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On Li-Shi Zhen's Pulse Diagnosis

by James Ramholz, Dipl.Ac., O.M.D.
Reprinted from Oriental Medicine Journal


Pulse diagnosis has always been an enigmatic and complex art. Not surprisingly, acupuncture colleges offer little formal education in this area even though Li Shi Zhen’s Pulse Diagnosis (1) and various editions of the Huang Di Nei Jing have been available for many years. Even when classical literature or modern commentary is part of the curriculum, many students complain they receive confusing and conflicting advice on pulse movement and the diagnosis it presents.

When read correctly, pulses form a rich and detailed tableau of the patient’s condition and history. They are the only real-time system of diagnosis. When you put a needle in, you can see the pulses change immediately. You know what you’ve accomplished and when you’ve missed the mark in your treatment stategy. One of the most important things that pulses can reveal is the development of a condition before there are any symptoms or other signs. For example, we can often see the development of breast or prostate cancer months before the first physical sign or an actual lump is found. Many stories of this sort are found in medical literature and anecdotal history.

The Paradigm Press edition of the Li Shi Zhen’s Pulse Diagnosis remains the best introductory material for studying pulses. Modern authors simply reiterate its elements without discussing obvious dilemmas and obscurities in the text. It is to some of those conflicts and difficulties that I address this series of articles.

According to Li Shi Zhen there are 27 basic pulse states (2) and these movements can be observed in any of nine fundamental sectors (3) on each wrist. The division of each wrist into three depths forms a grid in which "the area and nature of the disease can be determined from the wrist pulse."(4) In this nine-sector grid, the cun position indicates diaphragm to crown, the guan position indicates navel to diaphragm, and the chi position navel to feet. The superficial comprises emotional, exterior, and meridian activity, the middle shows organic or metabolic activity, and the deep level shows the adapted or bone-level activity. Together, these fractal sectors create a dynamic picture of the entire body; similar in character to the mapping of the tongue, ear, feet, or eyes but in far greater detail.

Mathematically, these nine-sector grids form 486 simple combinations. But because each state is never seen alone but always in combination with one or more types of energy–what Li Shi Zhen calls a "composite pulse" (5)–the possibilities quickly expand (6). In developing a model of this complexity, we hope to create a richly detailed and sophisticated system of diagnosis. By adopting Li Shi Zhen’s guidelines, we anticipate a method of diagnosis that is truly as unique as the patient. Ultimately, we can have a far more sophisticated description than 8 Principles–for example, we can calculate a system that is ‘5 elements of 5-elements of 5-elements.’ A model this detailed gives us a much clearer picture of complex diseases like cancer, AIDS, emotional problems, and chronic illness. We will even be able to see that many problems have their own characteristic patterns or signatures. We won’t always have to ask the patient what their symptoms are beforehand.

Unfortunately, American authors can not describe or teach this level of sophistication and complexity. Typically, contemporary texts divide the pulse levels into the yang and yin organs, then specify a diagnosis method using TCM’s Eight Principles in the cun, guan, or chi positions. Many different types of problems are reduced to the same, elementary rubric–"stagnated liver energy," "dampness in the spleen," etc. As a result, complicated and chronic problems can easily be misunderstood, misdiagnosed, and inappropriately treated. When contemporary commentators take the relationships found in the pulses and parse them down to smaller and smaller pieces for analysis, this is simply the most harmful aspect of the Western mind at work–reductionist and mechanical; unmindful of the holistic view and inductive reasoning of the Chinese mind. It fails to see the richness, subtlety, and interaction of a living system. Pulse movements are an alphabet which can build into elaborate descriptions; not a kind morse code.

Compounding this problem is the difficulty of the subject matter itself, differentiating and interpreting subtle activity inherent in pulses especially for chronic and catastrophic illnesses which present highly complex pulse patterns. It is unrealistic to work with models like the Li Shi Zhen without comprehensive classroom study and extensive clinical practice with supervision. This problem is further compounded by confusing and conflicting information in Li Shi Zhen’s text. Thankfully, Li Shi Zhen himself provides us with our first important insight, asserting that all this can be simplified.

The theory of the pulse is very complicated but it is based upon the four principles–floating, sinking, slow, and rapid. Once they are understood, by elaborating on them, the entire subject can be clarified. (7)

Li Shi Zhen asks us to divide the pulse into yang and yin vectors along both vertical and horizontal lines of symmetry, creating a type of fourfold analysis. For him, pulse diagnosis is an art of deconstruction, a geometry of meaning.

The model that best illustrates these dimensions is the Tai Chi diagram, a familiar symbol that can also be used to decipher the particulars of its applications. It is the classic emblem of complementary opposites, cyclic continuity in time, and harmonious interrelationship–all essential parameters of health in the human body. Yang rises vertically and accelerates horizontally; yin sinks vertically and decelerates horizontally. Using the Tai Chi symbol as our paradigm, we can analyze how yang and yin should ideally communicate, exchange, and balance.

The circle itself is a traditional symbol of unity. The sine wave through the diameter of the circle is the complete and basic pulse wave. It is the result of balance, interaction, and harmony. Any deviation from it provides information on how yin and yang have changed from that ideal balance and what are the consequences to health. All 27 basic pathological pulse states discussed by Li Shi Zhen can be derived from it.

Tai Chi is process-orientated, coherent, evolving, and interactive in contrast to the TCM’s typical emphasis on substance, fixed or "solid" components. In it, yang and yin are more than their sum; they create and dynamically balance each other. As a complex system, the Tai Chi diagram can be seen in a wide range of natural scales and applications–for example, the double-helix of the DNA molecule, the change of day and night, the spiral nature of galaxies. Because this symbol is found at the heart of Taoist philosophy, I Ching, the Chinese 60-year calendar, feng shui, martial arts, and a variety of other Taoist systems, it will be useful as a basis for analysis and comparison–a kind of Rosetta Stone.

Li Shi Zhen’s advice on how to initially organize our study of pulses suggests another important first step in understanding. It would be pointless busy work to memorize all 27 pulses if we did not understand their dynamics and how they relate to each other. As a basic group, the 10 pulses listed illustrate how yin and yang relate to each other in various ways. They show a view of the essential symmetry, dynamics, and types of energies we will see in all pulses. It is important to remember that they are derived from, and refer back to, a balanced pulse state and fulfill Li Shi Shen’s fourfold criteria:

  • Healthy or Balanced
  • Floating & Sinking
  • Rapid & Slow
  • Big/Small, Long/Short
  • Slippery & Choppy
  • Knotted


The Healthy or Balanced Pulse

When Li Shi Zhen’s Pulse Diagnosis speaks of the different qualities of a normal pulse in section 3.2 (8), the descriptions used are not "normal" nor "healthy" in either a theoretical or clinical sense. This data essentially repeats the pathological indications described later in the book by the terms scattered, choppy, blocked, wiry, tight, slippery, soft, etc. This confusion is probably due to the countless editors the manuscript has seen. Only the description of the middle pulse of the spleen and stomach feeling "regular, neither fast nor slow" comes close to accurately portraying the symmetry, energetic balance, coordination, and harmony expected in a healthy pulse movement. Clearly, these other descriptions are "normal" in the sense that they are typical of critical problems associated with those organs or characterize a perverse energy that is often dominant in that organ. For example, if the liver only showed a wiry pulse, etc., it means the organ is no longer in communication with the other elements (energetically isolated) and is beginning to fail. As it becomes more wiry the patient becomes increasingly susceptible to various types of liver yang problems. If we see a wiry movement in the second half of the liver pulse at the organic level without support in the first half or connection from the kidney pulse, it can mean that a stroke is immanent.

Inherent to Li Shi Zhen’s thinking is the communication and symmetry of yin and yang. The sine wave is formed from the synergy and coordination between yin and yang. Their dynamic is reciprocal and nonlinear, not simply the sum of isolated or independent elements. This relationship is as important as the constituents and becomes their context as well as genesis. The Tai Chi movement represents the ability of living systems to continuously regulate and renew themselves and to regulate this process in such a way that their integrity and structure is maintained–what is today sometimes called autopoiesis.

We could expect other systems of thought to be derived from this, and in fact we see it at the heart of many illustrations in Chinese philosophical and medical literature. Whereas a machine is geared to output a specific product, a living organism is primarily concerned with renewing itself. We should expect to see this sine wave in all healthy relationships and in the pulse positions of a healthy person. It is the way systems cycle or energetically balance and perpetuate themselves. Therefore, any deviation from this symmetry or wave movement provides us with important information about what is happening to the body, mind, and energy of the patient as well as the body's response to disease and its environment.

Pulse Wave Energy Segments

  • AB qi/Yang of yang/function
  • BC qi/Yin of yang/function
  • CD xue/Yin of yin/capacity
  • DE xue/Yang of yin/capacity

The Normal pulse is often identified with the stomach energy because it is the organ which supplies nourishment and support for all others. Together with the spleen, the earth Phase absorbs, coordinates, and transforms; five elementally, it is at the center of the sine wave movement. The substinative quality attributed to its pulse character is also indicative of that nurturing and supportive role. For example, that central importance is emphasized in the seasonal 5-Phase scheme: each Phase communicates with the earth before cycling to the next Phase in the shen cycle (9).

In a perfectly healthy person, all the pulses would present this smooth, balanced sine wave movement connected at all positions and depths–and it should be present during the entire year, not only in late summer. The energy movements of the four seasons add their wave shapes to the patient's energetic movement. The interactions of those two wave forms uniquely describe the patient's reaction to the seasonal change. While the seasonal energy will have some influence in the pulses, emotions have a much stronger and immediate influence

The basic wave can be further analyzed by dividing it into its yang and yin components. The normal pulse begins with an ascending or yang movement. The convex portion indicates the yang energy or qi of the movement [ABC], while the concave portion describes the state of yin energy or blood of each organ [CDE]. To determine the balance within this movement, check the size, angles, and texture of the yang portion and compare it to the yin portion. Ideally, the yin and yang portions of each pulse should be symmetrical, hold the same capacity, and display the same textures. A sharper angle of ascent indicates that the pulse contains more yang energy or heat; a smoother angle indicates that yin is more prevalent. If the ascending movement is more prominent, the pulse will have a tendency to float; when the descending movement is more prominent it will have a tendency to sink (10). When the rising movement is dominant it can also have a tendency to be more superficial or express an acute syndrome. If it is a chronic condition the syndrome expressed will be light, superficial, or immediate.

If the pulse begins with a descending motion (the sine wave is reversed), the organ energy is reversing and, if more than one pulse position presents this reversal, the mother-son rule of the 5-Phase theory is breaking down and the condition is becoming critical.

Symptoms are created by contrasts in function, energy, or movement. The capacity of a pulse movement to create symptoms can be measured by the area of the yang [ABC] or yin [CDE] portion of the pulse. For example, if the yin portion of the pulse is larger, then the yin energy has the greater capacity to express a symptom. The pulse is not necessarily obliged to express this capacity, but we can see the potential for expression. And our diagnosis does not have to rely solely on the patient's report of their symptoms, we can often observe problems before the patient can even become conscious of them. This capability from pulse reading is essential in discriminating the root of the problem from the branch, as well as in cases where the patient has forgotten or is hiding aspects of their condition.

These elementary rules can be applied repeatedly as tools to analyze any pulse shape or energy. Taking the first half or yang portion as our focus, the movement going up is yang of yang while the second movement of the first half of the basic wave is yin of yang. In the yin portion of the basic wave, the movement descending is yin of yin; the movement ascending to the horizontal axis is yang of yin. The yang of yin portion connects to the next pulse position, feeding its yang of yang movement.

The clinical implications of this fourfold analysis are far-reaching (11). Let's consider several examples of a Flooding (hong) pulse, which can, in general, indicate heat or bacterial inflammation. First, we need to keep in mind that when the upbeat is yang, it indicates the qi and when the downbeat is yin, it indicates blood. The ascending movement of a Flooding pulse can be smaller than the descending motion, or the rising motion can be larger than the descending motion. These two pulses offer us different information even though both are Flooding.

Both present bacterial inflammation with a certain range of fever or temperature. Where the downbeat is larger it indicates that the yin energy or blood is more influenced by the heat than the qi therefore we should expect more pus formation and lymphatic blockage. In the other example, heat affects the qi more, and we should expect a higher fever but less pus formation.

If we want to see if the heat expressed in the Flooding pulse is affecting the upper or the lower body, we can observe it the chi, guan, cun divisions. If the Flooding pulse is moving towards the cun it indicates that it is affecting the upper part of the body and if it is moving towards the chi it indicates that it is affecting the lower part of the body.

Consider a wave movement in the cun position of the right wrist, the large intestine (12). A pulse that rises in a normal sine curve but becomes wiry in the yin portion before it returns to the horizontal axis indicates that qi is not a problem but there is some problem in the yin or blood movement related to that organ. It may indicate that some heavier materials are stagnating and the organ itself is now being affected because that heavy material has not been eliminated. The organ does not have enough energy so elimination is impaired, building toward a toxic condition. This can be a condition of constipation due to blood deficiency or dryness of the stool.

If the situation was reversed and the upbeat was wiry and the downbeat was normal, it would indicate that the large intestine itself is affected energetically and not able to handle routine material. The organ itself is the problem rather than the material that the organ is managing. The difference between these two conditions can be illustrated by a person trying to lift a box who cannot do it. There are two possible reasons: either the person is too weak or the box is too heavy. If the downbeat is the problem, it indicates that the box is too heavy; if the upbeat is the problem, it indicates that the person trying to lift it is too weak.

Floating (fu) & Sinking (chen)

Floating and Sinking refer to the movement on the vertical axis of symmetry independent of the horizontal. The Floating pulse is found at the superficial level and the sinking pulse in the deep level. Generally, the Floating pulse indicates yang excessiveness due to wind or heat, and the Sinking pulse indicates yin excessiveness due to cold energy. Floating and Sinking refer primarily to the depth at which the pulse is found.

Floating and Sinking can also refer to the direction the energy is moving along the vertical axis, even when found at different pulse depths or sectors. We may also sense degrees of a Floating or Sinking state as a stronger yang of yang movement or yin of yin movement at any depth.

Rapid (shuo) & Slow (chi)

Rapid and Slow refer to movement along the horizontal axis of symmetry and the speed of the pulse movement when compared to the patient's breathing. The normal or balanced pulse is four beats per breath. A Rapid pulse is more than 4 beats per breath; a Slow pulse is less than 2 beats per breath. A pulse can become Rapid due to a "deficiency of yin and an excess of yang" energy. The Slow pulse results from "a deficiency of yang and an excess of yin"(13). In general, the Slow pulse indicates cold energy and Rapid pulse indicates hot energy. If the pulse moves faster than 6 beats or slower than 2 it is an extremely critical sign, usually indicative of death; yang and yin no longer communicate with each other and are about to be cut.

When the pulse is excessively fast, the energy will be cut at the chi position, move towards the cun, and finally dissappear. When the pulse is excessively slow, the energy will cut off at the cun position and move towards the chi and finally disappear. For these two examples simply compare the energy of someone who just came out of a sauna and is about to faint from the heat to someone who was exposed to freezing weather and is about to pass out.

When the pulses are slow in comparison to the rate of breathing,we can say that the patient does not have sufficient yang energy or that his interior can be cold or damp. The Rapid pulse indicates that there is too much heat, that the condition is affecting the upper warmer, or that it is taking place at the surface. It could be excessiveness or it could be a condition caused by an attack of perverse energy, etc. Heat in the interior, for example near the bone, will be found in the deep level but will present a rapid movement. A slow movement at the superficial level indicates cold energy invading at the surface of the body.

Big & Small, Long (chang) & Short (duan)

Big and Small refer to the vertical dimension of the wave form, its amplitude. In general they indicate the amount of active qi available at a given moment. Long and Short refer to the horizontal dimension of the wave, its frequency. These pulses indicate the capacity of the related organs, and are often related to the hot and cold energy balance. Big and Long pulses indicate that the qi flow is greater than the blood flow, while the Small and Short pulses indicate that the blood flow is greater than the qi flow.

The horizontal dimension of the pulse wave indicates what the capacity the wave form holds. Compare the vertical movement to voltage and the horizontal to wattage. So if it is Big and Long it means that the output is strong, but if it is Small and Short it means that the output is diminished but the movement can still last for an extended period of time. When the pulse is Small it means that it will not last because it does not have enough energy support to continue. Endurance or the capacity of a particular stress, that is how long it will last, depends on the horizontal movement.

Slippery (hua) & Choppy (se)

These two states describe specific textures of the pulse wave and not necessarily the shape itself. The previous pulse states show a yang/yin scale in specific dimensions, these two pulse states are a comparison between the qi and blood and illustrate the relationship of qi within the blood and the blood within the qi–similar to the portion of the Tai Chi symbol which shows yang within yin, and yin within yang.

The Slippery pulse feels "round and smooth and flows evenly"(14). The sensation is like touching oil or wet and hard beads, it curves evenly up and then back down. In general it indicates dampness or that qi is deficient in comparison to blood. Li Shi Zhen comments (15) that a Slippery pulse can be created when yuan qi fails "and is unable to hold liver and kidney fire." Typically you can expect mucus secretion or, if it is the dominant character, a blockage to the blood flow because of a very low qi movement. You will commonly verify a mucus problem by looking at the spleen's relationship to the other involved organs. It can be found in women during pregnancy; and, if over forty, it can be evident in the menopause pattern.

The Choppy pulse feels "thin, minute, and short and has an uneven flow, beating three and five times with an irregular rhythm." It is often described as feeling like touching very fine sandpaper or a "knife scraping bamboo"(16). In terms of our Tai Chi model, the horizontal movement of the qi is not supported by the yin energy. Like the knife, the momentum pushes forward but is carried in a jerky motion. In general, it feels very thin and irregular, making it sometimes difficult to flow. It indicates a dry condition, where qi is more abundant then blood. It can often be observed in anemic patients and in those recovering from surgery because of blood loss.

Knotted (jie)

In the previous pulse patterns, there was always an implied connection or reference to a balance. In the knotted movement, the symmetry of the Tai Chi model is completely broken. A Knotted pulse is an indication of excessive yin–"whenever excessive perverse yin qi coagulates"(l7). A Knotting pulse may not occur every pulsation and can appear irregularly. It indicates energy blockages, mucus blocks, moving clots, cysts, tumors, and even cancer. This pulse tends to hold the peak for a prolonged period of time and then drop, or hold the bottom and go up without a pronounced peak.

As a general rule, we know that a deficiency of yin will lead to an excess of yang. If yin energy becomes deficient, the pulse will not be able to connect to the deep level. This will be compensated by the further growth of Yang energy or further strengthening of the upbeat. But since the yang movement cannot energetcially go beyond the top level, which is superficial, it will compensate by a build up intensity at that level. As the yin energy becomes more and more deficient, the strength of the yang upbeat will bud correspondingly, manifesting in a Knotted pulse with a pronounced peak. If the energy is Knotting in every pulsation, it is more serious and can indicate cancer. In this last case, it shows a severe loss of stability of the Tai Chi equilibrium; the yin and yang dynamics is no longer reciprocal.

If this pulse shows up between two pulse waves as an independent movement, then it could be an early sign of cancer, even though it is not clearly Knotting in the organic wave. In some cancer movements, the pulse can be felt to rise and actually knot or vibrate in situ: without a descending movement. This Knotted state–as well as others which we will look at later–is usually picked up in the top or bottom of each pulsation but they can occur in other levels of each wave as well.



  1. Translated by Hoc Ku Huynh and published by Paradigm Publications in 1981. This text is sometimes referred to by its author's name, as the Li Shi Zhen. It is a translation of a modern commentary of Li Shi Zhen's work, and remains the most reliable source currently available in English.
  2. Pulse Diagnosis, p. 116
  3. Pulse Diagnosis, p. 5 Each pulse position–cun, guan, and chi–is divided into three vertical levels on both wrists. Each wrist would then form a nine-sector or tic-tac-toe pattern.
  4. Li Shi Zhen, Pulse Diagnosis, p. 6
  5. Li Shi Zhen, Pulse Diagnosis, p. 11
  6. 27 shapes times 27 shapes times 18 sectors = 23,122. This number is an arbibary one because there are a variety of ways to calculate the possible number of positions and wave-shape combinations. The level of complexity depends on the model chosen. For example, in the Dong Han method and similar systems of pulse diagnosis, each of these nine sectors can be divided into smaller sectors.
    For example, in the Dong Han method, the pulse is actually viewed in its true three-dimensional character. One of Li Shi Zhen’s nine sectors is divided into 27 smaller sectors–like a Rubic’s Cube–for possible 19,683 different combinations per sector or almost a quarter of a million possible mathematical combinations for all positions in both wrists. Fortunately, in living systems certain conditions must be fulfilled for three-dimensional bodies to occur in four-dimensional space. So even within this anticipated chaos there is a strict order.
  7. Pulse Diagnosis, p. 11
  8. Pulse Diagnosis, p. 7
  9. Maciocia, Giovanni, The Foundations of Chinese Medicine, p. 18-29
  10. See later in this article for details of Floating and Sinking.
  11. In clinic, the basic pulse should also be compared to different body types but we are limited in space and cannot do so here. Briefly, when looking at the basic wave, analyze the ratio of qi and blood. You should expect the yang portion to be larger in thin and skinny people because a skinny person has a greater ratio of qi to body weight. If a very skinny person has the same size upbeat as downbeat, the downbeat is either too big or his qi is insufficient. In either case, there is an disparity in the energy balance their body should hold.
  12. The association of the large intestine differs in various systems of pulse diagnosis because some systems are designed around different energetic perspectives, sometimes physical space is emphasized and sometimes energetic or phase space. For example, while observing the pulses in the right cun, different patients can show a wide variety of conditions: lactation, breast cancer, constipation, anxiety, etc. The practitioner can distinguish between these conditions by comparing this energetic movement with other organs.
  13. Pulse Diagnosis, p. 16-17
  14. Pulse Diagnosis, p. 68
  15. Pulse Diagnosis, p. 69. The clinical examples given in this section also mention that a Slippery pulse results "when there is an abundance of yang qi in the body." The other examples offered here are due to excessive yin energy, most often mucus created from wind and heat.
  16. Pulse Diagnosis, p. 70
  17. Pulse Diagnosis, p. 25. Also see my article, "Cancer from the Perspective of Dong Han Pulse Diagnosis," in Oriental Medicine Journal, Volume 3, #2.


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