, defecation or ingestion of liquids.
• Pulse diagnosis should take place in a calm, restful environment.
• Silence should be maintained during the procedure.
• Western medications can interfere with reading, as can hypertension, and structural anomalies.

The Normal Pulse

Reflects good Heart Qi and Blood.

It should be calm, smooth, soft, but not too soft, and not slow, rapid, rough or hard. It should be regular. Its quality should not change very often or easily. Deep level and rear position should be felt clearly, indicating that the Kidneys are healthy.

The Main Pulse Images

1. Fu Mai (Floating, Superficial)
2. Hong Mai (Surging, Flooding)
3. Ge Mai (Leathery, Drumskin, Tympanic, Hard)
4. Kou Mai (Hollow or Scallion Stalk, Green Onion)
5. Ru Mai (Soft or Soggy)
6. San Mai (Scattered)
7. Xu Mai (Forceless, Empty, Deficient)
8. Chen Mai (Deep)
9. Fu Mai (Hidden)
10. Lao Mai (Firm, Confined)
11. Ruo Mai (Weak)
12. Chi Mai (Slow)
13. Huan Mai (Slowed down, Moderate, or Relaxed)
14. Se Mai (Choppy, Hesitant)
15. Jie Mai (Knotted, Bound)
16. Shi Mai (Excess, Full, Replete, Forceful)
17. Hua Mai (Slippery, Rolling)
18. Jin Mai (Tight, Tense)
19. Chang Mai (Long)
20. Xuan Mai (Wiry, Taut)
21. Wei Mai (Minute, Faint, Indistinct)
22. Xi Mai (Thready, Thin)
23. Duan Mai (Short)
24. Dai Mai (Regularly Intermittent
25. Shuo Mai (Rapid)
26. Ji Mai (Racing, Swift, Hurried)
27. Cu Mai (Rapid-Irregular, Skipping, Abrupt)
28. Dong Mai (Moving, Throbbing, Stirring)
29. Da Mai (Large, Big)

Fu Mai (Floating, Superficial)

Description

Located in the exterior. With the finger raised, it has a surplus, when pressing down it is insufficient, weak, or disappears. When pressure is released, it regains full strength.

Indications

External invasion, Yin Xu with Yang floating upwards, Qi or Yang Xu.

Aetiology

Mainly an exterior condition, syndromes due to Xu or Yang Qi losing its root in the lower part of the body and floating to the upper regions.

Hong Mai (Surging, Flooding)

Description

Floating, large (i.e. wide) comes on exuberant, departs debilitated. "Coming onto the shore with force and retreating without force"

Indications

Extreme heat; if with thirst, high fever it can be Yangming heat or internal heat. If surging and forceless, this is Xu surging.

Aetiology

This pulse has been said to arrive strong at the chi position and depart at the cun position, thus its wave-like character. The Yang is floating excess and upward, this is a manifestation of fire floating upward and water drYing internally(i.e. loss of blood, diarrhea)

Ge Mai (Leathery, Drumskin, Tympanic, Hard)

Description

Bowstring and large (wide) with an empty centre; feels like the head of a drum. Felt with light pressure. Floating, large, and hard and resistant to pressure.

Indications

Haemorrhage, Spermatorrhoea, Abortion, Excessive Menstrual Flow, Xu Cold.

Aetiology

The Qi becomes detached and floats to the exterior, the healthy Qi is failing to store sperm and blood.

Kou Mai (Hollow or Scallion Stalk, Green Onion)

Description

Floating, soft, large body, but empty in the center. Forceless--large and weak.

Indications

Haemorrhage, Damage of Yin, Great Blood Loss (severe diarrhoea/haemorrhage)

Aetiology

There is a failure to fill the vessels by insufficient Ying and Blood causing Yang Qi to detach and float to the surface.

Sources disagree on the description of this pulse, some say that the beats around the middle level are palpable(i.e. light or heavy pressure) and the beats at the middle level are impalpable.

Bob Flaws says that "a pulse which is empty in the centre is an extreme floating pulse which not only gets weaker when one presses down but disappears altogether. It only reappears again when pressure is released to the superficial level."

Ru Mai (Soft or Soggy)

Description

Floating, fine, soft and flexible. Can be felt with light pressure but cannot be obtained by heavy pressure. "Floating, thready, and soft" "Like a silk thread in water".

Indications

Primarily means Dampness, can be Yin Xu, Blood Xu, Spleen Xu

Aetiology

The dampness is obstructing the vessels or the Qi and Blood are unable to fill the vessels giving it its soft quality. This is distinguished from other floating pulses, which tend to be large (i.e. wide)

San Mai (Scattered)

Description

Floating, large (i.e. wide) and without root; with light pressure it is easily irregular, becoming scattered and chaotic; with heavy pressure it is impalpable.

Indications

Dispersion of Yuan Qi, Kidney Yuan Qi Xu, severe deficiency and exhaustion of internal organ Qi.

Aetiology

This pulse is without root, without definite edges and boundaries, not characterized as an irregular beat pulse, although it feels chaotic. It is a further progression from the Kou Mai (Hollow), being even weaker than the Kou Mai. "Like wind blowing hair or scattered leaves"

Xu Mai (Forceless, Empty, Deficient)

Description

Generalised term for various types of forceless pulses or is described as a floating, large, slow, empty, deficient, soft, forceless pulse image.

Indications

Qi and Blood Xu. Can be damaged by summer heat.

Aetiology

Chen Mai (Deep)

Located near the bone. Cannot be detected with light or moderate pressure but can be felt with heavy pressure. (Not to say it is impalpable at lighter pressure).

Indications

Interior patterns.

If deep and rapid=Interior heat.

If deep and slow=interior cold.

If deep and forceless=Qi and Yang Xu.

If deep and forceful=excess of internal disease.

Aetiology

Pathogens in the interior are obstruction healthy flow of Qi and Blood.

Fu Mai (Hidden)

Description

Difficult to feel, under the sinews, not obvious, requires heavy pressure to obtain. Almost to the bone. Deeper than the deep pulse.

Indications

Severe pain, extreme stagnation (of food or of pathogens), syncope, last stage of an illness, coma, lack of circulation.

Aetiology

Lao Mai (Firm, Confined)

Description

Pressed superficially or moderately, it does not respond but can be obtained by heavy pressure. Hard, firm, not changeable, replete, large, bowstring, and long.

Indications

Internal cold, perhaps hernia, abdominal masses. Can also indicate wind epilepsy, inflexibility, and cramping, hard accumulations hidden in the interior, running piglet and sudden violent counterflow.

Aetiology

The pathogenic factors are steady, there is interior cold and decline of Yang Qi

Ruo Mai (Weak)

Description

Deep, fine, soft like a thread.

Indications

Simultaneous Qi and Blood deficiency

Aetiology

Blood Xu results in failure to fill the vessels and Qi Xu results in its forcelessness.

Chi Mai (Slow)

Description

Below 60 BPM or less than 4 beats per practitioners breath.

Indications

Cold syndromes. Forceful and slow=accumulation of cold; Forceless and slow=cold from Xu Slow and floating=external cold. Slow and deep=interior cold. Slow and choppy=blood disease. Slow and slippery=Qi disease.

Aetiology

There is stagnation of Qi due to cold. There may be other factors as well, such as obstruction of blood due to the accumulation of heat, this pulse must be forceful and excessive when palpated (i.e. Yangming)

Huan Mai (Slowed down, Moderate, or Relaxed)

Description

As a ping mai, or normal pulse it is level and harmonious, relaxed and forceful. As a bing mai or abnormal pulse it is relaxed, loose, slack, on the verge of slow. About 60 BPM. The beats come and go slowly, feels viscous, the rate is like normal but the slowness shows up at the end of a beat, before a slow pulse.

Indications

Syndromes of Damp, SP/ST Xu. Not enough Qi and Blood to fill the vessels.

Aetiology

May also be due to wind if floating and relaxed. If it is deep and relaxed is damp syndrome.

If large and relaxed=liver wind internally.

If relaxed and weak it may signify heart Qi Xu.

Se Mai (Choppy, Hesitant)

Description

Slow, relaxed, stagnant, difficult, fine. May stop and lose a beat but then recovers. It is not smoothly flowing. It feels like a knife scraping bamboo.

Indications

Consumption of essence, Blood Xu, Stagnation of Qi, Blood Stagnation, Phlegm or food stagnation. It can also be due to heart palpitations.

Aetiology

Blood and essence failing to nourish the meridians. Blood is not flowing smoothly.

Jie Mai (Knotted, Bound)

Description

Slow, relaxed, stops at irregular intervals.

Indications

Stagnation of Qi due to excess Yin, Blood Stasis due to cold phlegm, Blood Stagnation. Sometimes abdominal masses also indicates Heart palpitations.

Aetiology

Yin and Yang out of balance due to excess Yin. (This represents an irregular beat or palpitation stemming from the ventricle of the Heart)

Shi Mai (Excess, Full, Replete, Forceful)

Description

Bowstring, a large, hard and replete pulse which has a surplus at all 3 levels of cunkou.

Indications

An excess condition where both pathogenic and antipathogenic factors are strong.

Aetiology

Blood vessels are full with both Qi and Blood

Hua Mai (Slippery, Rolling)

Description

Comes smoothly flowing and uninhibited; feels smooth like pearls rolling in a dish. Beats come and go fluently and smoothly, feeling slick to the fingers.

Indications

Phlegm retention, indigestion, excess heat. May also indicate dampness. The Hua Mai is considered normal (ping mai) for women during pregnancy or menstruation.

Aetiology

The smooth and slick pulsation is caused by the accumulation of pathogens in the interior with a sufficiency of Qi and Blood.

Jin Mai (Tight, Tense)

Description

Tight, has strength, feels like a taut rope. Feels like a stretched and twisted rope.

Indications

Cold or Pain. Undigested food

Aetiology

Caused by the contraction of tense vessels resulting from the conflict between cold and healthy Qi and the obstruction of Yang Qi

Chang Mai (Long)

Description

Long and can be felt beyond its location. Felt past the cun position.

Indications

Excess liver Yang, Yang and Heat Excess in the Interior, Strong Pathogenic factors

Aetiology

A long and smooth pulse can be normal (ping mai) for some people, the long characteristic is usually present with wiry.

Xuan Mai (Wiry, Taut)

Description

Feels straight, long and tense, like the feeling of pressing a tight string of a musical instrument. Crisp and distinct edges tends to reveal itself when one slightly lets up on the pressure.

Indications

Liver and Gall Bladder disease, various painful disorders, phlegm retention, malaria, abnormal circulation of Qi.

Aetiolgy

Tense vascular Qi due to the liver not gently performing its function can also be due to the retention of a pathogen in the liver. If wiry, Thready and forceful-like feeling the edge of a knife is indicative of Stomach Qi exhaustion.

Wei Mai (Minute, Faint, Indistinct)

Description

Insufficient, extremely fine, soft, barely palpable. It may be felt and then sometimes it is lost. "Extremely thready and soft".

Indications

A decline of Yang Qi. Yin, Yang, Qi, and Blood Deficiency.

Aetiolgy

The Yang Qi cannot push the blood in the vessels or the Yin/blood cannot fill the vessels.

Xi Mai (Thready, Thin)

Description

Soft, feels like a silken thread, weak, without strength but not scattered by pressure.

Indications

Qi and Blood Xu, various deficiency syndromes, disorders due to Damp. Does not indicate weakness.

Aetiology

Impairment of Ying Blood fails to make the vessels plentiful. Qi is too deficient to move the blood. May also occur due to compression of vessels by dampness.

Duan Mai (Short)

Description

Does not reach (i.e. fill longitudinally) its location or range. Can be felt most clearly at the Guan position, more indistinct at the Cun and the Chi.

Indications

Short and forceful indicates Qi Stagnation, Short and weak indicates Qi Xu

Aetiology

Qi is failing to move the Blood.

Dai Mai (Regularly Intermittent)

Description

Comparatively relaxed and weak stops at regular intermittent intervals. These intervals may be strikingly long.

Indications

Decline of Zang Fu (organ) Qi, Wind Syndromes, Pain, Terror, Fear, Trauma.

Aetiology

Flaws: "Patients with this pulse have advanced heart disease according to western medicine and should be immediately referred to a western doctor".

Shuo Mai (Rapid)

Description

Above 90 BIM, or more than 5 beats per breath.

Indications

Heat Syndromes. Forceful and rapid = excess heat. Weak and rapid = Deficiency Heat.

Aetiology

Hyperactivity of heat accelerating Qi and Blood. A rapid pulse may be weak when it's Yin Xu due to a chronic disease resulting from interior deficient heat. Rapid pulse, when seen in cases of floating of Yang Xu, must be large and weak with a sense of emptiness.

Ji Mai (Racing, Swift, Hurried)

Description

Very rapid, over 120 BIM, or 7-8 beats per breath.

Indications

Excess of Yang and exhaustion of Yin, impending exhaustion of primary Qi Can also be due to Heart Palpitations.

Aetiology

Exhaustion of Yin in the lower body and excess of Yang in the upper parts. Often accompanies high temperatures. Swift and wiry=not enough true Yin, an overabundance of Yang. Swift and forceful=Primary Yang will be exhausted.

Note: This can be normal for infants.

Cu Mai (Rapid-Irregular, Skipping, Abrupt)

Description

Rapid and irregularly interrupted.

Indications

Excess Heat, Domination of Yang, Qi, Blood, Phlegm and Food Stagnation. This can be from an Atrial Fibrillation.

Aetiology

This is clinically very severe, Yin and Yang are not in communication.

Dong Mai (Moving, Throbbing, Stirring)

Description

Slippery, rapid, forceful, feels like a bean--strong and throbbing abruptly. "Without head or tail" This is most distinguished at the Guan position, and is a subcategory of the short pulse.

Indications

Pain, Fright, Shock.

Aetiology

A conflict between Yin and Yang, disturbance of ascending and descending, leading to a faster circulation of Qi and Blood which makes it appear smooth, rapid, and forceful yet palpable over a narrow region.

Da Mai (Large, Big)

Description

Large, fills up the fingertip, forceful. Similar to the Hong Mai, but does not have the wave-like shape.

Indications

An advance of a disease due to a domination of pathogenic factors and also Deficiency Syndrome.

Aetiology

It is possible to differentiate exuberance or decline of pathogenic factors and the health of the Qi according to whether a Large pulse is forceful or weak.

Table: Pulse quality and possible pathology

Pulse Descriptions, Qualities and Clinical Significance

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