A bowstring pulse. The pulse is hard and forceful and gives the sensation of pressing on the string of a bent bow. It may be normal or it may be seen in diseases where there is hyperactivity of the yang of the gan-liver.

A gliding pulse: This is round and forceful, like beads rolling on a plate. It is often seen in cases of indigestion or obstruction of phlegm. Sometimes a gliding pulse may be seen in a healthy person, especially in pregnancy.

An intermittent pulse. The pulse is irregular. This occurs in retardation of qi and stagnation of blood, causing a deficiency of qi in the xin-heart, such as atrial fibrillation.

Palpation for all other pathology, such as mass or trauma, follows the same rules as in Western medicine.

VIII. The Differentiation Of Syndromes
The Chinese described symptom pictures which allow the differentiation of specific Zang Fu syndromes. The major syndromes are described below and provide further useful information which will enable the acupuncturist to reach a clear Zang Fu diagnosis.

Syndromes of the Xin-heart

1. Weakness of the qi of the xin-heart
Clinical Manifestations: Palpitations, dyspnoea aggravated by exertion, a pale tongue and a thready xu or irregular pulse. If there is evidence of a deficiency of the yang of the xin-heart then cold limbs, pallor, and purplish lips can be found. Exhaustion of the yang of the xin-heart may manifest itself as profuse sweating, mental confusion and a fading, thready pulse.

Aetiology and pathology: This syndrome is usually caused by general malaise after anxiety or a long illness, which injures the qi of the xin-heart. When the qi of the xin-heart is weak it fails to pump blood normally resulting in palpitations, dyspnoea and a thready irregular or xu pulse. Alternatively, a prolonged weakness of the qi of the xin-heart may lead to weakness of the yang of the xin-heart. When the body lacks yang it lacks energy and heat, therefore symptoms such as chills, cold limbs and pallor occur. If the yang of the xin-heart is exhausted, the defensive qi of the body surface can no longer protect the essential qi and lets it dissipate, this results in profuse sweating and a fading, thready pulse.

2. Insufficiency of the yin of the xin-heart

Clinical Manifestations: Palpitations, insomnia, dream disturbed sleep, anxiety and possible malar flush with a low grade fever. A red tongue proper and a thready and rapid pulse will also be found.

Aetiology and pathology: This syndrome is usually due to damage of the yin by a febrile disease or anxiety, which consumes the yin of the xin-heart. Insufficiency of the yin of the xin-heart often leads to hyperactivity of the fibber of the xin-heart, resulting in the above symptoms. Insufficiency of the yin of the xin-heart may also cause insufficiency of the blood of the xin-heart. If this happens then there is not enough yin and blood to nourish the xin-heart, and the xin-heart fails in its function of keeping the mind. The symptoms of insomnia, poor memory and dream-disturbed sleep will therefore appear.

3. Stagnation of the blood of the heart

Clinical Manifestations: Palpitations, cardiac retardation and pain (paroxysms of pricking pain, or in more severe cases colicky pain often referred to the shoulders and the back), peripheral and central cyanosis and a thready or irregular pulse.

Aetiology and pathology: This syndrome is due to anxiety leading to stagnation of qi and stagnation of blood. It may also be due to insufficiency of the qi of the xin-heart after a chronic illness; if the qi of the xin-heart is too weak to sustain the cardiac circulation then stagnation of blood of the xin-heart and obstruction of the blood vessels results. Stagnation of the blood often impedes the distribution of yang qi in the chest causing discomfort in the chest (angina) and peripheral cyanosis. A dark purplish tongue proper, or purple spots on the tongue, and a thready or irregular pulse are manifestations of stagnation of blood and confinement of the yang qi.

4. Hyperactivity of the fire of the xin-heart
Clinical Manifestations: Ulceration, swelling and pain in the mouth and tongue, insomnia accompanied by fever, a flushed face, a bitter taste in the mouth, hot, dark and yellow urine, a red tongue proper and a rapid pulse.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The depressed qi may turn into endogenous fire and disturb the mind, causing the symptoms of insomnia and fever to appear. As the xin-heart has the tongue as its orifice, and its function is reflected in the face, a disorder of the fire of the xin-heart may cause many of the above symptoms.

5. Derangement of the mind

Clinical Manifestations: Depression, dullness, muttering to oneself, anxiety, incoherent speech, mania and in severe cases coma.

Aetiology and pathology: This syndrome is often due to mental irritation which causes depression of qi. The body fluid stagnates to form damp and/or phlegm which causes blurring of the xin-heart and mind, resulting in dullness and depression. If the depressed qi turns into fire and the phlegm and fire disturb the xin-heart, anxiety, incoherent speech and mania result. Blurring of the mind by phlegm and/or damp, or phlegm and/or fire causes coma. A high fever, coma and delirium resulting from invasion of the pericardium by heat, are due to pathogenic heat invading deep into the interior of the body and disturbing the mind.

Syndromes of the Gan-liver

1. Depression of the qi of the gan-liver
Clinical manifestations: Hypochondrial and lower-abdominal pain and distension, a distended sensation in the breasts, discomfort in the chest and belching, sighing, or a sensation of a foreign body in the throat. Women may experience irregular periods.

Aetiology and pathology: This syndrome is usually due to mental irritation causing depression of the qi of the gan-liver and stagnation of the qi in the liver channel. This leads to hypochondrial and lower abdominal pain and distension, a distended sensation in the breasts and discomfort in the chest. Stagnation of the qi of the gan-liver may affect the stomach, causing failure of the qi of the stomach to descend and resulting in belching. The sensation of a foreign body in the throat is due to stagnation of the qi of the liver channel, which with the phlegm forms a lump in the throat. Depression of the qi of the gan-liver and the subsequent lack of freeing may further impair the gan-liver's function of blood storage. Stagnation of qi leads to stagnation of blood, the cause of irregular periods.

2. Flare-up of the fire of the gan-liver
Clinical manifestations: Dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth, a flushed face, irritability and sometimes haematemesis and epistaxis can occur. The tongue proper is red with a yellow coating and the pulse is wiry and rapid.

Aetiology and pathology: This syndrome is often due to a longstanding depression of the qi of the gan-liver which can turn into fire. It may also be due to over-indulgence in alcohol and tobacco causing an accumulation of heat which turns into fire. The upward disturbance of the fire of the gan-liver causes dizziness, a distended sensation in the head, headache, red eyes, a bitter taste in the mouth and a flushed face. Fire injures the gan-liver, causing impairment of its function in promoting the free flow of qi and this causes irritability. When the fire of the gan-liver injures the blood vessels it causes extravasation of blood and haematemesis and epistaxis can occur.

3. Stagnation of cold in the liver channel
Clinical manifestations: Lower-abdominal pain, swelling and distension in the testis with tenesmus. The scrotum may be cold and contracted and these symptoms can be alleviated by warmth. The tongue proper is pale with a white coating and the pulse deep and wiry or slow.

Aetiology and pathology: The liver channel curves around the external genitalia and passes through the lower abdomen. When cold, which is characterized by contraction and stagnation, stays in the liver channel, stagnation of the qi and blood may occur and cause lower-abdominal pain, swelling and distension of the testis with tenemus. Cold and contraction of the scrotum are also due to the pathogen cold.

4. Insufficiency of the blood of the gan-liver

Clinical manifestations: Dizziness, blurred vision, dry eyes, pallor, spasm of the tendons and muscles, numb limbs and a scanty light coloured menstrual flow with a prolonged cycle.

Aetiology and pathology: This syndrome often occurs after a hemorrhage or another chronic disease in which blood is destroyed, and the reserves of the gan-liver are depleted, thereby resulting in a failure of the gan-liver to nourish the channels. A xu (deficiency) of blood may cause endogenous wind so that the symptoms of muscle spasticity and numb limbs appear. An upward disturbance of endogenous wind (xu type) can cause dizziness and blurred vision. Insufficiency of the blood of the gan-liver and disruption of its blood storage function results in emptiness of the chong channel which will cause menstrual abnormalities.

5. Stirring of the wind of the gan-liver by heat
Clinical manifestations: High fever, convulsions, neck rigidity (Opisthotonos) and coma. A deep-red tongue proper and a wiry, rapid pulse are also found.

Aetiology and pathology: This syndrome is due to transmission of the pathogen heat from the exterior to the interior, which burns the yin of the gan-liver and deprives the tendons and blood vessels of nourishment. Furthermore, pathogenic heat in the interior stirs up endogenous wind causing fever, convulsions and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.

Syndromes of the Pi-spleen

1. Weakness of the qi of the pi-spleen
Clinical manifestations: Sallow complexion, anorexia, loose stools, oedema, and lassitude. There may be distension and a bearing-down sensation in the abdomen, a prolapse of the rectum and/or uterus, or a chronic blood disorder such as purpura, bloody stools or uterine bleeding. A pale tongue proper and a thready xu pulse will be found on examination. If there is evidence of xu (deficiency) of the yang of the pi-spleen, symptoms of cold such as cold limbs will occur.

Aetiology and pathology: This syndrome is often caused by irregular food intake, excessive mental strain or chronic disease. These problems result in weakness of the qi of the pi-spleen and impair its function of transportation and transformation, which consequently results in a poor appetite and loose stools. Accumulation of fluid in the interior is the cause of the oedema. The general malaise is due to a lack of food failing to provide a nourishing basis for blood formation. When the qi of the pi-spleen is weak, it loses its ability to uplift tissues so that there is distension, a bearing-down sensation in the abdomen and a prolapse of the rectum and/or uterus. Weakness of the qi of the pi-spleen also causes the blood disorders. Xu (deficiency) of the yen of the pi-spleen causes cold limbs.

2. Invasion of the pi-spleen by cold and damp
Clinical manifestations: Fullness and distension in the chest and epigastrium, a poor appetite, a heavy feeling in the head, malaise, borborygmii, abdominal pain and loose stools. A white sticky tongue coating and a thready pulse will be found.