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[Observation of Tongue]

A moldy, sauce-colored tongue coating indicates cold damage complicated by food retention. This is caused by food stagnating in the Taiyin Spleen meridian, obstructing and depressing the Middle Jiao, preventing Qi from dispersing and venting. Over time, it ferments into a sauce-colored coating. If the symptoms manifest as abdominal fullness and intermittent pain, Guizhi Tang (Cinnamon Twig Decoction) with Zhishi (Immature Bitter Orange), Houpo (Magnolia Bark), Chenpi (Tangerine Peel), and Banxia (Pinellia Rhizome) should be used. If caused by consuming cold food, Paojiang (Prepared Ginger) should be added; if the pain is severe, Dahuang (Rhubarb Root) should be added. (Original note: Moldy yellow tongue coating is due to damp-heat stagnation in the Middle Jiao).

A blue tongue coating represents the pure color of the Liver organ. After the disease has been treated with sweating or purging methods, Stomach Qi is extremely damaged, Heart Fire loses its foundation, and Spleen Earth loses its support. Consequently, Lung Metal cannot be generated, Liver Wood loses its restraint, and rebels against Spleen Earth. Thus, the tongue coating becomes indigo-blue, which is an incurable condition. If only faint blue streaks are visible and not deep, it indicates Wood injured by Metal, and the Zang Qi is not yet exhausted. If the pulse is not deep and choppy but slightly wiry, Xiaochaihu Tang (Minor Bupleurum Decoction) with Huangqin (Scutellaria Root) removed, and Paojiang (Prepared Ginger) and Rougui (Cinnamon Bark) added, is the primary treatment.

[Observation of Eyes]

Eyes that prefer to be open indicate a Yang syndrome. Eyes that prefer to be closed indicate a Yin syndrome. Gradual swelling of the eyelids indicates water retention. Grayish discoloration under the eyes indicates cold fluid retention. Eye pain belongs to the Yangming exterior syndrome. Red eyes indicate excessive heat in the meridians. A dull gaze without spirit indicates Yangming fu-organ excess syndrome. Eyes lacking luster indicate inherent deficiency of Kidney Qi. Dazed eyes, dry nose, and rinsing the mouth with water without swallowing indicate excessive Yang heat about to cause epistaxis. Yellow eyes, head sweating, and aversion to eating indicate dampness about to transform into jaundice. Any condition involving dim vision, upward deviation of the eyes, retraction of the eyes, fixed staring, or "daiyan" (eyes fixed upward) is difficult to treat.

[Observation of Nose]

A bluish nose tip with cold pain in the abdomen (original note: Wood overcoming Earth) indicates death. A slightly black nose tip indicates water qi; white indicates blood loss; red indicates wind pathogen; yellow indicates cold in the chest and diaphragm, failure to transform grain Qi, and phlegm accumulation; dry and black indicates consumptive disease. Clear nasal discharge indicates cold damage. Nasal congestion with dry heaving indicates wind injury. Dry nostrils with a floating and rapid pulse indicate impending epistaxis. Heavy snoring and difficulty speaking indicate wind-warmth. Flaring nostrils indicate lung wind. A nose resembling soot indicates Yang toxicity.

[Observation of Lips]

Red and parched lips indicate spleen heat. Red and swollen lips indicate stomach heat. Blue-black lips indicate Yin cold. Pale white lips indicate Qi deficiency. Sores on the lips and mouth indicate Huhuo disease (aphthous stomatitis/complex ulcer). Dry cracks on the upper lip indicate heat in the muscles. Blackened lips and teeth require urgent purgation. If the corners of the mouth turn blue, the area around the mouth turns dark, the mouth opens like a fish's, breath does not return, lips tremble continuously, and the philtrum flattens, these are all signs of death.

[Auscultation and Olfaction of Voice]

A voice clear and unchanged from normal indicates easy recovery despite illness. A heavy voice with nasal congestion indicates wind injury. A voice sounding as if from a jar indicates dampness in the middle. Sluggish and hesitant speech indicates wind-phlegm. Repeating words at the end of a sentence indicates shortness of Qi. Cursing without avoiding relatives indicates mental confusion and mania. Lazy and timid speech, starting light and becoming heavy, indicates internal injury to Middle Qi. Loud and fierce speech, starting heavy and becoming light, indicates exuberant external pathogenic factors. Frowning and groaning during diagnosis indicates painful headache; groaning inability to walk or rise indicates waist and foot pain; shouting while pressing the heart region indicates epigastric pain; sighing during diagnosis indicates Qi stagnation; twisting and groaning indicates abdominal pain; emaciation with hoarseness in incurable tuberculosis indicates lung flower sores in the throat; sudden aphonia is caused by latent wind-phlegm and fire, or violent shouting in anger; sitting with shortness of breath indicates phlegm-fire disease; chronic shortness of breath is a critical sign. Mutters alone without responding to questions indicates Spirit injury. New onset hiccups indicate either fire or cold; chronic hiccups indicate impending exhaustion of Stomach Qi. (Original note: If a patient speaks silently but likes to startle with a shout, the disease is in the joints; if the voice is low and unclear, the disease is in the heart and diaphragm; if the voice is fine and long, the disease is in the head.)

[Inquiry into Symptoms]

First, ask when the illness began. Second, ask about aversion to cold and fever. Third, ask about headache and body/lower back pain. Fourth, ask about dietary indiscretion. Fifth, ask about cold or warmth of the four limbs. Sixth, ask about vomiting, regurgitation, and thirst. Seventh, ask about chest tightness or abdominal pain. Eighth, ask about the patency or obstruction of urination and defecation. Ninth, ask about taste preferences. Tenth, ask about emotional states such as anger, joy, labor, depression, and worry. For female patients, inquire further regarding the menstrual cycle. If the patient answers lazily or merely nods, it indicates deafness or deficiency-cold weakness.

Pulse Principles from *Suwen* and *Lingshu*

In one expiration, the pulse beats twice; in one inspiration, it also beats twice. Between breaths (fixed息), the pulse beats five times, plus occasional deep sighs (Tai Xi), called a healthy person (Ping Ren) (Original note: Exhalation involves Heart and Lung Qi moving out; inhalation involves Liver and Kidney Qi moving in. In one expiration, pulse moves 3 cun; in one inspiration, pulse moves 3 cun. Total 13,500 breaths per day and night). One beat per expiration and one per inspiration is called Shao Qi (deficient Qi) (Original note: *Mai Jue* considers this a failing pulse; *Nan Jing* calls it Li Lei Pulse). Three beats per expiration and three per inspiration is called Zao (restless) (Original note: Indicates a rapid pulse state). Heat in the Chi (cubital fossa) area indicates Warm Disease (Yuan note: Chi is Yin, Cun is Yang; both hot). No heat in Chi, slippery pulse indicates Wind Disease; choppy pulse indicates Bi Syndrome (Yuan note: Slippery indicates Yang excess; choppy indicates blood deficiency). More than four beats per expiration (Yuan note: *Mai Jue* calls this Tuo Pulse; *Nan Jing* calls it Duo Jing Pulse), pulse stopping intermittently, irregular rhythm, or lack of Stomach Qi (Yuan note: lacking harmonious and moderate quality) all indicate death.

Spring pulse resembles a string (Xian). Spring corresponds to Liver, East, Wood, and the beginning of growth. The Qi comes soft and slippery. Straight and long is Xian. Soft and string-like, like the tip of a long pole held up, is Normal Liver Pulse. Firm and string-like, like feeling a long pole, is Liver Disease. Hard and tense, like a newly strung bow, is Dead Liver Pulse (Yuan note: Dead liver pulse is weak on superficial palpation, feels like a cord on deep pressure without returning, or curved like a snake, indicating death).

Summer pulse resembles a hook (Gou). Summer corresponds to Heart, South, Fire, and peak growth. The Qi comes strong and departs weak, called Gou. Beads strung together is Normal Heart Pulse. Rapid and connected with slight curvature is Heart Disease. Curved front and stationary back, like holding a belt hook, is Dead Heart Pulse (Yuan note: True heart pulse is hard and rolling. Like feeling Coix seeds, indicates death. Dead heart pulse is solid on superficial palpation, like hemp seeds, more restless on deep pressure, indicating death).

Autumn pulse resembles floating (Fu). Autumn corresponds to Lung, West, Metal, and harvest. The Qi comes urgent and scatters, light and void, called Fu. Floating and slow, like falling elm seeds, is Normal Lung Pulse. Floating and choppy, like feeling chicken feathers, is Lung Disease. Floating and empty, like wind blowing hair, is Dead Lung Pulse (Yuan note: Dead lung pulse is empty on superficial palpation, weak like a green onion leaf on deep pressure, without root, indicating death).

Winter pulse resembles Ying (camp/deep). Winter corresponds to Kidney, North, Water, and storage. The Qi comes deep and firm, called Ying. Bead-like and firm on pressure is Normal Kidney Pulse. Coming like pulling vines, harder on pressure, is Kidney Disease. Emerging like a tug-of-war, snapping like stones, is Dead Kidney Pulse (Yuan note: Dead kidney pulse is hard on superficial palpation, chaotic like rolling pills on deep pressure, descending into Chi, indicating death).

Spleen pulse is Earth, the solitary organ irrigating the four directions. Harmonious and soft, like a chicken treading ground, is Normal Spleen Pulse. Solid and full-rapid, like a chicken lifting its foot, is Spleen Disease. Like a bird's beak, like a leaking roof, like flowing water, is Dead Spleen Pulse (Yuan note: Dead spleen pulse is large and hard on superficial palpation, like an inverted cup, clean and shaking on deep pressure, indicating death). All five Zang organs derive Qi from the Stomach. Zang Qi cannot reach the Hand-Taiyin Lung meridian alone; it must rely on Stomach Qi to reach the Hand-Taiyin and circulate through the meridians. Therefore, the pulse is rooted in Stomach Qi (Yuan note: Harmonious and moderate pulse indicates presence of Stomach Qi).

If the pulse follows Yin-Yang principles, the disease is easily cured; if it opposes them, it is difficult to cure (Yuan note: Yang disease with Yang pulse is favorable; Yin disease with Yin pulse is favorable. Yang disease with Yin pulse, or Yin disease with Yang pulse, is unfavorable). Floating and large pulses in Spring/Summer, or deep and choppy pulses in Autumn/Winter are normal variations. However, getting Autumn pulse in Spring, Winter pulse in Summer, Summer pulse in Autumn, or Long Summer pulse in Winter is called opposing the Four Seasons, and the disease is difficult to cure. Wind-heat with a quiet pulse, diarrhea/blood loss with a solid pulse (disease in interior), or empty pulse (disease in exterior), and choppy/firm pulses are all difficult to treat. Absence of deep pulse in Spring, wiry in Summer, choppy in Winter, or rapid in Autumn is called Si Sai (Four Obstructions) (Yuan note: Although the ruling Qi is prosperous, the Mother Qi is exhausted).

Jing Mai (Meridians) are inside (Yuan note: Inside the straight meridians); branches going horizontally are Luo Mai (Collaterals); distinct branches of Luo are Sun Mai (Sun Collaterals). The emptiness or fullness of Luo and Jing cannot be seen directly but is known via Qikou (Cunkou/Radial Artery) (Yuan note: Qikou, also known as Cunkou, is the great convergence of all pulses).

Food enters the Stomach, its essence overflows and travels up to the Spleen. Spleen Qi scatters the essence, sending it up to the Lung. Lung governs all vessels, distributing essence to skin and hair, regulating water passages, and transmitting downwards to the Bladder.

Pulse is the residence of Blood. Long pulse indicates regulated Qi; short indicates diseased Qi; rapid indicates vexation in Heart; large indicates progression of disease. Upper excess (Yuan note: Cun position) indicates high Qi; lower excess (Yuan note: Chi position) indicates abdominal distension. Dai (moderation/interruption) pulse indicates Qi decline; thin pulse indicates Qi scarcity; choppy pulse indicates Heart pain (Yuan note: Blood deficiency). Pulse coming like a spring gushing and leaving like a broken string are both untreatable (Yuan note: Urgent right Qikou, large and rapid pulse, heat surging from middle/lower, causing Yong Hernia. Yue Ren).

Excess of pathogenic Qi constitutes Excess syndrome; depletion of essential Qi constitutes Deficiency syndrome. Heat in Qi with full pulse is Heavy Excess; slippery is favorable, choppy is unfavorable. Empty Cun and Chi pulses constitute Heavy Deficiency; slippery indicates survival, choppy indicates death. Intestinal dysentery with bloody stool: fever indicates death, cold indicates survival; dysentery with mucus: deep pulse indicates survival, floating indicates death (Yuan note: Dysentery contraindicates fever and floating pulse); dysentery with pus and blood: hanging-abrupt pulse indicates death, slippery-large indicates survival. Epilepsy pulse: large and slippery will self-heal; small and firm is untreatable. Chronic Xiao Dao disease: large and solid pulse is treatable; hanging-small and firm is untreatable.

Deep and firm pulse indicates disease in the interior; floating and vigorous pulse indicates disease in the exterior. Small, weak, and choppy indicates chronic disease; floating, slippery, and rapid indicates new disease. Urgent pulse indicates Shan Jia (hernia/mass). Lower abdominal pain: slippery indicates Wind, choppy indicates Bi; slow and slippery indicates Heat in Middle, vigorous and tight indicates distension. Pulse circulates fifty times a day and night (Yuan note: Twenty-five cycles in Yang during day, twenty-five in Yin during night) to nourish Zang essence. Fifty beats without interruption means all five Zang receive Qi; one interruption in forty beats means one Zang lacks Qi; one in thirty means two Zang lack Qi; one in twenty means three Zang lack Qi; one in ten means four Zang lack Qi; less than ten beats before interruption means five Zang lack Qi, predicting imminent death.

Abdominal distension with fever and large pulse; borborygmus, fullness, cold limbs, diarrhea with large pulse; unceasing epistaxis with large pulse; coughing with hematuria, emaciation, small and firm pulse; coughing with fever, emaciation, small and rapid pulse—all are adverse pulses, death within fifteen days. Abdominal distension, cold extremities, emaciation, severe diarrhea is First Adverse; abdominal distension, bloody stool, large pulse with intermittence is Second Adverse; coughing with hematuria, flesh wasting, pulsating third is Third Adverse; vomiting blood, chest fullness radiating to back, small and rapid pulse is Fourth Adverse; coughing/vomiting, abdominal distension, undigested stool, absent pulse is Fifth Adverse. Such cases result in death.

Heat disease with quiet pulse; sweating followed by rapid/restless pulse; diarrhea with洪大 (large/surging) pulse; Bi syndrome with muscle erosion and fever with absent pulse; pathogenic invasion causing emaciation, white complexion, fever, bleeding; cold-heat alternating with emaciation and firm/pulsating pulse—all are adverse pulses.

Internal heat with pulse failing to surge indicates Yang excess repelling Yin to the exterior; internal cold with pulse surging excessively indicates Yin excess repelling Yang to the exterior. This is called pulse-symptom contradiction (Yuan note: Large and solid pulse, difficult arrival, indicates Jueyin movement, hernia Qi in Bladder, lower abdominal swelling. Yue Ren).

[Diagnosis Methods]

Diagnosis is best performed at dawn, before eating, when Qi and Blood are undisturbed. Observation has order, starting with Yin-Yang. Origin has meridians, arising from Five Elements. Growth has measure, suitable for Four Seasons. Holding pulse requires the Way, with emptiness and tranquility as guarantee. Spring pulse floats like a fish in waves; Summer pulse is at the skin, abundant like all things; Autumn pulse descends to the skin, like insects preparing to hibernate; Winter pulse is in the bone, like insects fully concealed. Outer Chi observes Kidney; Inner Chi observes Abdomen (Yuan note: Left Chi governs Small Intestine, Bladder, anterior yin; Right Chi governs Large Intestine, posterior yin. Yu Jiayan says: Small Intestine at Left Chi, Large Intestine and Bladder at Right Chi); Left Guan observes Liver/Diaphragm; Right Guan observes Spleen/Stomach; Left Cun observes Heart/Shanzhong; Right Cun observes Lung/Chest (Yuan note: Cun governs Upper Jiao, observing throat; Guan governs Middle Jiao, observing diaphragm; Chi governs Lower Jiao, observing abdomen).

Floating palpation revealing deep pulse indicates accumulation in Heart/Abdomen; Deep palpation revealing floating pulse indicates fever in body (Yuan note: Deep large/firm, floating large/tight indicates disease in Kidney). Upper excess, lower absence (Yang rising not descending) causes cold waist/feet; Lower excess, upper absence (Yang descending not ascending) causes head/neck pain. Pressing to bone with weak Qi indicates waist/spine pain and Bi syndrome.

Pulse has three positions (Yuan note: Cun, Guan, Chi) and nine inspections (Yuan note: Superficial, Middle, Deep). First assess body fat/thinness (Yuan note: Fat people usually have deep pulses; thin people usually have floating pulses) to adjust Qi excess/deficiency (Yuan note: Fat people: Blood excess, Qi deficiency; Thin people: Qi excess, Blood deficiency). Full form, thin pulse, shortness of breath is critical; Thin form, large pulse, chest wheezing/fullness is fatal; Form and Qi matching indicates life; Discrepancies indicate disease. Nine inspections all deep/small/wiry/absent indicate death; all vigorous/restless/rapid indicate death; irregular intervals indicate death; harmonious pulses but wasted flesh indicate death; sunken eyes indicate death (Yuan note: Choppy Kidney pulse without connection indicates amenorrhea).

Floating and slippery pulse indicates new disease. Small and choppy pulse indicates chronic disease.

Chi skin very hot, pulse vigorous/restless indicates Warm Disease; vigorous and slippery indicates disease exiting; Chi skin cold, pulse small indicates diarrhea and deficient Qi.

*Nan Jing* Pulse Methods

Before Guan is Yang movement; floating past and straight to Fish Sea is Yi (Overflow). This is Yin invading Yang position, called Exterior Guan Interior Ge. Disease manifests as exterior heat with no sweat, interior cold with abdominal fullness and vomiting. After Guan is Yin movement; sinking past and straight into Chi is Fu (Cover). This is Yang invading Yin position, called Interior Guan Exterior Ge. Disease manifests as interior heat with constipation/urinary retention, exterior cold with cold limbs, all indicating death.

Floating, long, slippery are Yang; deep, short, choppy are Yin. Damaged/small on floating, solid/large on deep indicates Yin excess/Yang deficiency; Damaged/small on deep, solid/large on floating indicates Yang excess/Yin deficiency. (Yuan note: Generally, floating-tight is exterior pathogen; deep-solid is interior pathogen).

Zhi pulse rises from below; Sun pulse descends from above. First Sun affects skin/hair; second Sun affects blood/vessels not nourishing Zang/Fu; third Sun affects muscles wasting, food not transforming; fourth Sun affects tendons relaxing; fifth Sun affects bones atrophying. Damage to Lung: benefit Qi; Damage to Heart: regulate Ying/Wei; Damage to Spleen: regulate diet, adjust cold/warmth; Damage to Liver: soothe center; Damage to Kidney: benefit Essence.

Three beats per expiration/inspiration is new disease. Large front/small back indicates headache/dizziness; Small front/large back indicates abdominal fullness/shortness of breath.

Four beats per expiration/inspiration is severe disease. Large pulse indicates vexation/fullness; deep/small indicates abdominal pain; slippery indicates interior heat; choppy indicates interior dampness.

Five beats per expiration/inspiration indicates fatigue; fluctuating size is difficult to treat.

One beat per expiration/inspiration is called Sun. Patient can walk but should stay in bed due to Qi/Blood deficiency.

Six beats per expiration/inspiration, or one beat every two breaths, are death pulses.

Pulse present above, absent below: if patient should vomit but does not, death; Pulse absent above, present below: still has vitality.

Accumulation diseases have knotted or hidden pulses. If knotted/hidden but no accumulation, or floating/knotted but no chronic disease, or having accumulation/disease but pulse doesn't match, it is pulse-disease mismatch, difficult to treat.

Pulse in Yin position showing Yang pulse is Yang invading Yin. Even if sometimes deep/choppy/short, this is Yang hiding Yin. Pulse in Yang position showing Yin pulse is Yin invading Yang. Even if sometimes floating/slippy/long, this is Yin hiding Yang.

Extreme Yang leads to Mania; Extreme Yin leads to Depression/Epilepsy. Loss of Yang leads to seeing ghosts; Loss of Yin leads to blindness.

Disease with closed eyes aversion to light should have strong/long Liver pulse; if instead Floating/Choppy/Short Lung pulse appears, death.

Disease with open eyes, thirst, and epigastric hardness should have tight/solid/rapid pulse; if instead deep/soft/micro pulse appears, death.

Disease with vomiting blood/epistaxis should have deep/small pulse; if instead floating/large/firm pulse appears, death.

Disease with delirium and fever should have large pulse; if instead cold limbs and deep/micro pulse appear, death.

Disease with large abdomen and diarrhea should have micro/choppy pulse; if instead tight/large/slippy pulse appears, death. (Yuan note: These five cases are all pulse-symptom contradictions.)

Excerpts from *Jingui Yaolue* Pulse Methods

Floating pulse in Cun position indicates exterior disease; floating in Chi position indicates interior disease. Both floating indicates exterior-interior concurrent disease. (Yuan note: Before Guan is Yang, exterior disease governs Yang; After Guan is Yin, interior disease governs Yin.)

Wind makes pulse float; Cold makes pulse urgent (tight). Fog injures skin/collaterals; Damp flows to joints; Food injures Spleen/Stomach; Wind injures skin/hair; Heat injures blood vessels; Extreme Cold injures meridians; Extreme Heat injures collaterals.

Meridian trembling leads to Wei syndrome over time.

Pulse should assess excess and deficiency. Micro Yang pulse, wiry Yin pulse indicates Chest Bi with pain. Reason: Upper Jiao Yang deficiency allowing Yin pathogen to invade.

Duyang pulse micro-wiry indicates abdominal fullness. If not full,必有 difficulty defecating and flank pain. This is deficiency-cold rising from below, treat with warming herbs. (Yuan note: Wiry pulse here indicates cold generating internally, Yin pathogen not dispersing, Yin orifices blocked, hence difficulty defecating).

Cun pulse wiry indicates hypochondriac stiffness/pain and aversion to cold. (Yuan note: Wiry pulse here indicates cold from exterior).

Rapid and tight pulse becomes wiry. Like bowstring, immovable on pressure. Rapid-wiry pulse requires purging cold. Tight-large-slow pulse indicates epigastric hardness; Large-tight pulse indicates Yang containing Yin, can be purged. (Yuan note: Purge with warming herbs).

Patient drinking much water causes sudden asthma/fullness. Eating little, drinking much, water stops in Heart region: severe cases palpitations; mild cases shortness of breath. Double wiry pulse indicates cold, usually after harsh purgation causing interior deficiency. Single wiry pulse indicates fluid retention.

All deep pulses should be suspected of water retention. Body swelling/heaviness, bright face, water disease with emerging pulse indicates death.

Deep, small, adhering-to-bone pulse indicates accumulation.

Pulse Formula Song