Palpation
Palpation of the pulse
The pulse provides a great deal of the information gained from palpation, although a mass or trauma will obviously have to be examined on a more Westernized basis. In classical Chinese medicine there are six pulses at each wrist. These pulses occupy three positions at each wrist over the radial artery, and each position has a deep and superficial pulse. Each of these pulses represents a different organ and in this way all twelve of the zang fu organs are represented by a wrist pulse. The character of the pulse indicates the state of health of each organ and also the balance between each organ. Although traditional pulse diagnosis is still used in China we were taught a much simpler form of pulse ‘generalization’ rather than the traditional pulse diagnosis, and it is this purse ‘generalization’ that will be discussed in the following section.

A superficial pulse: This pulse responds to the finger when pressed lightly and becomes weak on heavy pressure. It is often seen in the early stages of diseases caused by exogenous pathogens, such as infections.

A deep pulse: This pulse is not clear on superficial palpation but it is felt on deep pressure. It is often seen in interior diseases such as glomerulonephritis.

A slow pulse: This pulse is less than sixty beats per minute; it may be normal or it may be seen in atrio-venticular block, i. e. diseases of cold.

A rapid pulse: This pulse is greater than sixty beats per minute; it is often seen in diseases of heat.

A xu pulse: The pulse is weak and forceless and goes on heavy pressure. This is seen in diseases of xu nature, such as malnutrition or diseases of pi-spleen.

A shi pulse. The pulse is forceful and will not go on deep palpation; it is seen in shi diseases.

A large pulse: This is an abundant pulse; it is like a surging wave and is seen in diseases of shi nature and heat.

A thready pulse: This is like a thready flow of water and it is often seen in xu diseases

A bowstring pulse. The pulse is hard and forceful and gives the sensation of pressing on the string of a bent bow. It may be normal or it may be seen in diseases where there is hyperactivity of the yang of the gan-liver.

A gliding pulse: This is round and forceful, like beads rolling on a plate. It is often seen in cases of indigestion or obstruction of phlegm. Sometimes a gliding pulse may be seen in a healthy person, especially in pregnancy.

An intermittent pulse. The pulse is irregular. This occurs in retardation of qi and stagnation of blood, causing a deficiency of qi in the xin-heart, such as atrial fibrillation.

Palpation for all other pathology, such as mass or trauma, follows the same rules as in Western medicine.

VIII. The Differentiation Of Syndromes
The Chinese described symptom pictures which allow the differentiation of specific Zang Fu syndromes. The major syndromes are described below and provide further useful information which will enable the acupuncturist to reach a clear Zang Fu diagnosis.

Syndromes of the Xin-heart

1. Weakness of the qi of the xin-heart
Clinical Manifestations: Palpitations, dyspnoea aggravated by exertion, a pale tongue and a thready xu or irregular pulse. If there is evidence of a deficiency of the yang of the xin-heart then cold limbs, pallor, and purplish lips can be found. Exhaustion of the yang of the xin-heart may manifest itself as profuse sweating, mental confusion and a fading, thready pulse.

Aetiology and pathology: This syndrome is usually caused by general malaise after anxiety or a long illness, which injures the qi of the xin-heart. When the qi of the xin-heart is weak it fails to pump blood normally resulting in palpitations, dyspnoea and a thready irregular or xu pulse. Alternatively, a prolonged weakness of the qi of the xin-heart may lead to weakness of the yang of the xin-heart. When the body lacks yang it lacks energy and heat, therefore symptoms such as chills, cold limbs and pallor occur. If the yang of the xin-heart is exhausted, the defensive qi of the body surface can no longer protect the essential qi and lets it dissipate, this results in profuse sweating and a fading, thready pulse.

2. Insufficiency of the yin of the xin-heart

Clinical Manifestations: Palpitations, insomnia, dream disturbed sleep, anxiety and possible malar flush with a low grade fever. A red tongue proper and a thready and rapid pulse will also be found.

Aetiology and pathology: This syndrome is usually due to damage of the yin by a febrile disease or anxiety, which consumes the yin of the xin-heart. Insufficiency of the yin of the xin-heart often leads to hyperactivity of the fibber of the xin-heart, resulting in the above symptoms. Insufficiency of the yin of the xin-heart may also cause insufficiency of the blood of the xin-heart. If this happens then there is not enough yin and blood to nourish the xin-heart, and the xin-heart fails in its function of keeping the mind. The symptoms of insomnia, poor memory and dream-disturbed sleep will therefore appear.

3. Stagnation of the blood of the heart

Clinical Manifestations: Palpitations, cardiac retardation and pain (paroxysms of pricking pain, or in more severe cases colicky pain often referred to the shoulders and the back), peripheral and central cyanosis and a thready or irregular pulse.

Aetiology and pathology: This syndrome is due to anxiety leading to stagnation of qi and stagnation of blood. It may also be due to insufficiency of the qi of the xin-heart after a chronic illness; if the qi of the xin-heart is too weak to sustain the cardiac circulation then stagnation of blood of the xin-heart and obstruction of the blood vessels results. Stagnation of the blood often impedes the distribution of yang qi in the chest causing discomfort in the chest (angina) and peripheral cyanosis. A dark purplish tongue proper, or purple spots on the tongue, and a thready or irregular pulse are manifestations of stagnation of blood and confinement of the yang qi.

4. Hyperactivity of the fire of the xin-heart
Clinical Manifestations: Ulceration, swelling and pain in the mouth and tongue, insomnia accompanied by fever, a flushed face, a bitter taste in the mouth, hot, dark and yellow urine, a red tongue proper and a rapid pulse.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The depressed qi may turn into endogenous fire and disturb the mind, causing the symptoms of insomnia and fever to appear. As the xin-heart has the tongue as its orifice, and its function is reflected in the face, a disorder of the fire of the xin-heart may cause many of the above symptoms.

5. Derangement of the mind

Clinical Manifestations: Depression, dullness, muttering to oneself, anxiety, incoherent speech, mania and in severe cases coma.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The body fluid stagnates to form damp and/or phlegm which causes blurring of the xin-heart and mind, resulting in dullness and depression. If the depressed qi turns into fire and the phlegm and fire disturb the xin-heart, anxiety, incoherent speech and mania result. Blurring of the mind by phlegm and/or damp, or phlegm and/or fire causes coma. A high fever, coma and delirium resulting from invasion of the pericardium by heat, are due to pathogenic heat invading deep into the interior of the body and disturbing the mind.

Syndromes of the Gan-liver

1. Depression of the qi of the gan-liver
Clinical manifestations: Hypochondrial and lower-abdominal pain and distension, a distended sensation in the breasts, discomfort in the chest and belching, sighing, or a sensation of a foreign body in the throat. Women may experience irregular periods.

Aetiology and pathology: This syndrome is usually due to mental irritation causing depression of the qi of the gan-liver and stagnation of the qi in the liver channel. This leads to hypochondrial and lower abdominal pain and distension, a distended sensation in the breasts and discomfort in the chest. Stagnation of the qi of the gan-liver may affect the stomach, causing failure of the qi of the stomach to descend and resulting in belching. The sensation of a foreign body in the throat is due to stagnation of the qi of the liver channel, which with the phlegm forms a lump in the throat. Depression of the qi of the gan-liver and the subsequent lack of freeing may further impair the gan-liver’s function of blood storage. Stagnation of qi leads to stagnation of blood, the cause of irregular periods.

2. Flare-up of the fire of the gan-liver
Clinical manifestations: Dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth, a flushed face, irritability and sometimes haematemesis and epistaxis can occur. The tongue proper is red with a yellow coating and the pulse is wiry and rapid.

Aetiology and pathology: This syndrome is often due to a longstanding depression of the qi of the gan-liver which can turn into fire. It may also be due to over-indulgence in alcohol and tobacco causing an accumulation of heat which turns into fire. The upward disturbance of the fire of the gan-liver causes dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth and a flushed face. Fire injures the gan-liver, causing impairment of its function in promoting the free flow of qi and this causes irritability. When the fire of the gan-liver injures the blood vessels it causes extravasation of blood and haematemesis and epistaxis can occur.

3. Stagnation of cold in the liver channel
Clinical manifestations: Lower-abdominal pain, swelling and distension in the testis with tenesmus. The scrotum may be cold and contracted and these symptoms can be alleviated by warmth. The tongue proper is pale with a white coating and the pulse deep and wiry or slow.

Aetiology and pathology: The liver channel curves around the external genitalia and passes through the lower abdomen. When cold, which is characterized by contraction and stagnation, stays in the liver channel, stagnation of the qi and blood may occur and cause lower-abdominal pain, swelling and distension of the testis with tenemus. Cold and contraction of the scrotum are also due to the pathogen cold.

4. Insufficiency of the blood of the gan-liver

Clinical manifestations: Dizziness, blurred vision, dry eyes, pallor, spasm of the tendons and muscles, numb limbs and a scanty light coloured menstrual flow with a prolonged cycle.

Aetiology and pathology: This syndrome often occurs after a hemorrhage or another chronic disease in which blood is destroyed, and the reserves of the gan-liver are depleted, thereby resulting in a failure of the gan-liver to nourish the channels. A xu (deficiency) of blood may cause endogenous wind so that the symptoms of muscle spasticity and numb limbs appear. An upward disturbance of endogenous wind (xu type) can cause dizziness and blurred vision. Insufficiency of the blood of the gan-liver and disruption of its blood storage function results in emptiness of the chong channel which will cause menstrual abnormalities.

5. Stirring of the wind of the gan-liver by heat
Clinical manifestations: High fever, convulsions, neck rigidity (Opisthotonos) and coma. A deep-red tongue proper and a wiry, rapid pulse are also found.

Aetiology and pathology: This syndrome is due to transmission of the pathogen heat from the exterior to the interior, which burns the yin of the gan-liver and deprives the tendons and blood vessels of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pi-spleen

1. Weakness of the qi of the pi-spleen
Clinical manifestations: Sallow complexion, anorexia, loose stools, oedema, and lassitude. There may be distension and a bearing-down sensation in the abdomen, a prolapse of the rectum and/or uterus, or a chronic blood disorder such as purpura, bloody stools or uterine bleeding. A pale tongue proper and a thready xu pulse will be found on examination. If there is evidence of xu (deficiency) of the yang of the pi-spleen, symptoms of cold such as cold limbs will occur.

Aetiology and pathology: This syndrome is often caused by irregular food intake, excessive mental strain or chronic disease. These problems result in weakness of the qi of the pi-spleen and impair its function of transportation and transformation, which consequently results in a poor appetite and loose stools. Accumulation of fluid in the interior is the cause of the oedema. The general malaise is due to a lack of food failing to provide a nourishing basis for blood formation. When the qi of the pi-spleen is weak, it loses its ability to uplift tissues so that there is distension, a bearing-down sensation in the abdomen and a prolapse of the rectum and/or uterus. Weakness of the qi of the pi-spleen also causes the blood disorders. Xu (deficiency) of the yen of the pi-spleen causes cold limbs.

2. Invasion of the pi-spleen by cold and damp
Clinical manifestations: Fullness and distension in the chest and epigastrium, a poor appetite, a heavy feeling in the head, malaise, borborygmii, abdominal pain and loose stools. A white sticky tongue coating and a thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after rain, or it may be due to over-indulgence of raw or cold food. In both cases the pathogen cold and damp injure the pi-spleen impairing its function of transportation and transformation and resulting in a poor appetite, borborygmii, abdominal pain and loose stools. As pathogenic damp is sticky and stagnant, it is liable to block the flow of qi causing a sensation of epigastric fullness and distension.

Syndromes of the fei-lung

1. Invasion of the fei-lung by the pathogen wind
Clinical manifestations: An itchy throat and cough associated with fever and chills. If the wind is accompanied by cold then the patient usually feels cold and presents with nasal obstruction, a watery nasal discharge and mucoid sputum. The tongue coating is thin and white. If the wind is associated with heat, fever will be the most prominent symptom and will be associated with a red, swollen throat, a purulent nasal discharge and purulent sputum. The tongue coating will be yellow.

Aetiology and pathology: Invasion of the fei-lung by the pathogen wind disturbs its function of dispersal and descent. Normal respiration is affected producing the symptoms of cough and nasal obstruction. Cold is a yin pathogen and therefore liable to damage the yang qi. Consequently when wind is associated with cold, the sensation of cold will be more severe than that of fever and will be accompanied by a watery nasal discharge and white mucoid sputum. Heat is a yang pathogen, and if wind is accompanied by heat, fever will become the most prominent symptom and will be associated with a purulent nasal discharge and purulent sputum.

2. Retention of damp and/or phlegm in the fei-lung
Clinical manifestations: Cough, dyspnoea and white frothy Sputum The onset is generally precipitated by cold, and the tongue coating is white and sometimes sticky.

Aetiology and pathology: This syndrome is due to the disturbance of the normal circulation of body fluid, the body fluid accumulates and precipitates the formation of damp/or phlegm. When damp and phlegm remain in the fei-lung the passage of qi is blocked and the functions of the fei-lung are impaired, this results in the above symptoms.

3. Retention of phlegm and/or heat in the fei-lung

Clinical manifestations: Cough, dyspnoea, wheezing and thick yellow and/or green sputum (occasionally pus). This can be associated with rigors and a fever; the tongue proper is red with a yellow coating and there is a rapid pulse.

Aetiology and pathology: This syndrome is caused by invasion of exogenous wind and/or heat, or wind and/or cold, which later develops into heat. The heat mixes with phlegm, which remains in the fei-lung and blocks the circulation of qi; this impairs the functions of the fei-lung and causes cough, dyspnoea and wheeze. Heat exhausts body fluid causing purulent sputum. When phlegm and heat are found in the fei-lung, stagnation of blood results which in turn leads to purulent, bloody sputum.

4. Insufficiency of the yin of the fei-lung
Clinical manifestations: A dry, unproductive cough associated with sticky, scant, blood-stained sputum, fever, a malar flush, a feverish sensation in the palms and soles, a dry mouth and night sweats. A red tongue proper and a thready and rapid pulse will be found.

Aetiology and pathology: Such symptoms are usually caused by chronic disease of the fei-lung, which consumes the yin and results in insufficiency of body fluid. The fei-lung is deprived of nourishment, its functions are impaired and this produces a dry mouth. Xu (deficiency) of yin causes endogenous heat which drives out body fluid and injures blood vessels, this results in a fever, a malar flush, a feverish sensation in the palms and soles, night sweats and bloody sputum.

Syndromes of the Shen-kidney

1. Weakness of the qi of the shen-kidney
Clinical manifestations: A sore and weak sensation in the lumbar region and knee joints, urinary frequency, polyuria, dribbling, enuresis, urinary incontinence, dyspnoea, wheezing, and occasionally infertility. The pulse will be thready.

Aetiology and pathology: This syndrome is often caused by malaise after a prolonged chronic illness, or may be the result of senility or congenital deficiency. Weakness of the qi of the shen-kidney results in an inability of the urinary bladder to control urination; this causes enuresis, incontinence, frequency and urgency. Shen-kidney stores essence (shen), but when the qi of the shen-kidney is deficient, infertility can result. When the qi of the shen-kidney is weak, it fails to help the fei-lung perform its function of descent, qi therefore attacks the fei-lung resulting in dyspnoca and wheezing.

2. Insufficiency of the yang of the shen-kidney
Clinical manifestations: These are broadly similar to the syndrome described as ‘Weakness of qi of the shen-kidney’. The major symptoms are a dull ache in the lumbar region and knee joints, cold, pallor, impotence, oliguria and oedema of the lower limbs. A pale, tooth-marked tongue and a deep thready pulse will be found.

Aetiology and pathology: This syndrome usually occurs after a prolonged chronic illness in which the yang of the shen-kidney is injured, it may occasionally be due to an excess of sexual activity which also injures the yang of the shen-kidney. In either instance, the yang of the shen-kidney fails to warm the body which results in cold aching sensations in the low back and knee joints, and impotence. Then shen-kidney controls water metabolism, and an insufficiency of the yang of the shen-kidney results in oliguria; the subsequent fluid excess presents with the symptom of oedema.

3. Insufficiency of the yin of the shen-kidney
Clinical manifestations: Blurred vision, tinnitus, amnesia, feverish sensation in the palms and soles, a malar flush, night sweats, hot yellow urine and constipation. The tongue proper will be red and the pulse thready and rapid.

Aetiology and pathology: This usually occurs after a prolonged chronic illness in which the yin of the shen-kidney is impaired, it may also be due to an over-indulgence in sexual activity, which consumes the shen-kidney. Either of these factors can result in the shen-kidney failing to produce marrow and maintaining normal cerebral function. The symptoms that result are dizziness, blurred of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pericardium
The syndromes of the pericardium are seen clinically as the invasion of the pericardium by heat. The symptoms are a high fever, coma and delirium, these result from heat invading the interior of the belly, which in turn disturbs the mind.

Syndromes of the Small Intestine
Disturbance of the function of the small intestine is included in the syndromes of the pi-spleen, particularly with respect to its main function (transformation and transportation).

Syndromes of the Gall Bladder

Damp and heat in the gall bladder Clinical manifestations: Yellow sclera and skin, pain in the costal and hypochondrial region, pain in the right upper abdominal quadrant and a bitter taste in the mouth. Some patients may vomit sour and/or bitter fluid. The tongue coating is yellow and sticky.

Aetiology and pathology: The function of the gall bladder is to store and excrete bile, and this depends on the normal function of the gan-liver. Exogenous damp and/or heat (heat caused by depression of the gan-liver, damp and heat caused by overindulgence in alcohol and rich food) may accumulate in the gan-liver and gall bladder, thereby impairing the free flow of qi. Bile cannot therefore be secreted and freely excreted, and the subsequent biliary overflow causes jaundice, a bitter taste in the mouth and vomiting. Stagnation of the qi of the gan-liver and gall bladder also leads to stagnation of blood, causing right hypochondria! pain. This syndrome is closely related to the gan-liver, and is also known as ‘damp and heat in the gan-liver and gall bladder’. Syndromes of the Stomach

1. Retention of food in the stomach
Clinical manifestations: Distension and pain in the epigastric region, anorexia, belching, heartburn and vomiting. The tongue has a thick sticky coating.

Aetiology and pathology: This syndrome is usually caused by over-eating, which leads to the retention of undigested food in the stomach; the qi of the stomach ascends rather than descending.

2. Retention of fluid in the stomach due to cold
Clinical manifestations: The sensation of fullness associated with a dull epigastric pain, aggravated by cold and alleviated by warmth. The tongue coating will be white and sticky and the pulse thready or slow.

Aetiology and pathology: This syndrome usually follows a cold after rain, or may be precipitated by the excessive ingestion of raw or cold food. Either of these factors result in cold in the stomach which causes stagnation of qi and pain. Prolonged damage injures the yang qi of the pi-spleen and stomach so that body fluid is retained in the stomach instead of being transported and transformed, this results in vomiting.

3. Hyperactivity of the fire of the stomach
Clinical manifestations: A burning in the epigastrium, thirst, a preference for cold drinks, vomiting of undigested food or sour fluid, gingival swelling pain and ulceration, halitosis. The tongue proper will be red with a dry yellow coating.

Aetiology and pathology: This syndrome is usually due to overeating rich food, which causes heat to accumulate in the stomach. The heat consumes body fluid and causes the qi of the stomach to ascend. This results in a burning epigastric pain, thirst, a preference for cold drinks and vomiting. Halitosis and gingival ulceration are due to the fire element in the stomach.

Syndromes of the Large Intestine

1. Damp and heat in the large intestine
Clinical manifestations: Fever, abdominal pain, loose dark smelly stools, frequent bowel movements. White or red mucus may be present in the stool, and can be associated with perineal pain and tenesmus. The tongue proper is red with a yellow coating, and the pulse rolling and rapid.

Aetiology and pathology: This syndrome is usually caused by eating too much raw, cold or contaminated food. It may also be due to invasion of summer heat and damp. Damp and heat accumulate in the large intestine, blocking the passage of qi and disturbing its function of transmission and transformation; this produces diarrhea, abdominal pain and dark smelly stool. Damp and heat may also injure the blood vessels of the large intestine producing bloody mucus in the stool. The downward pressure of the damp and heat causes perineal pain and tenesmus.

2. Stasis of the large intestine
Clinical manifestations: A distended full abdomen, abdominal pain (intensified with pressure), constipation, nausea and vomiting. The tongue coating is white and sticky and the pulse shi and deep.

Aetiology and pathology: This syndrome may be due to food retention, gastro-intestinal parasites, or blood stagnation; all these factors cause obstruction of the qi and functional derangement of the large intestine. This results in constipation, abdominal distension and pain. The nausea and vomiting are caused by the qi of the large intestine impeding the des