Today
Thirty-six lessons on tongue and pulse, in five modules. Start with today's flashcards, then read the next lesson, and practise in between in the visual trainer.
Illustrated tongues, animated pulse models and cases: practise until you no longer confuse them.
Five modules: tongue, pulse, reading together, organ by organ and going deeper
XP: 100 per lesson, 300 per exam, 5 per quiz question you get right first time, 2 per flashcard and 10 when your deck for the day is empty. Your streak counts days with activity; one rest day a week does not break it. Everything is saved in this browser. Sources: The Foundations of Chinese Medicine (3rd edition); anything outside it is labelled, and evidence has been checked in PubMed, with a DOI link.
Make it visible.
Read the theory in the lessons. Here you explore the relationships, move the models and test your pattern recognition.
Yin and Yang are a relationship.
Change the relative strength of Yin and Yang. Explore the difference between Deficiency and Excess, and between Full and Empty Heat or Cold.
The waves only visualise the principle of alternation and mutual dependence. They are not a time series of Qi, temperature or biomarkers.
Experiment
Choose a classic archetype or move both sliders.
Why does a patient with Heat signs not automatically have Yang excess? Explain the difference between Full-Heat and Empty-Heat.
Read the full lesson on the Eight Principles →The Five Elements live in a network.
Click an Element. See what generates it, what it generates, what it controls and which Element controls it.
Which relationship might an acupuncturist cite for stress, abdominal distension and alternating stools when Liver-Wood affects the Spleen-Earth system?
Read the full lesson on the Five Elements →An organ is more than an organ.
Explore the functions of the five Yin organs and their paired Yang organs. The relationships shown are traditional and functional, not an anatomical network.
Besides these five pairs, classical Zang-Fu theory also includes the Pericardium and the Triple Burner (San Jiao), among others.
Spleen-Qi deficiency is not a diagnosis of anatomical splenic insufficiency. Try to explain each organ in TCM terms, without forcing a biomedical translation.
Read the full Zang-Fu lesson →From symptom to pattern.
Reveal further findings and watch the differential diagnosis shift. The bars are teaching recognition scores, not diagnostic probabilities.
Click a hidden finding to reveal it. Click again to remove it from your reasoning.
Weighted matches between the findings shown and the patterns. Not percentages or posterior probabilities.
Findings, then Ba Gang, then Zang-Fu pattern, then treatment principle. Can you defend your pattern against a plausible second hypothesis?
Read the lesson on pattern differentiation →See the signs. Feel the nuance.
Look at traditional tongue signs and a moving, stylised pulse curve. The pulse waves are illustrations, not real measurements or reliable diagnostic simulations.
A colour, shape or pulse quality on its own does not prove a TCM pattern. The reproducibility and external validity of traditional assessment methods remain important concerns.
Tongue lesson → Pulse lesson →Follow the circulation through the 12 channels.
Move through the traditional sequence of the main channels. The circle shows connections and transitions, not an anatomically demonstrated flow of energy.
Choosing a distal point on the basis of channel theory is not the same as choosing a local point for segmental afferent stimulation. Compare the logic, not just the location.
Channels lesson → Thirty key points →What does the control group do?
Explore outcomes from studies discussed in the evidence lesson. Real figures and different outcome measures; never confuse them with a theoretical TCM mechanism.
1. Is a traditional pattern internally consistent? 2. Is an effect physiologically plausible? 3. Has clinical benefit been shown against the relevant control group?
See all studies, DOI links and methodological limitations →Five days. From foundations to sparring partner.
A concrete programme of 5 × 4 hours with links to the lessons, active recall and a view of your progress. The rest of the learning path stays available for going deeper.
How knowledge becomes usable
In every 60 minutes, spend about 40 min on the material, 15 min recalling it without peeking and 5 min on a clinical why-question. Revisit mistakes from earlier days. The blocks below are study suggestions, not a compulsory checklist. Evidence base: retrieval practice and spaced learning (Dunlosky et al.).
Go to the oral sparring simulation →Two patterns. One decisive difference.
Compare two patterns side by side. The horizontal bars are qualitative textbook associations. Look above all for features that set the patterns apart.
Differential heat map
INTERACTIVE0 = not characteristic in this simplified map, not: impossible. Overlap and combinations occur. The model does not calculate probabilities.
What makes the difference?
Try it yourself: write three questions that separate the two hypotheses before you look at the explanation.
The best differential diagnosis is not the longest list of symptoms; it is recognising distinguishing findings and a reasoned second hypothesis.
Patterns 1 to 10 → Patterns 11 to 19 →The case talks back.
Work through a consultation in four decisions: safety, distinguishing question, main pattern, treatment principle. Make your choice first; the explanation appears afterwards. There are several demonstration cases with different distractors.
Your clinical reasoning
This exercise trains internally consistent reasoning about the course material.
After each case, describe which finding would falsify your first hypothesis. That very question sharpens a conversation with an experienced acupuncturist.
Six worked cases → Exam →What exactly has been proven?
Not everything that is coherent within TCM is biologically proven; not every physiological response predicts clinical benefit. Click a claim and test theory, mechanism and effectiveness in turn.
Three layers of inquiry
The claim dissected
The pyramid visually separates three kinds of question; it is not a ranking of effect size or study quality.
Always ask about the outcome measure, the control group, clinical relevance and the specific hypothesis that was tested.
Clinical evidence → Mechanisms →Background: Vickers et al. (2018) and NCCIH: Effectiveness & Safety.
The colour of the tongue body
What colour is the tongue body, and what does it say about Qi, Blood, Yin, Yang and Heat?
After this lesson you can read the colour ladder from Pale to Blue with all the steps in between, separate the three kinds of Pale and the two kinds of Red, read colour by area and through the coating, recognise a colour that changes, say what light and camera do to colour, and name the colours that are a medical question first.
The colour ladder
The colour of the tongue body comes from the Blood flowing through it. If there is too little Blood to give colour, or too little Yang to pump it round, the tongue turns Pale. Heat makes it redder, and the deeper the Heat, the darker the red. If the Blood stagnates, it turns Purple, and with severe Cold, Blue.
Schematic; your screen differs from a real tongue, and real tongues have in-between shades. Arrangement following ch. 23 tongue, pp. 324 to 328; the interpretations are textbook.
Know by heart
- The ladder. Pale: Deficiency. Pale-Red: normal. Red: Heat. Deep-Red: Heat that sits deeper. Reddish-Purple: stasis with Heat. Bluish-Purple: stasis with Cold. Blue: severe Cold or stasis; mnemonic: too little paint is pale, fire colours red, standstill colours purple.
- Three kinds of Pale. Slightly Pale: Qi deficiency. Pale, Thin and slightly dry: Blood deficiency. Pale, wet and Swollen: Yang deficiency; mnemonic: dry lacks Blood, wet lacks fire.
- Two kinds of Red. Red with coating, especially yellow: Full-Heat. Red with little or no coating: Empty-Heat from Yin deficiency. Normal colour without coating: Yin deficiency that does not yet give Heat; mnemonic: first the moss goes, then the soil turns red.
- Deep-Red. With coating: severe Full-Heat. Without coating: severe Yin deficiency with Empty-Heat. With fever: Heat at the level of Ying and Blood.
- Colour by area. Tip redder: Heat in the Heart. Sides redder: Liver and Gall-Bladder. Sides Pale: Liver-Blood deficiency. Purple on the sides: stasis in the Liver.
- Looking at colour. Look at the edges and the tip, where the coating is thin; daylight, put out briefly; the body changes over weeks, so a change of colour within a few days is something you distrust first.
- Red flags. Blue with breathlessness: emergency services (112 in Europe, 999 in the UK, 911 in North America). Deep-Red and dry with high fever and drowsiness: a doctor straight away. Smooth, red and burning: iron, B12 and folate. Very Pale with tiredness, breathlessness or blood loss: Hb.
The rest of this lesson is reference.
Colours that are a medical question first
Before any TCM interpretation. Every colour on the ladder has a medical double. You check that first; only then do you read the colour in TCM terms. General medical knowledge.
| Colour | With | Think of | What first |
|---|---|---|---|
| Very Pale | tiredness, short of breath on exertion, palpitations, heavy periods, black stools | anaemia, blood loss | GP or primary care doctor: Hb, ferritin; black stools the same day |
| Smooth Red, papillae gone | burning feeling, tingling, vegetarian or vegan diet, stomach acid inhibitors or metformin | B12, iron or folate deficiency | GP: blood test |
| Deep-Red, dry | high fever, drowsiness, confusion, an older or vulnerable client | serious infection, dehydration | a doctor straight away |
| Bright red with coarse points | a child with fever; red eyes, red lips, fever for five days or longer | scarlet fever; Kawasaki disease | the same day |
| Blue or Bluish-Purple | blue lips, shortness of breath, chest pain | lack of oxygen | emergency services (112) |
| Bluish, for a long time | a known heart or lung disease, smoking | chronic lack of oxygen | known to the GP? Otherwise have it checked |
Not from the book; general medicine.
Colour by colour: what it looks like, what it means, what decides
A beginner recognises the colours best by a comparison. Choose a colour.
Colour through the coating. You read the colour of the muscle, not of the layer. Where the coating is thin, at the edges and the tip, the muscle shows through. If the coating is thick everywhere, look at the edges, the tip and the underside, and write "body poorly visible" in your report instead of guessing a colour.
Three kinds of Pale, and what separates them
| Qi deficiency | Blood deficiency | Yang deficiency | |
|---|---|---|---|
| Colour | slightly Pale | Pale, sometimes mainly the sides | Pale |
| Shape | normal, sometimes teeth marks | Thin | Swollen, often teeth marks |
| Moisture | normal | slightly dry | wet |
| Logic | the strength to give colour is somewhat less | too little substance: less colour and less filling | too little fire: the fluid is not transformed and stays in the tongue |
| In the history | tired, poor appetite, weak voice | dizzy on standing up, blurred vision, dry skin, scanty periods, difficulty falling asleep | chilly, cold hands and feet, watery stools or urinating at night |
| Patterns | Spleen-Qi deficiency; Lung- and Wei-Qi deficiency | Liver-Blood deficiency; Heart-Blood deficiency | Spleen-Yang deficiency; Kidney-Yang deficiency |
Textbook. Spleen-Yang and Kidney-Yang deficiency have the same tongue; where the cold sits is told by the history.
Full- and Empty-Heat, and the road between them
Red is Heat. Whether that Heat comes from an excess or from a lack of Yin is told by the coating. In Full-Heat there is a pathogen or an accumulated fire, and there is a coating, often yellow. In Empty-Heat the Yin is exhausted; the Stomach then no longer makes a coating either, and the tongue becomes bare.
- First the moss goes. In beginning Yin deficiency the coating becomes thinner, bare in places, while the body still has a normal colour.
- Then the soil turns red. If the Yin runs down further, Empty-Heat arises and the bare tongue turns Red.
- Then it turns dark and dry. In severe Yin deficiency it becomes Deep-Red, dry and sometimes cracked.
Why this distinction counts. Full-Heat calls for clearing. Empty-Heat calls for nourishing Yin; if you only cool, you use up the Yin that is already lacking. Reading Red without coating as Full-Heat is therefore one of the costliest mistakes in tongue diagnosis.
Textbook. Deep-Red with fever: the Heat has reached the level of Ying or Blood (Four Levels); that picture belongs to an acute, serious illness and so goes to the doctor first.
A different colour in one place
Often it is not the whole tongue that is different but one area. Then the colour says what is going on and the area says where. The map itself, with the variants between sources, is in lesson 7.
| Where | Colour | Interpretation (textbook) | Ask as well |
|---|---|---|---|
| Tip | redder | Heat in the Heart; stronger with red points; common with emotional strain | sleep, restlessness, palpitations, mouth ulcers; yellow coating (full) or none (empty)? |
| Tip and sides | redder, with a thin coating | Heat on the exterior: Wind-Heat | acute, sore throat, fever, aversion to wind |
| Sides | redder | Heat in Liver and Gall-Bladder; only the sides: stagnation that turns hot; whole tongue Red with yellow coating: Liver-Fire | irritable, headache at the temples, bitter taste |
| Sides | Pale | Liver-Blood deficiency | blurred vision, cramps, brittle nails, scanty periods |
| Sides | Purple | Blood stasis in the Liver | fixed, stabbing pain in the flank or lower abdomen; periods with clots |
| Centre | redder, often with a dry yellow coating | Stomach-Heat | hunger, thirst for cold drinks, heartburn, bad breath |
Textbook. In most maps the sides are Liver and Gall-Bladder over almost the whole length; some sources assign a broader strip in the middle of the sides to the Spleen (lesson 7).
A colour that changes, and what really changed
The body changes slowly, over weeks. A real change of colour therefore tells you something about the foundation. A sudden change within a few days is something you distrust first: light, time of day, drinking and putting the tongue out can do the same.
| From | To | Meaning (textbook) |
|---|---|---|
| Pale-Red | Red | Heat arises: from stagnation, from a pathogen moving inwards, or from Yin running out |
| normal, bare | Red, bare | Yin deficiency becomes Yin deficiency with Empty-Heat |
| Red | Deep-Red | the Heat moves deeper and uses up more Yin |
| Red | Reddish-Purple | Heat thickens the Blood: stasis is added |
| Pale | Pale with a purple tinge | a deficiency that no longer moves the Blood |
| Red or Pale | slowly back to Pale-Red | recovery; the foundation comes into balance |
Light and camera. Colour is the hardest thing on the whole tongue to see. Warm lamplight makes red redder, a phone camera adjusts the colours by itself, and two people see the same colour differently. So look in daylight, briefly, and above all compare a client with themselves. If you follow up with photos, compare mainly the coating and take the colour of the body with a pinch of salt; the protocol is in lesson 1.
Ch. 23 tongue, pp. 324 to 328: read which colours the book distinguishes, how it divides Pale, Red and Purple, and whether it treats Blue and Purple separately. Compare with the chooser in step 3.
Two Pale tongues, two patterns
Anna, 34. Seven months after giving birth, breastfeeding. Dizzy on standing up, blurred vision in the evening, dry skin and hair, calf cramps at night, her periods have returned but are scanty. Has difficulty falling asleep. Not chilly.
Henk, 63. Chilly for years, cold lower back and knees, tired and listless, urinates twice a night, clear urine. Appetite and stools normal.
First. Anna: anaemia after giving birth is common; Hb and ferritin, and the thyroid (it can become unbalanced after giving birth). Henk: urinating at night in a man of 63 can come from the prostate or from blood sugar; chilliness and listlessness also from an underactive thyroid. A GP. General medical knowledge.
Both Pale: both Deficiency. On colour alone they cannot be told apart.
Anna: Thin and slightly dry, too little substance to fill and colour: Blood deficiency. Henk: Swollen and wet, too little fire to transform the fluid: Yang deficiency.
Eyes, tendons (cramps), periods and dryness point to the Liver, which stores the Blood; the blood loss at the birth and the breastfeeding point to the cause. The difficulty falling asleep fits a Heart that is also getting too little Blood.
Cold in the lower back and knees and urinating at night point to the Kidneys, not to the Spleen: appetite and stools are normal.
Anna: Liver-Blood deficiency, with the Heart involved. Henk: Kidney-Yang deficiency.
Anna versus Heart-Blood deficiency alone: then palpitations, poor memory and difficulty falling asleep come first, without the eyes and cramps. Henk versus Spleen-Yang deficiency: then the cold sits in the abdomen, with watery stools.
Anna: nourish Liver-Blood. Henk: warm Kidney-Yang.
The learning point: Pale says Deficiency, but which deficiency is told by shape and moisture, and which organ by the history.
Colour plus coating: Heat, Cold, Deficiency or Excess?
Choose the colour of the body and the coating. The builder gives the reading in the Eight Principles and the question you ask next.
Eight tongues: which colour, and what does it say?
For each tongue, first name the colour with a word from the ladder, then what the coating and the moisture add, and only then the interpretation. Then choose A to H to compare your reading.
Practise further in the visual trainer: Read the tongue.
Interpreting colour
Flashcards
Where it goes wrong
- Reading Red without coating as Full-Heat. Then you cool a Yin that is already lacking.
- Reading Pale as one thing. You separate Qi, Blood and Yang by shape and moisture, not by the shade.
- Reading the colour of the coating. A yellow coating on a Pale tongue does not make the tongue Red. Read the muscle at the edges.
- Mixing up Deep-Red and Reddish-Purple. Look for the blue glow: that makes it purple, and so stasis.
- Believing a fast change of colour. The body changes over weeks; check the circumstances first.
- Always reading Purple as stasis. Cold at that very moment, smoking and lack of oxygen add colour too.
- Colour without the history. Pale in Anna and in Henk: the same colour, two patterns.
Colour as a measurement, as a hypothesis
Pale and the Hb grade B
In 390 patients a very Pale tongue was the best clinical sign of severe anaemia (likelihood ratio 9.9 at Hb below 7 g/dl), but agreement between two assessors was low (Kalantri 2010). On standardised photos of 533 women, tongue and face were measurably less red in anaemia (Fu 2025, cross-sectional). B for the link with the Hb; that Pale equals Blood deficiency is C. Testable via Hb, ferritin and MCV alongside a blinded judgement of paleness.
Red and blood flow grade B
In 1,711 participants the tongue became clearly redder in warm, humid months in people with diabetes, high blood pressure and heart disease, while the tongue colour of people without diabetes stayed stable all year (Zhang 2026, cross-sectional; abstract). Hypothesis: redness partly reflects blood flow and the response of the small vessels to warmth. B for the link, C for "Red is Heat". Testable via tongue colour alongside skin temperature, blood pressure and inflammatory markers, in the same people in summer and winter.
Purple and stasis grade B
In 38 Kampo patients a dark edge and tip and a bluish edge and back of the tongue were associated with wider veins under the tongue; together they distinguished blood stasis better than each on its own (Morita 2022, cross-sectional; abstract). B for the link between purple and the veins; what "stasis" is in physiology remains an open question (C). Testable via tongue colour and vein width alongside clotting values, viscosity or microcirculation.
Proposals, not equations. For all studies only the abstract was read. Something to think about: which colour of the ladder would you set against a blood value first, and which blood value?
Discussion questions
Discuss them with your study group, your teacher or an experienced acupuncturist.
- Where do you draw the line between Pale-Red and Red, and between Red and Deep-Red? Do you have a comparison for it that a colleague uses too?
- A Red tongue with a thin white coating: how do you decide whether the Heat is full or empty, and which questions help?
- In your experience, how long does it take for a Pale tongue to become Pale-Red again, and what changes earlier?
Prof Hu Chinese Medicine: 190. UJ online lectures:29 Diagnostics Tongue Diagnosis Tongue Colours (27 min)
Giovanni Maciocia: Reading the Purple Tongue: Blood Stasis Diagnosis (14 min)
AcuPro Academy: Tongue Diagnosis in Chinese Medicine (10 min)
Prof Hu follows the standard Chinese textbook line; Maciocia presents the line of the book.
Finish the lesson
Work through the practice questions until you get them all right first time, then mark the lesson as done below; your flashcards then go into your review deck. If you have the book, read the required pages shown in the book box at the top.
Feeling the pulse: position, depth and technique
Where do you place your fingers, how deep do you press, and what does a healthy pulse feel like?
After this lesson you can explain why the pulse is taken at the wrist, you find the three positions and adapt your grip to the arm, you know the two common maps of the organs, you work with three levels and three movements to a fixed protocol, you recognise the features of a healthy pulse and the variants of the vessel, and you know which findings go to a doctor first.
Where, how deep, and what is healthy
Three questions for every pulse, in this order: where are your fingers, at which depth do you feel what, and how does that compare with a healthy pulse?
Pulse report
| Depth | at all three levels, fullest in the middle |
|---|---|
| Rate | about 70 per minute (normal) |
| Rhythm | regular |
| Width | normal |
| Length | across the three positions |
| Strength | pushes back calmly |
| Smoothness | supple and even |
| Tension | supple |
Know by heart
- Why the wrist. At the cun kou, the Lung channel at the wrist, all the vessels meet (Nan Jing 1), and there the Stomach-Qi that nourishes all the organs shows itself (Su Wen 11); mnemonic: one artery, the whole body.
- The grip. Middle finger first on guan, next to the protruding bone on the thumb side; index finger on cun, towards the hand; ring finger on chi. Fingertips in one line, feeling with the pad; further apart on a long arm; mnemonic: middle on the bone, the rest follows.
- Three positions. Cun: above the diaphragm. Guan: diaphragm to navel. Chi: navel to feet (Nan Jing 18). In every map left Heart, Liver, Kidney and right Lungs, Spleen, Kidney (Ming Men); the Fu shift from map to map.
- Three levels, five depths. Light, medium, deep; in beans 3 Lungs, 6 Heart, 9 Spleen, 12 Liver, to the bone Kidneys (Nan Jing 5). You find the deep level by pressing until the pulse disappears and releasing until it just comes back.
- Three movements. Lifting (ju), searching (xun), pressing (an); first three fingers together (zong an), then each separately (dan an); on each side at least fifty beats or one minute; mnemonic: lift, search, press; together, apart; fifty.
- The healthy pulse. Shen: supple, with strength, regular. Stomach-Qi: calm and even, 4 to 5 beats per breath of your own, about 60 to 90 per minute. Root: felt at chi on deep pressure.
- Red flags. Pulse weaker or absent on one side: blood pressure on both arms, with a difference of 10 mmHg or more to a GP or primary care doctor. Cold, pale, painful or numb hand without a pulse: emergency services (112 in Europe, 999 in the UK, 911 in North America). Irregularly irregular: ECG. Rapid at rest with chest pain, breathlessness or fainting: emergency services (112).
The rest of this lesson is reference.
Feeling is learnt in real life. You practise the looking and feeling itself with people, under a teacher's guidance; this lesson trains the reading and the reasoning. A teacher can put their fingers next to yours on the same pulse and say what you are feeling; no text or drawing can do that. Count on years, not weeks.
What your fingers find that is not a pulse picture
Red flags first. Your fingers lie on an artery. What you sometimes find there belongs with a doctor, not in a pulse report. General medical knowledge, before any TCM interpretation.
| What you feel and see | Could also be | What first |
|---|---|---|
| No pulse, with a cold, pale, painful or numb hand or arm | acute blockage of an artery | emergency services (112) |
| The pulse is clearly weaker on one side | narrowing of an artery to the arm, vascular disease | blood pressure on both arms, simultaneously or straight after each other; a difference of 10 mmHg or more: GP |
| No pulse at the usual place, everything else normal | an artery that runs differently (step 7) | search around it; if in doubt, blood pressure on both arms |
| Irregularly irregular | atrial fibrillation | ECG via a GP; with symptoms the same day |
| Rapid at rest, with chest pain, breathlessness, fainting or confusion | arrhythmia, heart attack | emergency services (112) |
| Barely palpable in a client who is ill, clammy or confused | shock, severe infection | emergency services (112) |
| Strikingly slow or fast, and the client takes medication | beta blocker, thyroid medication, inhaler | note it; then do not read the rate as Cold or Heat |
Not from the book; general medicine. The figures on the difference between the arms are in step 12.
From nine measuring points to one artery
The oldest texts feel in more places: the Su Wen describes nine measuring points spread over the head, arms and legs. The Nan Jing chooses one place, the cun kou ("the mouth of an inch"), and explains why that is enough.
Classical references as paraphrase, not quotation. The nine measuring points: Su Wen 20.
Ten steps, the same every time
- Rest. First sit for five minutes; after cycling, coffee or rushing, the pulse is faster and fuller. Classically: early in the morning, before eating (Su Wen 17); otherwise note the time.
- Posture. Arm relaxed at heart height, palm up; nothing constricting.
- Your own breath. Breathe calmly: in the tradition your breathing is the clock (Su Wen 18). Count with a watch as well.
- Middle finger first. On the artery next to the protruding bone on the thumb side: guan.
- Index and ring finger. Index finger on cun, at the wrist crease; ring finger on chi, towards the elbow.
- Adapt to the arm. Long arm: further apart; short arm: closer together; young child: one finger rolling over the positions.
- The fingers themselves. Slightly bent, tips in one line, feeling with the pad. Not with the thumb: it has a strong pulse of its own.
- Equal pressure. All three equally firm. Some sources have the middle finger press a fraction more lightly: otherwise the bone under guan makes that position seem stronger.
- Together, then apart. First three fingers at once at three levels, then position by position (step 6). Fifty beats or one minute on each side, so that you do not miss a dropped beat (Ling Shu 5).
- Both sides, then record. Compare left with right; first write down features, only then a name (lesson 2).
Textbook. How the book describes the method: ch. 25 pp. 374 to 380.
Six positions, two maps
The Zang lie in the same place in every map. If you think in channels, you put the Intestines with their partner (Heart and Lungs, at cun); if you think in body space, you put them in the lower abdomen (at chi).
| Position | Map A: Intestines with their channel | Map B: Intestines in the lower abdomen |
|---|---|---|
| left cun | Heart, Small Intestine | Heart (and the centre of the chest) |
| left guan | Liver, Gall-Bladder | Liver, Gall-Bladder |
| left chi | Kidney, Bladder | Kidney, Bladder, one of the Intestines |
| right cun | Lungs, Large Intestine | Lungs (and the chest) |
| right guan | Spleen, Stomach | Spleen, Stomach |
| right chi | Kidney, Ming Men | Kidney (Yang), Ming Men, the other Intestine |
Map A follows the Mai Jing (3rd century), with right chi as Ming Men after Nan Jing 36. Map B is the common line in herbal medicine and later textbooks; which intestine lies on the left and which on the right at chi differs between sources. Which map the book uses: ch. 25 pp. 374 to 380.
Light, medium, deep: how to find them
The Nan Jing knows five layers, each with the tissue of an organ: 3 beans skin and Lungs, 6 vessels and Heart, 9 flesh and Spleen, 12 tendons and Liver, to the bone the Kidneys (Nan Jing 5). In practice you work with three.
| Level | Reading 1 (textbook) | Reading 2 (textbook) |
|---|---|---|
| light | Qi and Yang; the Fu | the exterior: a pathogen from outside |
| medium | Blood | Stomach and Spleen: the Stomach-Qi |
| deep | Yin; the Zang, especially Liver and Kidneys | the interior: the organs, the root |
Together and apart. Zong an: three fingers at once, for the whole. Dan an: one finger per position, the others slightly lifted. Do not read the levels mechanically as "Fu on top, Zang deep": they help you see a shift between exterior and interior.
Nan Jing 4 and 5; the two readings and the techniques are textbook, following the Chinese standard textbooks and English-language textbook traditions.
Shen, Stomach-Qi, root, and a vessel that runs differently
You read every deviation against a healthy pulse, with three features that overlap.
Pulse report
| Depth | at all three levels, fullest in the middle |
|---|---|
| Rate | about 70 per minute (normal) |
| Rhythm | regular |
| Width | normal |
| Length | across the three positions |
| Strength | pushes back calmly |
| Smoothness | supple and even |
| Tension | supple |
Pulse report
| Depth | with light pressure, disappears with deep pressure |
|---|---|
| Rate | about 70 per minute (normal) |
| Rhythm | regular |
| Width | wide |
| Length | across the three positions |
| Strength | weak, gives way under pressure |
| Smoothness | soft, without shape |
| Tension | slack, without tension |
The rate of a healthy pulse
Four to five beats per breath of a calm practitioner (Su Wen 18); at 15 to 18 breaths per minute that is roughly 60 to 90 per minute. Textbooks give narrower figures (the Chinese standard textbook about 72 to 80); treat the number as a direction, not a limit. So count by the clock as well (lesson 2). Children are faster; a trained endurance athlete may be under 60 without Cold.
A vessel that runs differently
Fan guan mai (反关脉). The artery runs on the back of the wrist. At the usual place you feel nothing; on the back a clear pulse. A normal variant, not a deficiency.
Xie fei mai (斜飞脉). The artery runs off at a slant from chi towards the back of the hand. Cun and guan seem empty while nothing is missing. Follow the vessel.
Textbook. What changes a normal pulse (season, age, training, meals, pregnancy): lesson 8 of this module.
Ch. 25 pp. 374 to 380: read how the book divides the positions and which map it uses, how it describes the levels and the method, and what it understands by a normal pulse. Note where the book differs from steps 4 to 7.
A pulse missing on the right
Case. Woman, 46, tired for months, dizzy when standing up quickly, blurred vision in the evening, cramps in the calves, scanty periods. On the left you feel a calm, regular pulse of 72 per minute, thin but clear. On the right you feel nothing at the usual place.
Pulse report
| Depth | at all three levels, fullest in the middle |
|---|---|
| Rate | about 72 per minute (normal) |
| Rhythm | regular |
| Width | thin as a thread |
| Length | across the three positions |
| Strength | pushes back calmly |
| Smoothness | supple and even |
| Tension | supple |
First. Is the right hand cold, pale, painful or numb? Then emergency services (112). If not: search for the pulse around it and measure the blood pressure on both arms. With a difference of 10 mmHg or more: a GP. Tired, dizzy and pale: Hb and ferritin.
Both hands warm and pink, no pain, no tingling. Blood pressure left 118/76, right 116/74: no meaningful difference.
On the back of the right wrist a clear pulse is beating: fan guan mai, an artery that runs differently. So the right side is not empty; you just cannot compare the right positions in the usual way here. Note that.
Rate, rhythm and width of the whole, and the left pulse: calm, regular, thin. Thin points to too little Blood or Yin.
Pale, Thin, the sides palest, slightly dry: Blood deficiency, with the Liver in the picture.
Blurred vision, cramps, scanty periods, Pale Thin tongue, thin pulse: Liver-Blood deficiency. Neighbour: Heart-Blood deficiency (then palpitations and trouble falling asleep come to the fore).
Nourish Liver-Blood, once Hb and ferritin are known.
A missing pulse is first a vascular question, then an anatomical question, and only after that perhaps a TCM finding.
Four times six positions
Which position deviates, which body region and which organ go with it, and which pattern would you test? Then choose A to D to compare your reading.
Practise further in the visual trainer: Read the pulse.
Position, depth and technique
Flashcards
Where it goes wrong
- Pressing hard straight away. Then the light level is gone before you have felt it. Always lift first.
- Feeling only lightly. You can only read a pulse that is strong on top once you also know the depth: that is where the difference lies between an Exterior pattern and Yin that cannot hold the Yang.
- Fingers at a fixed distance. The positions scale with the arm.
- The middle finger too heavy. Guan then feels stronger than it is.
- Feeling too briefly. In ten beats you miss a pause; feel fifty beats or one minute.
- No pulse means deficiency. First the vessels (cold hand, blood pressure on both arms), then the anatomy (fan guan mai, xie fei mai), only then the TCM.
- The positions as anatomy. Left guan is not the liver under your finger, and where the Intestines lie differs from map to map.
- Forgetting context. Cycling, coffee, a meal, medication: note them, and feel again after rest.
Feeling the pulse, as a hypothesis
Left and right differ grade B
In sixteen studies, 3.6 per cent of the general adult population had a difference in systolic pressure of 10 mmHg or more between the arms, 7.4 per cent of people with diabetes and 11.2 per cent of people with high blood pressure; measuring one arm after the other instead of simultaneously overestimated the difference about threefold (Clark 2016, meta-analysis). In 24 cohorts with 53,827 participants, every 5 mmHg of difference was associated with slightly higher mortality (hazard ratio 1.05); 10 mmHg was proposed as the upper limit of normal (Clark 2021, individual participant data meta-analysis). Abstracts read. A clearly weaker pulse on one side is therefore a vascular finding first; "right side empty" as a TCM interpretation remains grade C. Testable via the pulse judgement per side alongside blood pressure on both arms.
The positions differ measurably grade B
In 148 healthy adults, felt with a fixed procedure and concrete definitions, cun, guan and chi differed in some of the features; the pulse could be felt beyond chi in 90 per cent of the men and 56 per cent of the women, and there was little support for fixed differences between left and right by sex (King 2002; abstract). Hypothesis: part of the difference between the positions is anatomy (the bone under guan, softer tissue under chi). Whether the positions show organs has never been tested (C). Testable via ultrasound of the artery at the three positions alongside a blind judgement per position.
Why fifty beats grade B
In a meta-analysis of 21 studies, pulse palpation detected atrial fibrillation with a sensitivity of 92 and a specificity of 82 per cent against an ECG; an automatic blood pressure monitor scored 98 and 92 per cent (Taggar 2016; abstract). Finding an irregular rhythm is therefore the best-supported part of feeling the pulse, and for that you need to feel for long enough. Testable: count the dropped beats per minute, and refer.
Proposals, not equations. For all studies only the abstract was read. To think about: which part of what you feel is the artery and the tissue around it, and which part could be the state of an organ?
Discussion questions
Discuss them with your study group, your teacher or an experienced acupuncturist.
- How do you let a beginner feel the difference between the middle and the deep level, on one and the same pulse?
- Which map of the positions do you use, and how do you deal with the Intestines?
- When do you measure the blood pressure on both arms before you compare left and right?
Mary TCMTutor, pulse course: Where to Take the Pulse? Beyond the Cunkou (22 min); Finger Position, Timing, and Breath (19 min); Stomach Qi, Shen, and Kidney Qi in a Normal Pulse (8 min); Factors Influencing the Normal Pulse (14 min)
Prof Hu, Chinese standard textbook tradition: UJ online lectures 37, Pulse Diagnosis 1, General Introduction 1 (32 min)
Finish the lesson
Work through the practice questions until you get them all right first time, then mark the lesson as done below; your flashcards then go into your review deck. If you have the book, read the required pages shown in the book box at the top.