Monday, July 30, 2007

The Four Examinations, Part 6 (Palpation Diagnosis)


Pulse: (mostly TCM here, not Contemporary Chinese Pulse Diagnosis, except for a few concepts)

Left Right
Distal = cun (inch) = heart and small intestine lungs and large intestine
Middle = guan (bar) = liver and gall bladder spleen and stomach
Proximal = chi (cubit) = kidney (yin) and bladder kidney (yang)/san jiao and PC

Speed: hot/cold
Location: interior/exterior
Strength: excess/vacuity

Pulse has a close relationship to HT
Depends on HT qi
Can reflect pathogenic changes in
The HT, yin, yang, qi, blood; as well
As viscera, bowels, and channels

Location, speed, strength, form tell
About location, form and nature of disease
And the strength of the evil and right qi,
Strength of disease circumstances and
Prognosis of patient

Rate, Rhythm and Stability

Rate and rhythm are considered “larger segments” of the pulse along with the Stability of the pulse, uniform qualities on the entire pulse, at all depths or in each burner. The qualities at individual positions are unreliable signs until the larger picture is addressed. It is possible to deal only with the larger issues and achieve the greatest impact on the patient in terms of their needs and treatment.

“Big is Big”.

Deviations from normal in the larger segments of the pulse are generally the most critical in terms of seriousness of disharmony and order of treatment. Rhythm, rate and stability are clinical issues that take precedence over any quality or combination of qualities in diagnosis and treatment. Frequently when rate, rhythm and stability are brought into order and balance, other qualities and findings will automatically change.


Alteration from a normal rate is much more often a sign of significantly more far reaching processes than Heat and cold influences. In Dr. Hammer’s experience the rate more commonly involves factors that affect the Heart function and circulation, such as shock, over-exercise, overwork, physical and emotional trauma.

Normal Rates according to Dr. Shen (Hammer, 152)
Age Rate
Birth to 4 years 84-90/min
4-10 years 78-84/min
10-15 years 78-80/min
16-40 years 72-78/min
40-50 years 72/min
50+ years 66-72/min

Rapid Rate—
Common causes are External: pathogenic factor (wind-heat), heat stroke or trauma (physical or emotional) or Internal: heat from Excess (Heat in Qi level, Heat in the Blood: heat or Thick, liver Qi stagnation with heat, Nervous system Tense or “vigilance” pulse).
--Deficiency heat—Tight and less rapid than with Excess heat.
--Trauma—Effects of trauma on the pulse will depend on the condition of the True Qi of the person at the time of the trauma and since then depending on lifestyle, whether the trauma was local or extensive, time elapsed since the trauma.
Extensive physical trauma causes the pulse to be Very Rapid, Bounding, Tight to Wiry.
Local trauma will produce a less Rapid pulse with Tight to Wiry quality in the area of pain.
Emotional trauma leads to a very Rapid Bounding pulse with a very Tight quality over the entire pulse, especially in the Pericardium position at first, and later the left distal position. Change in Intensity and Rough vibration may occur over the entire pulse. The tongue and eyes are normal. (Hammer, 154)

Trauma is a shock to the circulation. Circulation into and out of the area is compromised. If the True qi is strong the pulse will become Inflated, meaning the energy is trapped in an area and it can’t get out. If the True qi is deficient, the pulse will become Flat, meaning the outside energy can’t get in due to the diminished Qi.
If the stagnation persists without intervention for a long time, energy is gradually depleted and the pulse becomes increasingly Reduced. It will be Feeble-Absent in the position corresponding to the body site affected by the trauma.

Slow rate—External cause: Cold from external pathogenic influence.
Internal causes:
--Cold from deficiency of qi and yang (chronic disease, overwork, over-exercise, over-sex, protracted emotional stress)
--Heart qi and yang deficiency—Heart is unable to circulate qi and blood which leads to a slowing of the rate. If constitutional, the left distal and proximal positions are Feeble-Absent; if the cause of the deficiency occurs after birth, the entire pulse is Feeble and the left distal Feeble or Absent.
--Aerobic exercise
--Shock—over time will lower the Ht rate if unresolved.


Rhythm is the single most significant aspect of pulse diagnosis. It is a measure of Heart and circulatory function. Instability in the Emperor is tantamount to chaos in the empire. This must be dealt with first. Irregularity is considered in terms of whether it occurs at rest or with movement, whether we are able to count a rate, whether the changes in rate are small or large, and whether it occurs constantly or occasionally.

Interrupted: Misses beats with no fixed cadence. If able to measure a rate, indicates moderate Heart qi deficiency. If unable to count a rate due to the arrhythmia, indicates Heart qi and yang deficiency.

Intermittent: Misses beats with regular cadence (every 2 beats or every 3 beats). Indicates Heart qi, blood and yang deficiency. (Hammer, 121)

Change of rate at rest: Heart Qi Agitation, if found occasionally (Heart Yin Deficiency, page 409). Heart Qi Deficiency if found consistently.

Rate on exertion: An 8-12 beat increase is normal. An increase greater than 12 denotes Heart blood deficiency. A decrease in rate on exertion is a sign of Heart qi and yang deficiency. The method for assessing the change in rate on exertion will be demonstrated in the hands-on portion of class.

Normal Pulse

The normal pulse is resilient, compressible, of moderate strength and with spirit. The qualities, intensity and amplitude are consistent over time and in each position. Seasonal variations occur in rare instances where there is little pathology. Normally the pulse is somewhat stronger on the right side in women, and on the left side in men.

Three features: (1) Stomach Qi: reflection of post-natal qi (even, calm, good rate)
(2) Spirit: orderly w/o chaos, not changing (in rate, rhythm, stability…)
(3) Root: reflects KI: prenatal qi. Is there a KI pulse?; also reflected in deep level of all positions

The following are some characteristics of the Normal pulse which serve as a baseline and standard for health:
1. Rhythm - Consistently regular
2. Rate - Consistent with age
3. Quality - Compressible, resilient and elastic
4. Shape - Long, smooth and continuous without turbulence
5. Strength - Moderate with spirit - luster
6. Spirit - Moderate Spirit (languid, Leisurely, Relaxed, Slowed-Down) depending on body build
7. Root and depth - Balanced between superficial, middle and deep. The greatest strength should be in the root, at the deepest or Organ depth and becoming lighter as one ascends to the Qi depth. There is strength in the proximal positions. The pulse is deeper in heavy people and more superficial in thinner people.
8. Balance - Balanced between positions with the middle position occupying the most space, the proximal position the next most area and the distal position being the most confined.
9. Intensity (buoyancy, elasticity and resilience of the pulse) - Stable over time
10. Amplitude (height of the pulse) - Stable over time
11. Consistency - Qualities stable and consistent over time.
12. Wave - Sine curve that begins at the Organ depth and gradually rises to the Qi depth, and then subsides again to the Organ depth.

Qualities, intensity, rhythm and rate are consistent over time and in each position. The pulse is resilient, compressible, moderate strength with spirit.

Pulses of women and children tend to be more rapid than those of men. Athletes tend to have slower rates. Normally, the pulse is somewhat stronger on the left for men and on the right for women. Seasonal variations occur in rare instances where there is little pathology.

Buoyancy: The normal pulse in a child and sometimes in a vegetarian may be more yielding. In a woman it may be more thin and in a man more wide.

Shape: Pregnant women usually have more slippery and more rapid pulses.

Wave Form: Normal is a sine curve that begins at the organ depth, gradually rises to the qi depth, and subsides again to the organ depth.
The wave form is the movement of the blood through the vessel. The fingers can perceive the shape of this movement. Abnormal waves give us information about the condition of the patient.

Tells about location of disease
Floating: exterior disease (usually): can be internal wind
Deep: interior

Strength: tells of length of disease: chronic or acute
New onset will be forceful b/c evil and right qi are strong
Chronic and enduring, qi will be forceless due to evil qi and right qi weakened

Does pulse match signs and symptoms? If no, prognosis is more difficult.

Considerations in taking pulse:
Time of day: best time is b/w 3:00am to 5:00am
State of mind: of you and patient. Must be calm, concentration, etc.
Rate: count for 60 seconds
Each position: spend a few minutes, check for abnormalities, changes in qualities, intensity…
Position of Patient: should be sitting down with hands at height of just below HT. Pillow under arms
See 3 depths.
Rolling methods to access aspects of both principal and complementary positions. Soulie de Morant and Maciocia document rolling the fingers as an integral part of pulse diagnosis. Maciocia states: “Nearly all ancient Chinese texts on pulse diagnosis say that the pulse is felt not by keeping the fingers absolutely still on the artery, but by moving the fingers in five different ways: (1) lifting tells you whether the pulse is Floating; (2) pressing (down) tells you whether the pulse is Deep; (3) searching (not moving the finger) is used to count the rate; (4) pushing (from side to side) tells you about the shape of the pulse (5) rolling (distally to proximally) tells you whether the pulse is Long or Short
Watch for abnormalities:
Fan Guan
San Yin Mai
Ganglion Cysts
Sex and Age:
Men’s pulse usually larger, and stronger on left
Women’s pulse thinner and stronger on right
Menstrual cycle affects: weaker after period; stronger before
Kids: faster rates
Elderly: weaker due to decline in qi and blood
Excess joy damages HT and causes pulse to be vacuous, or in extreme conditions deep
Overthinking injures SP/HT and pulse becomes bound, when extreme, string-like
Anxiety damages LU/HT/KI and pulse becomes rough, when extreme, surging
Anger damages LV and pulse becomes soggy; when extreme, rough
Fear injures KI and pulse becomes deep, when extreme, soggy
Taxation/inactivity/poor diet:
With poor nutrition: weak and forceless
After meals may become surging, slippery
Alcohol: rapid (choppy LV)
4 seasons:
spring: string-like
summer: surging
fall: floating
winter: deep

a. Floating: exterior, superficial, usually associated w/ Lung; cork floating on water
i. forceful: exterior repletion
ii. forceless: exterior vacuity

1. floating and moderate: wind damp in exterior
2. floating and slow: wind stroke
3. floating and tight: wind cold
4. floating and slippery: wind phlegm or food stag
5. floating and rapid: wind heat
6. floating and scallion stalk: blood loss
7. floating and scattered: extreme taxation
8. floating and rough: blood damage

b. Scallion Stalk/Hollow: floating and large, hollow in center; arrives softly, when pressed, center is empty
indicates severe blood loss and yin damage

1. hollow and rapid: vacuity heat
2. hollow and slow: blood loss w/ vacuity cold (shock)
3. hollow and skipping: blood stasis binding internally (usually from trauma)

c. Soft/Soggy: floating, fine and soft; like cotton floating on water
governs vacuity taxation and vacuity cold of SP/ST and warm damp diseases, ie (uterine bleeding, post partum bleeding)

d. Scattered: floating large and scattered. No root. Empty at middle level and disappears at deep w/ pressing. Abnormal rhythm and feels chaotic. May be seen before delivering baby; HIV
severe KI qi vacuity

e. Leather/Drumskin: floating stringlike and large. Tight on outside and empty inside. Hard and straight w/ light pressing, empty within as if pressing on skin of drum w/ heavy pressure. Like scallion stalk but also stringlike and tight
blood collapse, essence defic; uterine bleeding; chemotherapy, hemorrhage

a. Deep/Sinking: felt only w/ heavy pressure
interior diseases

1. deep and forceless: interior vacuity
2. deep and forceful: interior excess
3. deep and slow: interior cold
4. deep and fast: interior heat
5. deep and tight: cold pain
6. deep and stringlike: swelling and pain
7. deep and slippery: phlegm food accum
8. deep and rough: accum of qi (masses)

b. Hidden: deeper than deep pulse; deepest part of muscle/ b/w tendon and bone; need heavy pressure
1. hidden and forceful: repletion evil hiding internally and obstructing movement of qi and blood; can be accompanied by diarrhea, vomiting
2. hidden and forceless: chronic and enduring diseases

c. Confined/Firm: hard, confined and fixed; deep in muscle layer; replete, large, stringlike and long; vessel feels hard and fixed
chronic diseases w/ deep evil; usually masses, obstructions and stagnations

a. Rapid: can indicate heat (interior or exterior; repletion or vacuity) or can indicate HT shock, etc. (see Hammer)
1. rapid and surging: exuberant yang repletion heat
2. rapid and fine: vacuity heat
3. rapid and stringlike: phlegm fire or heat in LV/GB
4. rapid and rough: yin or blood stasis causing heat

b. Racing: usually infection or severe HT shock; extreme repletion of yang when yin is exhausted and can’t control yang. Or if racing and forceless, yin of lower burner is exhausted and yang of upper burner is hyperactive. Beginning of separation of yin and yang.

c. Spinning Bean/Moving/Stirred: only felt at middle position (I’ve felt it at special lung pulse); feels like spinning bean; slippery rapid forceful
very serious, impending death or illness in organ system; or with extreme pain, palps or w/ pregnancy (3 mos.)

d. Slippery: arrives and departs smoothly; round and slippery; pearls sliding under finger
strong qi and blood
overabundance of qi and blood, ie heat, phlegm, dampness, food accum

1. slippery and floating: wind phlegm
2. slippery and deep: phlegm rheum or food stag
Hammer: can be infection, damp heat in organ
3. slippery and rapid: damp heat or phlegm fire
4. slippery and slow: lower bowel problems (dysentery)

a. Slow: cold patterns (interior or exterior; repletion or vacuity) or can indicate HT qi defic; toxicity
1. slow and floating: exterior cold
2. slow and deep: interior cold
3. slow and slippery: cold phlegm
4. slow and fine: yang defic
5. slow and stringlike: pain
6. slow and forceful: cold damp obstructions

b. Moderate/Leisurely: rate neither fast nor slow. But when combined w/ other qualities can be abnormal. Can be slightly slow/retarded.

c. Rough/Choppy: opposite of slippery. Knife scraping bamboo. Feels rough, w/ edges
Stagnation of blood (in tissues). TCM says also stag of qi, food, phlegm.
Can also have change in rate or rhythm. If pulse consistently rough/choppy, look for masses. Can be stringlike and rough if qi stagnation.

a. Empty/Vacuous: slow large forceless. Felt w/ light pressure only.
Vacuity of qi and blood
1. empty/vacuous and floating: qi defic
2. empty/vacuous and rough: blood defic (can lead to stasis)
3. empty/vacuous and rapid: yin defic heat
4. empty/vacuous and slow: yang defic

b. Minute/Faint: extremely fine, extremely soft; sometimes disappears. Extreme qi and blood defic; serious loss of blood or fluids (diarrhea, sweating, vomiting)

c. Weak: deep fine and forceless. Vacuity of qi and blood, but more of an internal condition where original qi is being consumed.

a. Replete: arrives w/ force, full and large.
Excess heat, fever, food stag, constip.
Watch for replete pulse w/ chronic condition. Can be separation of yin and yang
Good in healthy person

b. Tight: like a twisted string vibrating under finger and hitting w/ force
indicates cold, pain, fright-wind, cold phlegm, hernia

c. Flooding/Surging: comes w/ strength and goes softly like a wave. Usually large vessel and loose. Normal in summer.
Yang ming pattern: 4 Bigs (pulse, sweat, fever, thirst)
May also appear in vacuity patterns where it will be forceless waves

a. Abrupt/Skipping: rapid, skips beats w/o pattern
1. skipping and forceful: yang repletion w/ evil blocking flow of blood
2. skipping and forceless: HT palps or chronic vacuity cough

b. Knotted/Bound: slow and irregular
1. Bound and forceful: qi and blood stag; phlegm and food accum; masses; emotional problems (depression….)

c. Regularly Intermittent: forceless and skips w/ regular rhythm
indicates organ qi vacuity, esp Heart; extreme pain patterns or extreme fright; can be (normal if 3 mos. Pregnant?)

a. Large: vessel is large
heat: repletion or vacuity
if forceful, beginning of disease
b. Fine/Thready/Small/Thin: clearly felt like a thread
qi and blood vacuity; yin defic
c. Long: exceeds normal pulse positions; soft and flexible, yet forceful
normal in spring
surplus of yang qi
repletion patterns

d. Short: felt in middle positions, but not in others
Lung or HT qi vacuity

e. String-like/Wiry: long and straight and stiff under fingers (violin string); like a tight pulse w/o vibrating. Usually thin and narrow
Liver pulse: liver stag, wind, fire; LV/GB heat
Slightly string-like is normal in spring
Phlegm accum or masses

Feel for temperature, quality (rough, smooth), moisture, lumps, bumps
Look for discoloration and visible lumbs
General color
Use back of hand to feel face
Feel forehead for heat and feel hands at same time
If palm is hotter than forehead: vacuity heat
If dorsum is equal or hotter than forehead: repletion heat

Look at fontanel in child/infant.
If protruding: liver wind stirring
If sunken: fluid depletion

Feel for lumps/bumps on neck. Are they soft and moveable (qi stag) or hard and fixed (blood stag)? Are they painful? Hot?

Feel for temp, moisture/dryness, swelling
Hotter on inside: yin defic heat
Hotter on outside: yang repletion

Exterior heat: scorching when first touch, then diminishes
Internal heat: gets hotter and hotter
Heat blocked: don’t feel heat right away, then gets hot
Sweat on body: info on body fluids
Skin rough/dry: yin, blood vacuity
Skin swollen and sinks when touched: water swelling
Skin swollen and tight and doesn’t sink: qi swelling

Hands and Feet
If hot: hyperactive yang
If body and limbs are cold: yang defic
If limbs ice cold: reverting cold; yang exhaustion
Palms hot, body not hot: yin defic heat
Dorsum hot, body hot: external evil
Children w/ high fever: if fingers get cold watch for convulsions
If hands and feet both cold: SP/ST yang defic

If sores on body, palpate sores: hot or cold? Soft or hard?
If protrudes the skin and hot and pain worse w/ pressure: yang type sore
If level w/ skin, not hot, only slightly painful: yin type sore
If hard and painful when press, pus hasn’t developed
If soft, pus has developed

Lying down comfortable w/ knees slightly bent (supported from underneath)
Make sure your hands are warm





If pain in abd relieved by warmth: cold pattern
If pain in abdomen relieved by cold: heat
If better when pressed: vacuity
If worse when pressed: excess

If lumps: where are they? What do they feel like:
If soft and moveable: jia: conglomeration (middle jiao)
Qi-type Ju: gathering (lower jiao)

If hard and fixed: zheng: concretions (middle jiao)
Blood-type Ji: accumulations (lower jiao)

Channels and Points
Palpate bilaterally (note differences)
Palpate 5 shu points; front mu; back shu; xi cleft; yuan source; luo connecting (tell about repletion/vacuity in channel itself and associated channel); lower he sea

Look for tenderness, abnormalities, lumps, muscle tone (tense=repletion; soft=vacuity), changes in color and temperature

Palpate A-shi points

Lung: LU 1, KI 27, UB 13, LU 6
HT: UB 15, Ren 14, HT 1
Women: SP 6,9, Ren 4
General Constitution: Ren 4,6

The Four Examinations, Part 5 (Inquiry/Asking Diagnosis)

The "10 Questions"


Demographics: name, age, sex, profession, life circumstances, birth place, where they live…

Past Medical History: Birth history (did mom have trouble conceiving, did she have any health problems during or prior to pregnancy, early, late, induced, breech, forceps, stuck in birth canal, cord wrapped around neck, jaundiced, blue, other complications…)

Childhood illnesses, learning disabilities

Traumas: sudden death of loved one, abuse (sexual, physical, emotional, verbal), major accidents, broken bones……………


Medication history: antibiotics

Smoking/Recreational Drugs/Coffee

Exercise history: child athlete?………….

Family Medical History:diabetes, hepatitis, high blood pressure………….

Chief Complaint: why did they come in, when did it start (acute, chronic, what induced it), where is it located, progression, what makes it better or worse…..

10 Questions: 1. temperature: hot/cold; fever/chills
w/ chronic heat, can be from too much yang or too little yin
acute pathogenic invasion: wind-cold, wind-heat
yang pathogens: w-h, dryness, summerheat
yin pathogens: cold, damp
simultaneous fever and chills:
a. wind cold: more chills than heat (subjective), strong aversion to cold (wei qi can’t get to surface and warm you up; blankets don’t help), body aches; tongue normal b/c acute; pulse floating tight. This is the tai yang level of disease –most superficial
b. wind heat: more fever than chills, slight aversion to cold, sore throat, rashes, tongue normal or thin yellow coat, pulse slightly rapid and floating.
Alternating fever and chills: bitter taste in mouth, hypochondriac pain (malaria at its worst). The pathogen has penetrated into shao yang level.
Fever and no chills: internal heat
Chills and no fever: internal cold

Temperature can also tell us about vacuity/repletion
Cold: maybe spontaneous sweating, body/limbs cold, clothes help, fear of cold
Heat: no aversion ot cold, heat in 5 centers, chronic

Cold: strong aversion to cold, bland taste in mouth, no thirst, diarrhea, clothes don’t help
Heat: acute, strong fever, 5 bigs

2. sweating
lungs disperses wei qi; fluid of heart; spleen and kidney w/ fluid metabolism; yin or qi defic? Excess yang or heat
a. where is person sweating?
a. Only on hands: nervous condition or lung qi defic
b. Only on extremities: spleen qi defic
c. Only on head and back of neck: ST heat or dampheat
d. Only on chest, palms and soles: yin defic
e. On head only: defic
f. All over body plus constip: repletion heat
b. What time of day?
a. Spontaneous sweat during day: qi is not holding/regulating pores/qi defic
b. Sweats in evening or during sleep: yin defic
c. Quality of sweat
a. Oily: yang defic. Looks like pearls
b. Profuse cold sweat after chronic illness: yang defic
c. Yellow: damp heat
d. W/ external pathogen: wind cold or wind damp: if doesn’t resolve: wei qi defic
d. Smell of sweat
e. Quantity of sweat

3. pain/head (dizziness)
head is most yang aspect of the body. All yang channels meet there. Sense organs on head

a. headaches:
i. acute: exterior attack, usually wind cold
ii. gradual onset: interior condition
iii. severe: excess/repletion
iv. annoying dull: defic/vacuity
v. daytime headache:
i. yang defic (annoying/dull)
ii. qi defic
vi. night headache: annoying: yin defic/ blood defic
Location: locations of meridians are important.
i. back of neck into eye: Tai yang channels
ii. frontal HA: yang ming
iii. side of head: shao yang
iv. vertex: liver
v. whole head band around: dampness
vi. pain inside head: damp; phlegm
What makes it better or worse.
i. worse w/ cold: cold pathogen. Better w/ heat
ii. averse to heat: heat pathogen
iii. better w/ pressure: vacuity
iv. aggravated by pressure: excess
v. fixed location/stabbing: blood stasis
vi. pain moves location and intensity: qi stag
vii. heavy: damp
viii. worse w/ activity: defic. Better w/ rest
ix. worse w/ rest: repletion. Better w/ activity

b. dizziness: due to wind, fire, defic of qi, or phlegm
i. swaying, losing balance: vertigo: internal wind
ii. head and ear clogged: phlegm

i.and ii. Are both excess conditions w/ fire components bringing up phlegm

iii. worse w/ fatigue, change of position: qi defic

4. hearing and vision
kidneys open to ears; liver to eyes. Gb and SJ have special affinity w/ ear


i. acute and repletion patterns: dealing more w/ channels involved and EPI and occasionally w/ externally/internally related channel (liver)
ii. chronic and gradual onset: vacuity. Dealing more w/ Kidneys
iii. better w/ pressure: defic
iv. worse w/ pressure: excess

Quality of Sound
v. tinnitus:
a. low pitch: KI defic
b. high pitch/whistle: repletion/Liver
vi. deafness:
a. sudden onset: repletion
b. gradual: vacuity

Liver opens to eyes. Many meridians feed eyes (ht, st, gb, ub, sj)
Pain, swelling, itching, redness (wind-heat (acute) or internal liver fire)
Sharp stabbing pain like needles: toxic heat, fire poison in heart channel
Sand in eyes: spleen damp
Blurred vision, floaters, flowery, photophobia, chronic dryness: liver blood defic
Pressure in eyes: kidney yin defic

5. stool and urine
no pain w/ bloating: LV qi stag (harmonize ST and SP)
amount and color; well formed w/ no undigested food; easily eliminated
better w/ bowel movement: replete
energy of bowel movement tires you: defic
constipation: due to excess, defic, defic qi, blood, yin, yang, liver qi stag
acute: full heat in ST or intestines (yang ming). Tongue red w/ thick yellow coat
constip: from dryness in intestines
goat stools: small hard droppings (heat in intestines drying or LV qi stag)
abd cold to touch: cold or yang defic
abd hot: heat
alternating constip: LV qi stag invading SP and ST

diarrhea: could be same etiology as above; could be SP qi not transforming
foul smelling: heat
lack of smell: cold
cock’s crow: first thing in morning: KI and SP yang defic
blood in stool: damp heat in intestines
black stools: more serious: blood stasis (high in GI tract)
pus/mucus in stool: dampness
flatulence: LV qi stag
w/ odor: damp heat
no odor: cold in ST
borborygmus: gurgling: SP qi defic
Ask about color, amount, pain, inhibition, etc.
pale/clear: cold in bladder or kidney
Dark yellow/brown: heat
Cloudy/turbid: damp
scanty: heat (dried out fluids), KI yin defic (scanty but frequent), KI qi defic
copious: KI qi defic not consolidating (KI should mist up to Lungs and control bladder)
dribbling: KI qi defic
Pain before urination, relief after: qi stag in lower jiao
Painful urination: heat in bladder
Retention of urine: damp-heat in bladder
Inhibited urine: can also be LV qi stag

6. appetite and thirst (taste)
Appetite: tells about SP and ST
Aggravated by eating: replete
Alleviated by eating: vacuity
Better w/ bowel movement: replete
Lack of appetite: SP qi defic
Excess appetite: ST heat
Appetite (hunger) w/o desire to eat: ST heat turning to yin defic heat. (May have red tongue w/ no coat)

Desire for hot temp: cold
Desire for cold temp: heat
5 Element correspondences
craving or aversion for 5 element tastes
little stimulates: too much dampens/weakens
odd taste in mouth: look to 5 element correspondence; (ie bitter taste = LV/GB disharmony)
No taste: SP
7. sleep
shen is stored in HT and blood peacefully stored in LV. Sleep depends on state of blood and yin in body. If enough blood and yin, you sleep peacefully
Can’t fall asleep, but once asleep, stays asleep: HT blood defic
Wakes easily: KI yin defic, HT yin defic
Combo of first two: HT and KI not communicating: usually more severe sx
Excess HT fire
Excess LV fire
ST heat due to food stagnation
Sleepy after eating: SP qi defic
Fatigue (extreme) and cold: yang defic
Fatigue and heavy limbs: damp
Lethargy w/ signs of stupor and heat: external invasion of PC
Wakes up and doesn’t feel rested: GB qi defic
Grinding teeth:

8. chest and abdomen: pain/pressure, etc.
tightness in chest: lungs, heart, muscular
pain in sides/ribs/hypochondria: LV qi, GB qi stag (binding, constricted, can’t take deep breath, gas, bloating)
pain in lower abd/navel: intestinal cramping (SP), menstrual (LV/KI)
pain in epigastrium/solar plexus: ST region, food stag, or ST qi defic (differentiate by how pressure makes it feel)
pain in inguinal region/testicles: liver channel

9. gynecological: thorough history, first onset, timing, quantity and quality of blood, PMS, pain before, during or after periods, pregnancy and contraceptive, and sexual history, discharges, etc.
Chong and Ren: Need good LV blood and storage to fill Chong. Need enough KI yin and essence to make blood and SP to hold blood
If periods to frequent or comes early: heat: Liver gets hot; or SP qi not holding or LV qi not storing
Excess: thick, fire engine red
Defic: thin, watery
Period too late (more than 35 days): pregnant?:
Cold: congealed blood
Qi blood stagnation
Not enough blood: blood defic
Little blood: obstruction (qi, blood, cold) or defic
Lots of blood: qi defic (not holding) if pale, thin, or heat (more bright red and thick)
White discharge: no odor: cold (yeast infection?)
Yellow discharge: smell: heat (yeast infection?)

10. lifestyle: rest/sleep/stress/emotions/tendencies
previous illnesses
old illnesses may show root of present disease
prior successes, failure
habits contributing to illness
demographics and emotional life and exercise, working conditions, etc.

The Four Examinations, Part 4 (Listening and Smelling Diagnosis)

Some info on the Listening and Smelling exam

Listening and Smelling
Quality of voice: faint, frail, diffic getting words out: Lung qi defic or Yuan qi depleted

Rough, loud, full: repletion of yang qi

Hoarse voice: repletion if something blocking voice (will have other sx)
Defic if other defic sx

Reluctant speech, withdrawn, slow: coldness

Incessant speech: heat

Sudden loss of voice: wind heat

Gradual loss of voice: lung vacuity

5 element sounds:

Quality of Shen thru verbal expression:
full and impaired consciousness and talking loud: dampheat

listless and mumbling: heart qi vacuity

Listening to movements: keeps still but utters groans: joint pain
Clear voice but distinct and low and succinct: headache
Weak and indistinct: chest constriction/weakness
Coarse and loud: repletion/fullness
Difficulty breathing: vacuity/feeble/emptiness

Asthma: Diffic inhaling: feeble/empty: feels better w/ deep breath: Kidney qi not grasping Lung qi (slight wheezing)
Acute: coarse and loud: better w/ exhale (can’t exhale): repletion pathogen in lung: phlegm

Coughs: loud: fullness/repletion
Dry: unproductive, no phlegm: lung yin defic
Dry w/ tickle at night: kidney yin defic (KI 6)

Hiccoughs: if short, just diaphragmatic spasm
Loud: repletion heat –usually stomach qi
Long-term, but low and weak: weak stomach qi (usually coldness)

Smell: bad breath: stomach heat or oral dental decay
Belching: foul or sour belch is retention of food in stomach
5 phase smells:
hepatic problems: sticky sweet
cancer and diabetes: ammonia

strong or foul smells usually associated with heat and repletion.
Absence of smell or ammonia: cold diseases and vacuity

The Four Examinations, Part 3 (Pediatrics: Diagnosing Children with Chinese Medicine)

In pediatrics, we have this problem in that we can’t really palpate the way we palpate adults. So we have a very special diagnosis, which is part of the Looking diagnosis for children. And we look at a vein on the index finer. This is only good for children under the age of 3, because after that the area in this space thickens. Basically, we look at this vein (lateral side of index finger). Now if you look at your own hand you have all these little joints, phalangeal joints… you stretch the skin and then you rub it 40-50 times (in China they actually use different mediums – ginger based water or water – to act as a medium and magnification). So you rub and you watch to see how far the vein comes up. These are called Gates or Bars. This (proximal joint) is called the Wind Gate or Bar. The middle one is called the Qi Bar or Gate. And the distal one is the Life Bar or Gate. Wind, Qi or Life.

As you massage, the vein becomes more distended. How much it rises gives you your prognosis. If it rises just a little past the Wind Bar, the diagnosis is mild, external Wind attack. The prognosis is very good. If it goes up past the Qi Bar, then the diagnosis is usually that the internal Qi has been affected; usually the disease is in the Zang Fu organs – there might be problems with digestion, constipation; there might be more of an organ problem. Still manageable, but more deep. If it goes past the Life Bar, then we have a very serious condition. It just gives us how deep has it penetrated (doesn’t tell us what it is or where it is).

Now in a healthy child this vein is really thinly visible, but it’s visible. Usually pale purple, maybe a little brownish in color. And only in that Wind Bar area. As you massage it, if it goes up, you’re developing a pathogen interiorly. If it turns more red, it usually indicates more heat. Green or blue indicates more cold. If it turns black, that’s usually blood stasis.

The Four Examinations, Part 2 (Tongue Diagnosis in Chinese Medicine)

The tongue is one of the major pillars of diagnosis, the other main one being the pulse. The tongue body proper is going to give you information more about the Yin organs, the blood organs in particular. How much is it feeding? The tongue coating is the result of digestion. So we’re looking at two overall things. We’re looking at a body and we’re looking at a fur coat. Now the body itself is going to have not only color, but a size and shape to it. And it might have cracks, and it might have red raised areas. And whether or not you can hold it out and it stays firms or moves around and quivers is going to mean something. And the tongue fur, it’s going to have a color and a thickness to it. And it’s going to have areas that it’s distributed in, and maybe some areas that it’s not.

When reviewing the tongue, the best light to look it is natural light. And foods also affect the tongue (change the color, etc.). Pepto Bismal does a nice job on a black tongue. Eggs make it yellow and orange juice also makes it yellow. Cigarettes do lots of things… stain it a little bit of brown.

The tongue is a muscle. It reflects the Yin organs. All channels are indirectly reflected in the tongue. SP connects w/ root of tongue and scatters over bottom; KI goes to root; HT connecting vessel goes to root; UB and SJ tendinomuscular channels go directly to tongue. Mostly it reflects the state of the Spleen and Heart. It shows the state of the Blood and it shows the state of Yin. The tongue coat shows the state of digestion. When you digest, the Stomach and Spleen digests, part of the Essence is said to go up to the tongue to become dirty dampness – it coats the tongue. Tongue coat shows the effect of the organs, especially the Stomach Qi. Now, when you’re dealing with a pathogenic invasion, the tongue coat tells you about the penetration of the pathogen. For instance, when you first get sick, the coat doesn’t change. As it (pathogen) progresses in, it (tongue coat) gets thicker; it might change color.

Eg. Somebody comes in with a Wind Cold attack. The cold penetrates in. Two days later, it’s now trapped heat. The tongue coat was nothing; now it’s thicker white. Then it becomes thicker and it’s going to turn yellow. Now the cold has changed to heat, they now have a fever of 104-105. They’re sick. Now the tongue is very red and the tongue coat is yellow. Three days later this person has burnt up all their Yin. The tongue coat falls off. Now they have a bright red tongue with cracks and it’s peeled. It’s absolutely glossy. Now it’s really deep in. They break out with delirium, macules and now they’re dead.

A normal tongue should be pale red (they say the color of fresh meat). So it should be red, but not bright red. It should be supple, soft and flexible, even shaped and it should have no cracks. And it should have an even, slightly moist, thin, white coat.

The very tip of the tongue – that’s said to be the Heart. The area behind the tip, that’s associated with the Lung. The area in the middle is associated with the Stomach and Spleen. The rear of the tongue is associated with the Kidneys, but also with the whole Lower Jiao area, so it also includes the intestines, both small and large, the bladder and the uterus. Now the Liver and Gallbladder are on the sides. The right side is thought to be more associated with the Gallbladder and the left side is associated with the Liver, but most folks just say Liver and Gallbladder. So that’s the most common use. Another easier way is to say that the back of the tongue is the Lower Jiao, the middle of the tongue is the Middle Jiao and the front of the tongue is the Upper Jiao.

The tongue body shows the condition of Zang Fu organs, especially Zang, the Yin organs. Especially about blood. The overall color, that’s the state of the blood. The tongue is the only muscle that you can see and reflects what the muscles look like inside; that’s how much they’re nourished.

SPIRIT reflects good moisture/fluids, qi and blood
1. thriving: soft, flexible, moist
2. withered: dry, stiff, can’t protract, emaciated, dusky: no spirit

We look at the color first. It’s either going to be paler, redder or purplish or bluish.

Pale: A tongue can be slightly pale, but when you see a pale tongue, it almost looks white. It looks like it’s not being fed blood. Pale being Qi and Blood deficiency, Yang deficiency and Cold.
Difference between Qi insufficiency and Blood insufficiency is going to be in the moisture. If the tongue is insufficient in Qi or Yang, it’s going to be moist. If a tongue is insufficient in Blood, that’s going to be more of a dry tongue.

Repletion cold: fur is white slippery and thick, pale body
Vacuity cold: body pale and enlarged and tender, damp and scalloped

Red tongue. This is going to be either a full heat or empty heat.
Full/replete heat, the whole tongue is red.
Empty heat, the tip of the tongue is redder. The tip of the tongue is the Upper Burner (heat rises). Can be tender, with little or no fur.
If red in specific area, heat in that organ

Crimson, scarlet or deep red color – it just means there’s some extreme heat in the body. Usually they’ll have some febrile disease or you’re really insufficient in Yin. Can also be blood stasis. Heat in blood level.
Vacuity heat: little fur left/peeled
Blood stasis: crimson w/ stasis macules: usually skin disorders, too

Purple or dusky – usually the Qi or Blood is static. Now purple’s a mixture of two colors – blue and red. If it’s more blue-purple, it’s usually dealing with some cold. And if it’s a red-purple, it’s usually dealing with more heat stagnating.
Cold: cold in LV/KI and tends to be dampness
Qi and blood stagnation creating heat: stasis macules, a dry mouth (w/o desire to drink)
Purple: heat in blood
Swollen and large: alcohol toxins affecting HT
Purple or Blue-Green: less severe stasis, just certain areas, usually LV/GB first

Every once in a while there’s an orange color to a tongue (on the sides). Giovanni and Hammer say it’s liver blood insufficiency.

When you talk about size and shape, you’re talking about something that’s either too big or too small. Flabby or swollen usually has to do with either Qi or Yang is insufficient to hold it, or there’s excess Damp that’s making it too big. Sometimes there’s teethmarks on the side. That’s called scalloping. It’s usually worse in the morning.

Tough and Tender:
a. Tender: looks like beaten meat; indicates vacuity
b. Tough: appears hard and rough: indicates repletion

Swollen w/ scallops: spleen qi defic w/ dampness
Swollen and pale: yang qi defic: replete yin
Swollen pale white tender and moist: SP/KI yang vacuity
Swollen and red: damp heat

Thin or narrow:
Thin and red: Yin insufficiency
Thin and pale: Qi insufficiency. Can also still be Yin/Blood Insufficiency as they often come together.

Prickles: if papillae stick up high
Usually reddish: heat

Fissures/Cracks: usually yin defic.
Crack down center, depending on length, can indicate severity of disease and progression
Crack in Center: SP/ST yin defic
Crack down center to tip: HT pathology

Scallops: SP qi vacuity often w/ dampness

Tongue Sores: usually LV/GB and HT
Protruding, tight, painful, red: heat toxins in HT
Ulcers, herpes-type: heat in LV usually (can be HT)
Less painful and not protruding or tight: yin defic heat

Sublingual Veins/Network Vessels: under tongue
If dark and distended: blood stagnation
How far does the vein go?

The demarcations that you look for are cracks or raised areas. The cracks, they might be congenital, otherwise they mean something has eaten up the fluids. If you find cracks that are horizontal, that almost always means Yin Insufficiency. If you find cracks on a pale tongue, it usually means that the Qi and the Blood is deficient. And if you find cracks on a red tongue, it usually means that there’s heat – either excess heat that’s burned up the tongue or there’s insufficiency of Yin, usually Stomach Yin. You’ll start finding that (vertical) central crack that usually gets deeper and deeper. That’s usually Stomach Yin burning up.

The eruptions, the red areas that get raised, the little prickles – they’re always replete heat. Most people have it in the back of the tongue and the other place you’ll find them is on the side.

How one moves the tongue. Now the tongue should be able to be flexible and it should be able to sit there for a little while without shaking or moving around like a snake.
Rigid, can’t stick out – Wind. Or it can be a problem with Phlegm heat or Heat, but really extreme though. Delirium.
Deviated, that actually pulls off to the side, shows that there’s some obstruction of Wind and Phlegm in the channels. Wind stroke.
Trembling: heat creating wind; Wind or Qi or Yin Insufficiency. When it’s Qi or Yin insufficiency it’s really mild. When it’s Wind… their tongue is wandering all over.
Dog tongue, the panting or lolling tongue: replete heat.
Limpness: floppy soft w/o strength, hard to turn from side to side or curl: usually in serious conditions
Limp and pale: serious qi and blood defic
Limp dry and red: heat burning yin
Stiffness: hard stiff and straight, not flexible, diffic to stick out or retract: lack of ST qi (critical)
Contracted: unable to extend out of mouth. Critical sign: wind-stroke or extreme heat burning yin
Protrusion and Worrying: licking lips constantly
Developmental problems, ie source qi defic
If adult and red: heat in HT and SP
If adult and purple: epidemic toxin affecting HT
If occurs suddenly in children: fright wind (childhood epilepsy)
Tongue Doubling: veins under tongue swollen and distended, looks like second tongue: due to fire heat surging up HT channel
Palsy: numb and doesn’t move flexibly: due to blood defic causing stirring of LV wind or wind-phlegm
Protracted: extends out, difficult to retract; long and hangs out
If numb: qi and blood defic
If deep red and drool: wind phlegm, phlegm fire

Tell us about circulation. When diseased, they are swollen, distended; one side or the other or both. They become bluish-purplish – tells us about blood stasis. The distention tells more of Qi stag; the purple/blue/black tells of blood stasis.

This is the excess of the turbid Stomach qi. Good stomach qi produces a good tongue coat. It’s part of the healthy digestive process. Normal coat is thin white smooth and evenly distributed and slightly moist. Abnormal coat is generated by evil qi.

The coat can also tell of a pathogenic invasion and location. How deep the pathogen has penetrated.
white: cold, exterior conditions, dampness
body red, coat thin white moist: external wind heat
body normal, coat thin white moist: wind cold
thin white and dry fur: ext evil transforming into heat and damaging fluids (body usually red)
thick white glossy: damp turbidity or cold damp, usually w/ pale white body
thick white can mean heat in certain situations: if looks like snow powder and body is red can be damp heat internally or epidemic type disease or hidden heat
Yellow: heat, deeper the color means stronger the pathogen
Yellow thin: wind heat or wind cold transforming
Yellow thin and dry: heat damaging fluids
Yellow thin and moist: fluids still ok
Yellow thick and glossy: damp heat accum and stag in SP/ST
Yellow thick and dry: heat evil damaging fluids
Yellow thick w/ pale white enlarged body: SP/ST defic w/ water dampness
Yellow slimy: damp heat in SP/ST or phlegm or food accum
Yellow burnt w/ cracks and prickles: extreme heat consuming qi and yin
Yellow and white together: evil moving internal
Grey black: extreme heat (w/ crimson body) or cold (w/ pale body and moist/swollen)
White → yellow → grey (chronic) → black
Repletion Heat: black dry burnt w/ red body
(Yang) Deficiency Cold: thin black damp w/ pale white body and tender or pale purple

Moldy Sauce: mixed colors: yellow/red/black
Long term chronic damp heat complicated w/ summerheat

Peeling: where is it peeling?
If many sections: depletion of ST qi/yin

True fur has root (ST qi rooted). If fur can be scraped off → false fur (no ST qi)

Thin: can see thru coat: normal
Thick: can’t see tongue body: excess repletion. Thicker the coat: stronger the pathogen
Tofu: large clumps of fur, unrooted,
Loose: can be brushed off: severe dampness; stomach not transforming; repletion heat evaporating and transforming turbid dampness in SP/ST
Moldy: over entire tongue or in spots: improper rottening and ripening of ST
Pus-like: thick and sticky and looks like sores: internal abscess
Greasy: pathogen plus dampness
Slimy: greasy and dirty; smaller pellets/clumps which are sticky: damp turbidity
Peeled: no coat: either stomach yin defic (can’t make coating) or Kidney yin defic if no coat all over and red

Topography: see diagram above

Moisture: tells about state of body fluids; normal is moist w/ no pooling, supple
Too wet: yang qi not transforming or dampness
Dry: heat or body fluid dryness (blood)

Water makes tongue more moist
Olives, coffee, plums, turn fur black/yellow
Vitamins C, riboflavin, tea, cigarettes, stain yellow
Milk makes fur white
Antibioitics cause tongue to peel and/or thick tongue fur
Eggs stain fur orange
Candy will change fur color

Tongue Body reflects:
a. circumstances of right qi: change in color, form or bearing reflect right qi, viscera and bowels; ie. Thin=qi vacuity; pale=blood vacuity; deviated=wind/blood stasis
b. vacuity and repletion of zang fu
c. debility/exuberance of qi and blood

Tongue Fur reflects:
a. circumstances of evil qi: yellow=heat; white=normal or cold
b. depth of disease: tongue fur thicker if interior.
c. existence of ST qi

The Four Examinations (Chinese Medicine Diagnosis, Part 1)

One of the major strengths of Chinese medicine is its ability to diagnose imbalance. It does this via the 4 Examinations or 4 Diagnoses, Inspection/Looking, Listening/Smelling, Inquiry/Asking and Palpation (pulse, abdomen, channels).

Over the next series of posts, I will present an outline of my teaching notes on these examinations.

1. Inspection, “Looking examination”
a. looking at the form of a person, how they’re built, how they carry themselves: their form, their bearing. individual structure; the complexion, the sense organs; you look at their Shen, their eyes
b. tongue

2. Listening and Smelling exam.
a. We listen to the quality of someone’s voice, the quality of the sounds they make; the quality of a cough, quality of respiration; coughing, wheezing.
b. And then we smell, we use our nose. The pictogram of smell is actually to taste the air around them. And we smell any unusual odors. Probably the hardest one to describe when we start talking about that. Overall, we’re going to smell unusual odors.

3. Inquiry or Asking exam.
a. We’re going to ask questions from head to toe. We’re going to ask a lot about the chief complaint, the onset of the chief complaint, plus the progression of the illness (the clinical course of the chief complaint – what have they done, how did it start, what’s the past history, how has it changed?)
b. Ten Questions. symptoms overview in terms of Chinese Medicine. We ask about their temperature, how they feel – whether they’re hot or cold. We ask whether or not they sweat, we ask about any problems with their head or dizziness. We ask about their hearing, we ask about their respiratory system. We ask about their appetite, their taste. We ask about their digestion and elimination – we ask about bowels, we ask about urine. We ask about any pain that they have. And for women, we ask about their menstrual cycle. It’s basically a patient’s subjective response to questions regarding their condition.

4. Palpation Exam or Touching.
a. We palpate the chest, the abdomen, the limbs. We palpate the channels and acupuncture points.
b. Pulse: very detailed at the radial artery, the pulses on both sides

Diagnosis involves using your eyes, ears, nose and mind plus your hands to touch. Must be present you’re your patients to find out what’s wrong with them. The goal is to determine a pattern of disharmony.


Bone structure, shape, form – Jing. Long-term changes. Then, flesh, nourishment – Qi. Medium term changes. Then, complexion – Shen. Momentary changes. The Three Treasures.

Shen is about engaging in the world, in terms of interactions, communication, appropriateness. It’s about participation in this world. It’s a combination of the Jing and the Shen. It’s a combination of the facial expression, complexion, the quality of the voice. But when we’re looking just at Shen, we’re looking at somebody who either has Spirit or does not have Spirit. And then we have something called False Spirit.

When someone has Spirit or has Shen, what you’re really seeing is someone who’s bright-eyed and chipper; respond coherently to questions. It means that their True Qi is unchanged, that their vitality is not really being taxed completely and their prognosis is good. Even if they’re in a lot of pain, even if they seem to have a serious illness, their prognosis is good because their Shen is still present and clear. So, they are present, they are able to respond to you appropriately.

Now someone who lacks Spirit (Weismann likes to refer to this as Essence Spirit Debilitation – he always combines the Jing in there). They have a severe lack of either mental vigor or physical vigor. Usually they have a dull facial complexion, a dull look to their eyes. There might be abnormal speech or abnormal responses to questions. Now there’s a lot of space between these two. But you either have someone who has spirit or you have someone without spirit. When someone is without Spirit, their prognosis is very poor because they’re not there to work with you.

False Spirit
Worst prognosis is something called False Spirit. Now, False Spirit is not someone trying to be happy when they’re sad – that (person) still has Spirit. False Spirit is very, very specific. False Spirit is really the last, flickering light of a dying individual. It’s when someone who is at death’s door, without other changes, all of a sudden becomes spirited; all of a sudden becomes alert and active and engaged without any other real significant changes. If somebody’s going to get better, that happens slowly, they slowly come into themselves, they slowly regain their appetite. When someone all of a sudden, who’s at death’s door, turns lucid and clear and hungry and available. This is called False Spirit. When Yang and Yin are separating and Yang rises to the surface, which gives that last burst of energy before death. It could be 2 weeks, it could be 2 days, but the prognosis is not good. Usually it’s associated with something called the Grease Paint Smear – along the places you have a malar flush, it looks like oil paint, like a red smear right here (across cheeks). It’s bright red, much more of a vibrant color. This is a time usually when death is imminent. It’s time to say goodbye.

Complexion reflects the state of Qi and Blood.
First, you look at the texture, the luster of the skin. Healthy skin should have a shine to it, should have a luster, but should not be oily. Unhealthy is usually oily or dry: dry being usually deficient or having more vacuity and oily being more of a repletion state. If it’s just shiny, it means the stomach Qi is good. If it’s too shiny, it’s oily and there’s repletion. If it’s dull there’s usually some insufficiency, usually the stomach Qi is not forming the fluids well.

Green/Blue (Qing – the color of dragon scales). Wood. Liver or Wind. Or it’s associated with congealed Blood or congealed Qi. Qi and Blood Stasis. Around the eyes, around the mouth, around the sense organs… the temples, especially for the liver, the gall bladder, the gall bladder meridian area, between the eyes. But usually around the sense organs, where the bones come up, and around the mouth. You’ll see lips turn blue: blood stasis; when you have a heart attack or poor circulation.

Red. Fire. Heat patterns.
Vacuity heat: malar flush. Usually afternoon.
Full heat: whole face is red.
False Spirit red, which is that strip of great paint.

Yellow. Earth. Dampness or with Vacuity, usually. Spleen not transforming fluids properly. You often will call this sallow, kind of like a pale yellow, puffy skin. Sallow. It’s usually associated more with Spleen/Stomach vacuity.

Jaundices in Chinese Medicine. Yang type jaundice and a Yin type jaundice.
Yin type jaundice. It’s called Cold Damp Yin Jaundice – it’s usually associated more with some disharmony of the Spleen, Spleen Damp Coldness. Person just looks yellow, not yellow sclera. It’s the color of yellow and usually in Western Medicine you’re going to be seeing something like cirrhosis of the liver or pancreatic cancer, chronic hepatitis. Basically… the organs are getting taxed in a more malingering way where the tissue is actually drying out. It’s a Cold Damp Yin type jaundice.

Yang type jaundice. Yang type jaundice is a Damp Heat Yang jaundice. More associated with the liver. The person has yellow skin and yellow sclera (the whites of the eyes). This is more hepatitis or acute gallbladder attack or gallstones.

What you see mostly is some people come in and they look kind of yellow, diagnose someone as jaundice, it’s usually stomach and spleen deficiency – it’s not uncommon. It’s kind of a yellow, sallow color to the skin.

White. Metal. pale. White usually indicates Cold or Vacuity. Now, the major thing here is what kind of moisture somebody has. If you have someone who comes in and they have a bright white complexion and they’re real puffy; bright white and there’s swelling. This usually is some sort of Qi or Yang Vacuity. So basically we have the Qi not transforming – so you have a bright white, puffy complexion as opposed to a lusterless, dry, white face, not puffy, but almost drawn. That’s more Blood deficiency. That’s more vacuity of blood. I like to say a withered complexion, that drawn look.

If somebody turns white suddenly, that sudden white, is usually associated with Faint, shock… it’s usually some sort of Yang Qi Desertion: Yang Qi just leaving through the feet, leaving the face white. Also, it can be associated sometimes with pain, but it’s the Yang Qi deserting.

Gray/Black/Purple. Kidneys, Water. And that usually means Kidney vacuity or Blood Stasis. Because a lot of those dark colors are just that purple, lingering for a long time – it starts looking gray or black. So Kidney Insufficiency or we have that kind of congealed blood kind of purple that turns black.

Facial Diagnosis according to the

Su Wen and Ling Shu:

Problems on the cheeks, both cheeks, if it’s not on one side, then you’re looking more at the Lungs. If the cheeks are puffy, we’ll say it’s more phlegm in the Lungs. Another place we look is something called a flaring ala nasi. The flaring ala nasi and with red around it, we’ll see as Lung Heat. Usually if the sores are more inside the nostrils, it’s more Large Intestine. But the nostrils should be even shaped. If they’re too small, that’s a constitutional weakness in the Lung. If they’re very large, they tend to also have ______________.

The nose is associated with the spleen. It should be well-formed, well-shaped. If it’s swollen, we tend to be looking at Stomach Spleen Dampness and Heat. A bulbous nose, from alcohol indulgence, Dampness and Heat. The size and the shape of it is more Spleen. If it’s white, if the nose is too pale, that’s usually Qi insufficiency of the Spleen. Some say it’s a Heart condition, too. There’s differences of opinion.

Liver. Usually when we’re looking at the liver, we’re looking more at the area, the frown lines (between the eyes). A large one is said to be a liver disharmony, especially if it’s red in excess. And two smaller ones, that could be called more Gallbladder. Right above the nose, like where the glasses fit, that’s more spleen. If that’s more white, that could be the digestive system getting cold. Liver is really right between the eyes. Also, the eyebrows are said to be the liver also. And the shape of them… one big solid one is said to be very angry…nice shaped ones have a nice disposition. The other place to look for liver and gallbladder is usually in the temples, where the gallbladder channel passes through. But we do look at the heart up here (forehead), too.

Ears. The ears are the opening to. Good big earlobes mean a really good, strong constitution, long life. Shouldn’t be attached. If they’re dry and withered, it’s often a sign that the Kidney Jing is very weak. If they’re red, it’s heat; if they’re blue, it’s cold. If they’re black it’s exhausted. All the meridians connect at the ear at some point.

We see the kidney underneath the eyes – so puffy eyes, swollen eyes are usually kidney disharmony. Puffy is usually the Qi insufficiency. By the time it gets black we’re usually looking at Blood Stasis. The other place to see the Kidneys is in the chin. A good, strong chin is supposed to be a solid foundation. This is supposed to be the reproductive area, too, like the pelvis, and they kidney’s associated with reproductive capacity by storing the Jing. Outbreaks here are also very common for women premenstrually; urinary tract infection, you’ll find that over here, prostatitis in men. Cleft chins – thought to be associated with sexual virility. So a cleft chin, also associated with good strong reproductive capacity.

Filtrum (between the nose and mouth), especially in women, becomes very important. It’s associated with the reproductive system. Usually a crease here (horizontally, between nose and mouth), you’ll see that problem with women who have hysterectomies. In older people you’ll see a vertical line.. as people age, that’s more Yin insufficiency – the little tiny ones. With hysterectomy it’s a sudden onset and that’s more like a big crease. As you get older, it’s more like a puckering.

Lips and mouth are the opening of the Spleen, usually associated with Stomach, Spleen. If they’re pale, usually you’re looking at cold, insufficiency. If they’re redder than normal, you’re looking at heat. If they’re dry and scorched you’re looking at drying of fluid. If they are Qing colored, that blue/green, you’re usually looking at pain, cold or stagnation of blood. If they’re chapped, you’re looking at either Stomach or Spleen heat. The corners of the mouth.. Upper lip being more associated with the stomach, and large intestine being the lower lip. Sometimes can be thought of as the whole thing being the Spleen. The corners of the mouth I’ve been taught at different times as being the small intestine… I’ve also read where the corners were associated with the Kidney.

Excessive salivation means the Spleen is weak or there’s Stomach Heat.
Mouth Askew or open, that’s usually thought to be Spleen weakness.
Can’t close your mouth, that’s great weakness.
Paralysis, when you’re pulling off to one side, that’s Wind. So when you have one side of the mouth, one side of the face drooping, that’s Internal Wind.

Jowls. Weakness in the legs. If this is the urinary tract (chin), then these are the legs (jowls). So if you have jowls, it’s weakness in the legs.

Teeth – ends of the bones – usually associated with Kidney, excess of bone. Usually weak teeth, gums that are swollen, red; usually Stomach Fire. It could be Yin deficiency from the Kidney. Loose teeth….

Hair is the magnificence or the opening, or shows the state of the Kidneys. But it’s also associated with the Glory of the Blood. It means, it tells you about the Kidney Qi and tells you about the state of the Blood. Usually if it falls out easily, you’re dealing with Jing Insufficiency or you’re dealing with dry Blood. You see this a lot with women who have been dieting. When it comes out in patches, usually the blood is being affected by Wind. Then you also have jing insufficiency as congenital baldness. Post-chemotherapy, you’re seeing heat that’s dried up the blood and also impacts the Jing.

Now the other thing you need to know is the Ling Shu. And it’s very different, it takes the whole body… and all the Yin and Yang organs are right here (nose). And I will not ask you to be able to draw it out. I would just like you to know where they are generally. Just be able to recognize on a picture….

The pupils should be normal, they should have some luster; should show some interest in the world. Five wheels shows the state of the different organs. The upper lid is thought to be associated with the Spleen. The lower lid is thought to be associated with the Stomach. The canthii, inner and outer canthus (corners), they’re going to be associated with the heart. The sclera, the white of the eye, that’s associated with the Lung. The coloring of the eye, the iris, is associated with the Liver. In iridology this (iris) is what they look at to diagnose the whole body. The very center of the eye, the black area (pupil), that’s associated with the Kidneys. This is called the Five Wheel Cycle.

So if you have red sclera, you might have Lung Heat. But you also might have Liver Fire or Heart Fire… Dark rings around the eyes, we talked about Kidney vacuity. Swelling under the eyes, slight puffiness, we have edemas due to Kidney insufficiency. Now in old age kidneys deplete – that’s normal – and what happens to the eyes? Most of the time you’ll see puffiness and that’s fairly normal. Bulging of the eyes – that’s phlegm; Phlegm Fire.

So Form and Bearing refers to how you’re built and how you carry yourself. Form means your physical aspects. Bearing is how one moves through the world. Now, when dealing with form, we’re dealing with the 3 constitutional things we talked about before. Constitutional ties with Jing being associated with the bone and long term changes. We talked about the Shen… Again, just like there’s many different constitutional types and there’s many different ways of reading the face, there’s very different form, like how your hands shake, how your ear’s shaped, you know, diagnosing through all these things. And then we talked about long term changes being the Qi and Flesh. And we talked about short term changes being the Complexion and Shen.

We’re going to look at these constitutional types, Forms. This is what you inherit. You have the earth character, Earth type, who has a large head with a fleshy, wide jaw. Usually they’re going to be tending toward a sallow complexion, tending towards overlarge bodies, but not always. Usually Earth types are either Damp or Deficient if they’re going to be out of balance. With Damp, you usually see fleshiness without support underneath: they say large physique with vacuous Qi. It’s not just size though. But we have the idea of fleshiness, flesh being associated with Spleen and Stomach. So you have this idea of large physique with vacuous Qi being Earth type, but also Stomach/Spleen Deficiency, where you can’t put on weight.

Now very few people will have just one of these. You have mixtures…

Metal – Metal types have broad shoulders usually, strong build, triangular face. Metal people have “hands like piano players”, long delicate fingers. And metal types are also very impeccably dressed, very sleek, put together, discriminating. Remember we talked about metal cutting through things. Harsh critics.

Water types have round faces and round bodies and really long spines. Usually more a tendency toward being “intense”.

Fire type has a small face, pointy head, balding usually. They usually have small hands. These people are said to have good lives, but short ones. Very fast, fun-loving individuals; know how to throw a good party.

And the last is Wood, which has a tall, slender, wiry body; very muscular. Very lithe and muscular. A tendency toward a kind of squarer head and a tall, slender, very wiry body.

But overall, you want…somebody who has a good, well-developed, strong body means a strong constitution. A poorly developed, emaciated body means a weak constitution.

How to carry yourself. All the movement; of the whole and all the body parts.

Agitated movements, rapid movements, jerky movements all indicate conditions that are more Replete, more Yang and more Hot. Slow movement, dislike of movement, sleeping curled up – this indicates more Cold, Vacuity and Yin condition.

Twitching, convulsions, deviation(deviation of the mouth, deviation of the eyes), shaking – they actually all indicate Yang excess conditions, but they also indicate Liver Wind. Dizziness can also be Liver Wind. A lot of times migraines are associated with Liver Wind. If we’re blood deficient, wind can take the space of Blood. They say nature abhors a vacuum, so if there’s not enough blood, wind comes in. Pronounced forceful contractions, that’s really a Repletion of Heat. Milder contractions, you’ll see more Vacuity and Wind. Contractions are all Wind.

Shaking can be, you either have wind or you have Qi deficiency. You see it with the tongue. You see it with a muscle. If I tell you to hold your hand up – after a while your hand’s going to start shaking… your Qi is deficient and you can’t hold it up anymore.

Monday, July 23, 2007

Do you have a pulse?

Often people check the pulse to see if someone is still alive. In Chinese medicine, this is no different. In our medicine, however, we are checking for life, or health, in every aspect of one's being. We look to each and every organ system in isolation (on its organic or parenchymal level) and in relation to every other system, i.e., how it participates or contributes to the overall energy, blood and dynamic of the organism.

In Chinese medicine, it is not enough to take a snapshot of an organ or area of the body in order to assess its health or lack of disease. As no organ acts in isolation, the information that this would provide would be insufficient to understand the person's well-being. For example, a patient with fibroids is recommended by her doctor to remove her uterus based solely on the presence of a mass in that organ. But this completely ignores that there is an etiology behind the formation of this mass and ignores the fact that this etiology will remain despite the surgical removal of an organ. Was it caused by Liver stagnation and poor blood circulation in the tissues; maybe a weakness of the Kidneys and hormonal system, or a sexual trauma effecting the Heart and circulation to the pelvis, etc.?

One can never understand health without understanding relationships and interrelationships. Pulse diagnosis is the single best tool to see these relationships in a real-time precise and objective manner. One can determine the mechanisms behind the fibroid and virtually every other symptom in the body. Is there excess in the Liver from stagnant blood invading into the Stomach and causing reflux and indigestion? Is that Liver excess moving into the Heart and causing anger and anxiety? Is their a rough vibration over the pulse reflecting a serious trauma? Is alveoli function impaired in the Lung causing shortness of breath and asthma, or is it from a weakness of the Kidneys not grasping the Lung qi? Are the headaches caused by excess in the Gall Bladder, weakness in the digestive organs, or a trauma to the head reflected by a vibration and pounding in the neuropsychological position? Is the person's adrenal exhaustion a result of genetics and poor constitution, or lifestyle, drug use, excessive sex, or an obsessive personality reflected in the hesitant pulse wave and a constant firing of the sympathetic nervous system?

Without taking into consideration all the organ systems and the myriad relationships, one can never decipher the subtle signs the body is trying desperately to convey. It truly is the hallmark of the superior diagnostician.

Thursday, July 19, 2007

Breaking Bad Habits

This is a response I wrote to a comment from a post in June on the Effects of Lifestyle. As comments from older posts are not as accessible, I thought I'd re-post it here. It was essentially a question on how to motivate oneself to make change in one's life:

Your question is significant and, of course, hard to answer. I can only discuss what motivates me and how I approach this subject, understanding that there are many roads to travel.

My first step is to come to the conclusion that I am not as healthy as I'd like to be. If you believe that you are healthy and feel great and can't benefit from changing your habits, then it is hard to make the change.

Secondly, you need to be confident that what you have learned about healthy living and eating, etc. can make the improvements you are seeking.

You see, it's not about sacrifices. We are not looking to deprive ourselves. We are looking to nourish ourselves. The difference is huge. One needs a shift in perspective. People think, oh, the ice cream tastes good, it makes me feel good, etc. and not having it feels like deprivation. A different perspective would suggest, what is the long-term (or even short-term, not immediate) effect of what I am doing? Knowledge would tell us that the ice cream which is filled with refined sugar, chemicals, empty calories, etc. is restricting our circulation in the stomach and intestines, draining out our adrenals, creating a mucus lining in out gut that prevents assimilation of vitamins and nutrients necessary for our well-being, etc. When I think of it that way, I don't feel deprived. I feel empowered.

Understanding the tremendous difference between pleasure and happiness is crucial. Yeah, ice cream tastes good to many, but it also leads to suffering/illness/imbalance in the future. Is it worth it?

These are the kinds of questions to ask oneself to help motivate change. But, yes, you are right. Change isn't easy. It's really difficult. And the best way to do it is to make small changes daily and commit to the process for one's own sake.

I hope this helps. Maybe it's too vague? Let me know. I'd love to continue the discussion.


Monday, July 16, 2007

The Disease as Part of the Treatment

Often in medicine, the tendency is to view illness as antagonistic. But, like everything else, a simple shift in perspective can point one in a whole new direction. If one thinks of their illness as part of themselves rather than something separate, one can view their illness as a way of getting to know oneself better. The Type A personality who has a heart attack may have an opportunity to slow down and "smell the roses;" the father who suddenly loses his job gets to spend time with his children; the cancer patient who comes to terms with her mortality and can fully appreciate the time that she has left, are just a few examples. I have had patients who later became very thankful for their illnesses and the lessons that they learned from them.

Illnesses, symptoms, etc. are a chance for us to purify ourselves; purify our negative karma, change faulty beliefs, let go of pain, sorrow, anger, etc. that no longer serves us. We need to view our symptoms as something that is trying to teach us something. Our job is to figure it out. We can't squash it with pain medication, or antibiotics, or chemotherapy. We need to face it head-on. To be a warrior and fight through the suffering to get to the other side. Be on a quest for truth, simplicity and finding one's inner nature.

And above all, don't be afraid to change. If you see your imbalances as rooted in your thought patterns, your past actions and your behaviors, without changing one can never heal. Your symptoms are your opportunity to make the necessary changes and adjustments. Failure to adapt and change breeds illness. Awareness is the first step.

Sunday, July 8, 2007

Rangnang Ogminling Bendirya Kunphen Ling

I wanted to inform everyone of the above-referenced monastery and medical school/clinic that Rinpoche has asked me to create on His behalf. I am in the process of forming a 501(c)(3) not-for-profit corporation in this name. This is a project that I am hoping will keep Rinpoche here in NJ for a good part of each year. He has expressed to me that He would like to spend the majority of His time here, and this monastery/school/clinic is the first step in ensuring this happens. Upon Rinpoche's request, the location of the monastery will be my home and office for the time being. When Rinpoche returns from Tibet in October, He will be bringing back all the silks and throne materials to make everything formal and official!

As with all ventures of this nature, help from as many interested parties is welcomed and necessary. The areas of help include:
1. Initial Fundraising: to set this monastery up properly and professionally we need to raise approximately $1,000 for the incorporation fees, filing of 501(c)(3) status, lawyer fees, articles of incorporation and bylaw drafting.
2. Website: I have begun putting up a temporary website. The address is . I am hoping for the assistance of those of you sangha members with web design experience to create a professional website for us. Anyone who can help with this please contact me as soon as possible.
3. On-going Fundraising: to keep the business running, there are a number of on-going fees, including: (a) website maintenance, hosting, design; (b) state and federal corporation and registration fees; (c) raising monies for the eventuality of a separate location (ownership, rental, etc.); (d) funding the workshops, lectures and other Buddhist teachings that will take place at the monastery, etc.
4. Executive Board: We will need to appoint/elect an executive board, so those of you who are interested in being an on-going part of this venture, please contact me.
I am very much determined to have this completed by the time Rinpoche returns from Tibet in October. Thus, time is of the essence!

To make a donation, or to help in any way, please contact me as soon as possible.

Thank you to everyone for their anticipated support. And PLEASE pass this information on to everyone that you know who may be interested in this project and all members of the sangha (as I do not have email addresses for most of them). We will need as much support as possible.

Thursday, July 5, 2007

Recent Vaccine Study

For some reason, the debate regarding vaccines still goes on. I'll let you guess my opinions on this subject :-) As this subject is immense, as I have mentioned in the past, I choose not to post much on it due to time constraints to do it justice. However, my friend and colleague, Dr. Stickley links to a recent study on vaccines and the strong correlation with neurological diseases, ADHD and autism. You can check it out here.

State of Mind

There is no more important determinant of one's health than the state of mind. Of course, genetics, constitution, lifestyle habits, etc. have a large impact, but the power of our minds has the most pivotal of roles. In Chinese medicine we differentiate causes of disease into multiple categories: (1) internal: emotions and state of mind (including, anger, fear, grief, overthinking, etc.); (2) external: climactic factors (wind, cold, damp, heat/fire, etc.); and (3) miscellaneous (which is not meant to minimize its importance): habits, trauma, toxins, etc.

Of these three categories, the emotions make up the largest percentage of the etiology of disease. Controlling one's emotions, therefore, would seem to have a tremendous impact on our health and the prevention of disease (or treatment thereof). Listening yesterday (again) to a series of lectures that Taoist priest Jeffrey Yuen gave on cancer and Chinese medicine, I couldn't help but notice the correlation between what Jeffrey states and Dharmakirti's psychological law (see previous post). Essentially, Jeffrey was mentioning how the diagnosis of cancer is viewed as a death sentence by most of us and that it is, in fact, how one handles this diagnosis that has tremendous influence on whether or not someone will heal. So often, people get so overwhelmed by the fear of death that they are constantly focused on death. This reinforcement perpetuates negative states of mind and set a vicious cycle in which the disease grows stronger and the patient's health deteriorates (mentally and physically). Jeffrey even goes to say that cancer support groups are for the most part detrimental in that they give credence and power to this deadly disease. He advocates for support groups which foster hope and the desire to heal.

As always, our minds have the greatest power and potential to either bring us towards happiness and health or towards undesirable states of mind and illness. It all depends on how much attention we give positive thoughts and emotions or negative thoughts and states of mind. On a website I visited recently, I read the following tale:

One evening an old Martial Arts Master told his young students about a “Great Battle of life and death” that goes on inside all Human Beings.
The wise man said, "The battle is between "Two Dragons" … They are battling for dominance inside us all.
One is Dark, it represents Evil. It is anger, envy, jealousy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.
The other is Light, it represents Good. It is joy, love, peace, hope, humility, kindness, benevolence, empathy, generosity, truth, serenity, compassion and faith."
The students thought about it for a while and then asked the Master: "Which Dragon wins?"
The old wise man simply replied, "The one you feed."
Unknown Author

Battle of the Emotions

HH The Dalai Lama's book The Universe in a Single Atom: the convergence of science and spirituality has a wealth of interesting discussions on the nature of consciousness, the origin of the universe, and on scientific exploration in general into the truth of reality. A relevant passage to achieving happiness mentions Dharmakirti's "psychological law" which posits psychological states and emotions as a field of opposing forces in constant flux. One family of emotion may consist of hate, anger and hostility, while the other consists of love, compassion and empathy. The argument is that if any one side of this polarity gains strength, the other weakens. Thus, the goal is to practice and reinforce the desired states of mind, effectively weakening the undesirable and transforming one's thoughts and emotions. Just as turning on a light dispels darkness, cultivating love and compassion can eliminate hate and anger over time with dedicated practice and intention.