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Pulse is the spirit of blood and qi, and a mirror for distinguishing pathogenic factors from healthy factors. Whatever exists internally must manifest externally; therefore, when blood and qi are abundant, the pulse will be vigorous, and when blood and qi are deficient, the pulse will be weak.

In the absence of disease, the pulse is normal; in the presence of disease, the pulse is abnormal.

Diseases in humans do not exceed the six categories: exterior (Biao), interior (Li), deficiency (Xu), excess (Shi), cold (Han), and heat (Re). Among these, only "deficiency" and "excess" are sufficient to encompass all pathological conditions. Since exterior, interior, cold, and heat syndromes all contain variations of deficiency and excess, once one understands the exterior-interior and cold-heat distinctions, and can resolve them using the concepts of deficiency and excess, then thousands of clinical presentations can be understood as a unified whole.

The methods for treating diseases do not exceed attacking (Gong) and tonifying (Bu). The choice between attacking and tonifying depends entirely on determining deficiency or excess. To observe deficiency and excess, nothing is more direct than examining the pulse. Although floating and deep pulses indicate different diseases, a single pulse type can accompany multiple diseases, and a single disease can present with various pulse types. Moreover, within all pulse types, there are variations of deficiency and excess. When a condition is critical, the key lies in accurately distinguishing deficiency from excess. If deficiency and excess are identified correctly, there will be no error regarding the root and branch, or yin and yang. If the pulse is ambiguous, one must combine it with symptoms to determine which is primary and which is secondary, which is slow and which is urgent. Understanding the root and branch, and the sequence of treatment, represents the utmost subtlety of diagnostic skill.

Floating pulse (Fu Mai): It feels abundant upon light palpation (lifting) but insufficient upon heavy pressure (pressing). Pulses such as surging (Hong), large (Da), knotted/empty (Kou), and drum-taut (Ge) belong to the yang category. They indicate deficiency of middle qi and insufficiency of true yin. Symptoms include wind-stroke or summerheat injury, presenting as exterior heat; abdominal distension and anorexia; or panting and urgency. A floating-large pulse indicates heat injury; floating-tight indicates cold damage; floating-slippery indicates retained food; floating-slow indicates wind or dampness; floating-empty indicates blood loss; floating-rapid indicates wind-heat; and floating-surging indicates mania and restlessness. Although these distinctions exist, treatment depends entirely on appropriate methods, and one must not adhere rigidly to a single pattern. Although floating pulses generally indicate exterior conditions, there are cases of genuine external contraction of wind-cold where the pulse does not float. If the pulse is tight and rapid with a slight floating quality, it indicates exterior pathogenic factors, accompanied by fever, absence of sweating, and body ache. If the pulse is floating and slow, it is mostly not due to exterior pathogens. Generally, a floating pulse that is forceful and spirited indicates excess yang; excess yang leads to fire, resulting in phlegm in the middle jiao or qi stagnation in the upper jiao, which can be inferred analogously. A floating pulse that is forceless and hollow indicates yin insufficiency; yin insufficiency leads to kidney water deficiency, blood failing to nourish the heart, or essence failing to transform into qi, indicating middle qi deficiency. Mistaking this for an exterior syndrome causes great harm. If the pulse is extremely floating, large, wiry, and hard, exceeding four times the normal rate, it is called Guan Ge (Gate and Grid). This is not a sign of vitality but rather extreme depletion of true yin with unrooted hyperactive yang, a dire omen. For any pulse appearing in a specific location, one should examine the corresponding symptoms based on that location. This applies to all pulse types.

Deep pulse (Chen Mai): It is not felt with light touch but requires heavy pressure. It belongs to yin. Pulses such as fine (Xi), small (Xiao), hidden (Yin Fu), and reversed guan (Fan Guan) belong to this category. It indicates stagnation of yang qi, leading to qi stagnation, cold syndromes, or fluid retention. Symptoms include fluid retention, mass formations (Zheng Jia), abdominal fullness and solidity, cold limbs, and profuse diarrhea. A deep-fine pulse indicates shortness of breath, cold-fluid retention, cold stomach, pain in the waist and legs, and accumulations. Deep-slow pulse indicates chronic cold and cold essence. Deep-slippery pulse indicates retained food and hidden phlegm. Deep-hidden pulse indicates cholera-like disorder and chest/abdominal pain. Deep-rapid pulse indicates internal heat. Deep-wiry and deep-tight pulses indicate chest and abdominal pain. Although deep pulses belong to the interior, one must assess whether they are forceful or forceless to distinguish deficiency from excess. Deep and forceful pulses often indicate qi stagnation, hence the saying, "If the pulse is deep upon initial palpation, know it is qi." For qi stagnation and accumulation, resolving or purging methods are suitable. Deep and deficient pulses result from yang failing to penetrate or qi failing to diffuse. For yang deficiency with qi sinking, warming and tonifying methods are indicated.

In cases of external cold contraction where yang is obscured by yin cold, the pulse may appear deep, tight, and rapid, accompanied by headache and fever. These still belong to exterior pathogens and should not be mistaken for interior conditions solely because the pulse is deep.

Slow pulse (Chi Mai): Fewer than four beats per respiration, belonging to yin. Pulse types such as intermittent (Dai), slow (Huan), knotted (Jie), and choppy (Se) are similar. It indicates excessive yin and deficient yang, manifesting as cold or deficiency syndromes. Floating and slow indicates internal qi deficiency; deep and slow indicates exterior qi deficiency. Slow pulse in the upper body indicates failure of qi to transform essence; slow pulse in the lower body indicates failure of essence to transform into qi. Cold qi fails to circulate; cold blood becomes stagnant. If slow pulse is combined with slippery and large qualities, it often indicates wind-phlegm and stubborn bi-syndrome; if combined with fine and small qualities, it indicates loss of true yang. If yin-cold accumulates in the middle, it causes diarrhea or pain; if yuan qi fails to nourish the exterior, it causes chills and spasms. Generally, slow pulses are due to insufficiency of yuan qi, and aggressive attacking methods should not be used recklessly.

Rapid pulse (Shu Mai) has both yin and yang aspects, though modern practice often associates rapidity with heat. Detailed examination of the *Neijing* states: "Urgent pulses often indicate cold; slow pulses often indicate heat." Slippery pulses indicate abundant yang qi with slight heat. Coarse-large pulses indicate yin insufficiency and yang excess, leading to internal heat. Slow and slippery pulses also indicate internal heat. The *Nanjing* states: "Rapid indicates heat, slow indicates cold," a view widely accepted today. However, my experience shows that in cases of internal heat and latent fire, the pulse is often not rapid, but rather surging, slippery, and forceful, as described in the classics. There are approximately seven scenarios for distinguishing rapid pulses: First, in external cold contraction, the pulse suddenly becomes tight and rapid. Initially, there is no heat, so warming and dispersing methods are appropriate. Only if the pulse is rapid, large, slippery, and solid, indicating excessive yang, can it be considered heat. If the pulse is rapid but forceless, it remains a yin syndrome, requiring warming of the center, not heat-clearing. Second, deficiency syndromes exhibit this pulse. Yang deficiency results in a rapid but forceless pulse, or one that is fine and small, with deficiency-cold signs. Warming is urgently needed, let alone clearing heat. Yin deficiency rapid pulses are typically rapid, wiry, and slippery. Even with irritability and heat signs, cold-cooling herbs must be used cautiously. Purely clearing fire damages the spleen. Patients with deficiency syndromes almost always have rapid pulses; among rapid pulse diseases, deficiency is most common. The more deficient, the more rapid; the more rapid, the more critical. Mistaking deficiency-rapid for heat-rapid leads to death. Third, malaria presents with this pulse. During attacks, the pulse is tight and rapid; during remission, it is harmonious and slow. Does fire arise only during attacks? Fire syndromes do not stop and start; only cold pathogens advance and retreat. Not all rapid pulses in malaria indicate heat. Fourth, dysentery presents with this pulse. Dysentery often arises from internal injury of cold and heat, damaging spleen and kidney, causing rapid pulses. If combined with wiry, choppy, fine, or weak qualities, it is deficiency-rapid, not heat-rapid. Warming and tonifying the Mingmen gate is effective. In robust patients with obvious heat signs, a surging, slippery, solid, and rapid pulse justifies clearing heat. Fifth, abscesses and ulcers present with this pulse. Rapid pulse without fever but with aversion to cold, or with normal appetite, or fever unrelieved by sweating, indicates abscesses. Ulcers can be yin or yang, treatable by attacking or tonifying; rapidity alone does not confirm heat. Sixth, tetanus/spasms present with this pulse due to undischarged toxic pathogens; once discharged, the pulse is no longer rapid. Differentiate yin and yang by deficiency/excess and size; do not assume rapidity equals heat. Seventh, masses and accumulations present with this pulse due to stagnation. If stagnation turns into malnutrition with bad breath and gum issues, clear stomach fire. Without heat signs, a fine-rapid pulse is not heat. Eighth, pregnancy presents with this pulse due to obstruction of Chong and Ren vessels, not fire. Differentiate cold and heat by strength; do not assume Huangqin (Scutellariae Radix) is the universal remedy. Regarding the above, excess pathogens often cause rapid pulses, and severe deficiency especially so. Whether it is truly heat or not can be inferred analogously.

Surging pulse (Hong Mai) is yang. It feels abundant upon both light and heavy palpation, large and solid. It indicates burning of blood and qi inside and out, a major heat syndrome. It may cause obstruction of urination and defecation, bleeding, headache, facial heat, mania, thirst, dry throat, sore throat, abscesses, or rashes. This indicates excess yang and deficient yin, excess qi and deficient blood. If surging and large exceeds four times the normal rate, it indicates separation of yin and yang.

Fine pulse (Wei Mai) is threadlike, lacking spirit, and extremely soft, termed a yin pulse. Fine, small, deficient, and soggy pulses belong to this category. It indicates dual deficiency of yin and yang, manifesting as fear of cold, dread, cold invasion, shortness of breath, abdominal fullness, indigestion, vomiting, hiccups, diarrhea, waist/abdominal pain, dizziness, and cold limbs. All result from loss of yuan yang, injury to essence, and blood loss.

Slippery pulse (Hua Mai) flows smoothly, like pearls rolling on a plate. Surging, large, empty, and drum-taut pulses are related. It indicates heat and qi congestion in blood, manifesting as food stagnation, rebellious phlegm, fullness, and vomiting. Large and slippery-rapid pulses indicate internal heat: upper heat affects head, eyes, throat, heart, and lungs; lower heat affects small intestine and excretions. In women, a slippery-rapid pulse with amenorrhea indicates pregnancy. In healthy individuals, a slippery and harmonious pulse indicates abundant Ying and Wei qi, a good sign. Overusing cold-cooling herbs creates pathogenic heat. Deficiency syndromes often show wiry-slippery pulses due to yin deficiency; dysentery often shows wiry-slippery pulses due to spleen-kidney injury; neither should be treated merely as fire.

Choppy pulse (Se Mai) is yin. It moves with difficulty, like rain soaking sand or a knife scraping bamboo. Deficient, fine, minute, slow, knotted, and hurried pulses are similar. It indicates dual deficiency of qi and blood, manifesting as spleen cold with poor appetite, stomach cold with frequent vomiting, irregular bowel/bladder function, cold limbs, bi-pain, spasms, numbness, worry, anhidrosis, blood loss, male essence injury, female infertility, and irregular menstruation. Choppy pulses often result from emotional stagnation damaging Ying and Wei, leaving blood unable to nourish and qi unable to flow freely. Upper jiao discomfort, lower jiao stagnation, exterior muscle/bone fatigue, and interior spirit depletion all belong to yang deficiency. Some claim qi is abundant while blood is scarce, but how can qi be abundant if the pulse is obstructed?

Wiry pulse (Xian Mai) feels abundant upon pressure, like a drawn bowstring, resembling hardness and tension. It is a sign of yin hidden within yang. It indicates disharmony of qi and blood, rebellious qi, pathogenic dominance, strong liver and weak spleen, deficiency consumption with alternating cold and heat, malaria, dysentery, bi-syndrome, hernia, chest/hypochondriac pain, phlegm-fluids, retained food, accumulations, distension, and spasms. If surging and wiry pulse interact, with exterior tightness and interior heat, carbuncles may develop. Wiry pulse transforms via wood energy, connecting to the liver; it can be yin or yang. Wiry-large with slippery indicates yang pathogen; wiry-tight with fine indicates yin pathogen. When organs receive Stomach qi, the five zang organs remain peaceful; invaded by Liver pathogen, all five zang organs become diseased. Wood grows from water and is nurtured by earth. If wood qi is too strong, water is depleted by the mother, and earth is damaged by being overcome. Kidney is the root of essence and blood; Stomach is the sea of water and grain. Damage to the root destroys vital qi. Thus, wood qi should not be excessive. Harmonious and slow pulses are auspicious; wiry and strong pulses are ominous; extreme wiriness leads to earth failure.

Empty pulse (Kou Mai) is floating, large, and hollow in the center, feeling like a green onion stalk upon pressure. Floating, hollow, deficient, and scattered pulses are similar. It indicates isolated yang and detached yin, manifesting as yin-deficiency fever, blood loss, dizziness, palpitations, panting, night sweats, qi having no home, and blood having no attachment. Although Kou is a yang pulse, its excess lacks root, signaling severe deficiency.

Tight pulse (Jin Mai) is rapid, forceful, hard, and resistant to finger pressure, resembling twisted rope. Wiry and rapid pulses are similar. It indicates excess yin and deficient yang. It is a sign of yin pathogen striking, indicating pain and cold. Tight-rapid on the exterior indicates cold damage with fever, headache, stiff neck, body pain, cough, nasal congestion, bi-syndrome, or malaria. Tight-deep on the interior indicates chest/hypochondriac pain, abdominal distension/pain, cold invasion with reversal cold, vomiting/diarrhea, yin hernia, accumulations, wind-epilepsy, or opisthotonos. In women, it indicates rebellious qi and menstrual stagnation; in children, it indicates convulsions.

Slow pulse (Huan Mai) has three types: Harmonious and moderate, felt equally in floating and deep positions, is the normal pulse of a healthy person. Slow with slippery and large qualities indicates excess heat, as stated in the *Neijing*. Slow with slow and fine qualities indicates deficiency cold, as stated by other authors. Excess heat presents as slow, large, and forceful, with irritability, bad breath, distension, abscesses, or difficult urination/defecation, often seen after recovery from cold damage or warm malaria with lingering heat. Deficiency cold presents as slow, late, and fine, with yang deficiency, fear of cold, timid qi, dizziness, bi-weakness, atrophy, cold limbs, palpitations, delirium, indigestion, incomplete digestion diarrhea, pain, cold essence/kidney, and frequent urination. In women, it indicates delayed menstruation, scant blood, or bleeding. For rashes, stroke, or postpartum conditions, the appearance of a slow pulse indicates easy recovery.

Knotted pulse (Jie Mai) stops suddenly and resumes. Historically, a rapid pulse with a pause was called Hurried (Cu), indicating heat and extreme yang; a slow pulse with a pause was called Knotted (Jie), indicating cold and extreme yin. Both are attributed to qi-blood-phlegm-food stagnation or emotional constraint. Floating knotted indicates exterior cold; deep knotted indicates internal accumulation. My experience suggests Cu resembles rapid pulses but is not necessarily heat-related; Jie resembles slow pulses but is not necessarily cold-related. Any pulse with pauses is a Knotted pulse. It often results from gradual decline of qi and blood, or exhaustion of vitality, causing intermittent stopping and starting. It is common in chronic illness, deficiency consumption, or after misuse of attacking/draining methods. Slow with knotted indicates yang deficiency; rapid with knotted indicates yin deficiency. Slow is manageable; rapid is severe. The severity of the knot reflects the rise and fall of yuan qi. For stagnation and constraint diseases, this pulse indicates deficiency, but only if the patient is strong and the pulse is forceful upon palpation. Some healthy people have a lifelong knotted pulse due to constitutional differences. If a long-standing illness gradually develops a knotted pulse, it indicates qi-blood depletion, requiring immediate tonification of the root.

Hidden pulse (Fu Mai) is barely perceptible, felt only against the bone. It indicates hidden yin and yang, blockage, and closure. It can be caused by fire closure, cold closure, or qi closure. Symptoms include extreme pain, cholera, hernia, epilepsy, constipation, rebellious qi, food stagnation, anger, cold limbs, and edema. Although Hidden pulse resembles deep, minute, fine, or collapsed pulses, it differs. Hidden pulse appears as if present yet absent due to temporary concealment. It occurs in severe chest/abdominal pain, qi rebellion blocking meridians, or sudden qi collapse preventing continuity. It is seen in acute severe disorders; regulating qi restores the pulse. In chronic wasting diseases, the pulse becomes minute and gradually hidden, signaling the end of life ("a dying furnace"), not true hiding.

Deficient pulse (Xu Mai) is forceless and lacks spirit, indicating righteous qi deficiency. Floating and forceless indicates blood deficiency; deep and forceless indicates qi deficiency; rapid and forceless indicates yin deficiency; slow and forceless indicates yang deficiency. Not only minute, soggy, fine, weak, slow, and choppy pulses are deficient; any pulse lacking spirit under the fingers is deficient. The classic states, "Pressing without resistance applies to all yang [deficiencies]," meaning this. Thus, surging-large without spirit indicates yin deficiency; fine-small without spirit indicates yang deficiency. Yin deficiency implies depletion of metal and water, allowing dragon-fire to flare, causing disorders of fluids and spirit, such as night sweats, spermatorrhea, bleeding, palpitations, panting, or consumptive fever. Yang deficiency injures fire and earth, daily depleting true qi, causing disorders of emperor-minister sources, such as dizziness, vomiting, yang collapse, chest blockage, distension, diarrhea/pain. To save yin, strengthen the source of water; to save yang, benefit the source of fire. Gradual growth brings life; gradual decline brings death. This is the critical juncture of life and death.

Excess pulse (Shi Mai) is strong upon both light and heavy palpation, beating vigorously, indicating pathogenic excess. Wiry, surging, tight, and slippery pulses are similar. It indicates congestion of the three jiao. Exterior excess is floating, large, and forceful, due to external contraction of wind, cold, summerheat, or dampness. Interior excess is deep, solid, and forceful, due to internal injury from diet or emotions. Fire excess is surging, slippery, and forceful. Cold excess is deep, wiry, and forceful, causing various painful stagnations. For qi or blood conditions with combined pulses, analyze by category. Excess pulses have true and false forms. True ones are easy to identify; false ones are hard to distinguish. One must inquire about the cause and examine symptoms carefully to grasp the spirit of the pulse, avoiding error.