The Four Ways of Diagnosis in TCM (Si Zhen)

The term Si Zhen denotes the four methods used in diagnosis and Ba Gang comprises the Eight Principles summarising the pathological condition of the patient. The Four Ways of Diagnosis are as the following:

1. Wang-zhen Diagnosis

– diagnosis obtained by merely looking at the patient. It consists of:

  • A general diagnosis (yiban wangzhen)
    • Expression of face. Agitated expression suggests hot, Yang diseases, while a depressed expression suggests internal, Yin diseases.
    • Colour and lustre of the skin. Fresh lustre suggests a new, superficial disease, dark lustre suggests old, inner disease. The red colour suggests the Fire Evil, the white colour the Cold Evil, the green colour the Wind Evil etc.
    • Constitution of the body.
  • Diagnosis of face (mianbu-wangzhen)
    • Colour of face and eyes.
    • Colour and lustre of the mouth, lips and nose.
  • Diagnosis of the four limbs (sizhi-wangzhen)
  • Diagnosis of tongue (shezhen)
    • The diagnosis of the tongue is very important. Attention must be paid to two things. 1. The nature of the tongue (shezhi) 2. The coating of the tongue (shetai).
    • The tongue can be divided in the following way: the root corresponds to the kidney, the middle to the spleen, the tip to the heart and lungs and its bilateral sides to the liver and gall-bladder. From the nature of the tongue insufficiency or excess (emptiness or fulness, xu and shi) of the Five Zang Organs may be judged, from its coating the Six Evils and the depth of their penetration can be judged.
    • If the tongue ls shrivelled and tough, it suggests excess (fullness); when it is thick and tender, it implies insufficiency (emptiness). When the tongue is dark red, it suggests an inner disease of a serious nature caused by the Fire Evil, and when it is scarlet, it suggests the accumulation of Blood.
    • The coating of the tongue may be white, yellow or grey (black).
      • White coating denotes mostly superficial diseases caused by the Cold Evil, but if the coating looks like accumulated powder and the tongue is dark red, it marks diseases caused by the Damp and Fire Evils.
      • Yellow coating manifests mostly the inner diseases, mainly those caused by the Fire Evil, but if the coating is thin and the tongue tender, it manifests the decrease of the spleen Yang.
      • Grey (black) coating is mostly found with the inner diseases. If the white coating changes into yellow, it means that the sickness gradually penetrating in to the body; if the yellow coating retreats and another thin coating appears, the disease is taking a good turn. If it changes from white into yellow and from yellow into grey and at least into black, the disease is deteriorating.
Tongue diagnostic

Tongue diagnostic. Source and more info:

2. Wén-zhen Diagnosis

– diagnosis of sound and bad smells. This method consists of:

  • Diagnosis of speech (yanyu)
    • Low voice and little talk mainly manifest the Yin diseases, while a sonorous, high or coarse voice and talkativeness belong to the Yang diseases.
  • Diagnosis of breath (huxi)
    • Forceful breath manifests the Yang diseases while the weak breath manifests the Yin diseases.
  • Diagnosis of cough (kesou)
    • Dry cough in a new disease indicates that the lungs have been injured by the Wind Evil; cough and hoarsiness in a new disease means that it is caused by the Wind and Cold Evils, but if they appear in older diseases, that means a serious stage in tuberculosis.
  • Diagnosis of bad smells (qiwei)
    • Abnormal smell corning from the mouth, sputum, sweat, urine or stool is also helpful in diagnosis. Putrid smell corning from the mouth or sputum indicates that the lungs or stomach are afflicted by the Fire Evil; sharp smell of the sweat suggests the diseases caused by the Damp and Fire Evils; sour smell coming from the urine or stool means that the intestines or bladder have been afflicted by the Fire Evil.

3. Wen-zhen Diagnosis

– diagnosis obtained by questioning the patient. The physician must become acquainted with the following things:

  • The history and duration of the disease
    • Besides the physician must know the normal construction of the patient, whether he has not any latent disease and which are the symptoms of the disease.
  • Fever
    • If at the beginning the patient shivers but does not perspire and suffers from a headache with pain in his whole body, his disease is a superficial one caused by the Wind and Cold Evils. If the fever is accompanied by perspiration, thirst, constipation and hallucination, it is an inner disease caused by the Fire Evil.
  • Perspiration
    • Diseases in which perspiration is absent, belong to the category of superficial full diseases, while those accompanied by perspiration belong to the superficial empty diseases. If in the superficial diseases perspiration appears and the temperature does not drop, it means that the Evil has already penetrated too deep.
  • Headache, pain in the body
  • Urine and stool
    • Constipation suggests a full disease caused by the Fire Evil, while diarrhoea indicates that the spleen and stomach have been afflicted by the disease caused by emptiness and Cold Evil. Incessant diarrhoea (5 times a day) suggests the insufficiency of Yang in the spleen and kidney. Yellow and red urine suggests the disease due to the fullness and the Fire Evil, while clear and long lasting urine suggests the disease due to the emptiness and the Cold Evil. Incontinence of urine with the clear urine indicates that the kidney and bladder suffer from the emptiness and are invaded by the Cold Evil.
  • Food and drink
    • A bitter taste in the mouth suggests that the liver and gall bladder suffer from the Fire Evil, while an insipid feeling in the mouth suggests that the intestines and stomach are invaded by the Damp and Cold Evils.
  • Painful spots on the chest and abdomen
    • When the patient suffering from pain refrains from touching the painful spot, it is mostly the disease due to fullness, if on the contrary he finds relief in touching the painful spot, it is the disease due to the emptiness.
  • Menstruation


Pulse diagnosis in TCM

Pulse diagnosis in Traditional Chinese Medicine. Source and more info:

4. Qie-zhen (Taking pulse) Diagnosis

– one of the most interesting features of ancient Chinese medicine is the theory of the taking of pulse. This method has been already described in NEIJING:

The way of medical treatment is to be consistent. It should be executed at dawn when the breath of Yin has not yet begun to stir and when the breath of Yang has not yet begun to diffuse; when food and drink have not yet been taken, when the twelve main vessels (jingmai) are not yet abundant and when the lo vessels are stireed up thoroughly; when vigour and energy are not yet disturbed – at the particular time one should examine what has happend to the pulse.

The pulse is the store-house of the blood. When the pulse beats are long and the strokes markedly prolonged (chang), then the constitution of the pulse is as well regulated, when the pulse beats are short and without volume (duan), then the constitution of the pulse is out of order. When the pulse is quick and contains 6 beats to one cycle of respiration (shu), then it indicates heart trouble, and when the pulse is large (da), the disease becomes grave.

The taking of pulse was considered to be an art and it takes time and patience to grasp this technique. It is taken on the right as well as on the left hand. The radial artery is divided into three parts. The starting point is just behind the radial apophysis, called Guan. In front of it in the proximal part there is a spot called Gun and in the distal part behind the apophysis is a spot called Chi. The pulses are superficial and deep. Thus counting the three superficial and the three deep pulses on both hands we get twelve pulses corresponding to the respective organs. On the basis of the examination of the pulse we can state the excess or fullness of Qi (shi) or the insufficiency or emptiness of Qi (xu) of the respective organs.

The following is the division by Li Shizhen which is still being adopted now.

Left hand:

1st position (Cun) superficial – pericardium
deep – heart
2nd position (Guan) superficial – gall bladder
deep – liver
3rd position (Chi) superficial – small intestine, bladder
deep – kidney

Right hand:

1st position (Cun) superficial – thoracic organs
deep – lungs
2nd position (Guan) superficial – stomach
deep – spleen
3rd position (Chi) 3rd position (Chi)
deep – kidney

The physician must first feel his own pulse in order to compare it with that of the patient. When the pulse is normal there should be four beats during the time when he makes one expiration and inspiration. The physician takes the pulse with his forefinger, middle finger and ring finger in such a way that first of all he puts his middle finger on the spot Guan and then the other two fingers on the spots Cun and Chi. He must exert different pressure with his fingers, a slight (fou qu), middle (zhong qu) and strong pressure (chen qu) in order to get an idea about the strength of the patient’s pulse.The pulse is individual. What for one person might be a symptom of a disease, for another person can be quite normal.

When pressing lightly the physician gets the superficial pulse, when exerting stronger pressure at a certain moment he can suddenly feel that he has found a pulse of quite different quality. It is the so called deep pulse. Felix Mann says:

It has been suggested that the pressure required for the superficial pulse diagnosis is the diastolic pressure, while that for the deep pulse diagnosis is the systolic pressure.

According to the intensity of the pulse one can recognise whether Yang or Yin is excessive or insufficient.

In ancient China the pulse diagnosis was used as a preventive medicine. Sometimes it happened that on the basis of the pulses the physician could recognise the coming disease before it broke out. The pulse, however, describes the momentary state, not the absolute one. Felix Mann introduces an example of a diabetic who after a dose of insulin had almost a normal pulse.

The normal pulse is characterised as not floating, not deep, not violent, not feeble, not rapid, not slow, regular with 4-5 beats within the time of one inspiration and one expiration. The pulse can be influenced by the climate, environment, food and mood, but the changes are of not pathological character. In spring the pulse is compared to the sensation one gets when touching the strings, in summer it is stronger; in autumn it is more superficial and in winter it is deeper. Women have a weaker and slower pulse than men, children have a faster one, the adult people have a normal, soft pulse, while the old people have a hard one; people working physically have a strong pulse while those working mentally have a weaker one. After physical exercise, wine drinking or bath the pulse becomes faster.

It is possible to take the pulse correctly only after a long practice based on a long-time comparison of the pulses of different patients.

Classical records talk about 28 different qualities of the pulse, but only 14 of the most important ones are given here.

The first eight pulses are the basic ones.

  • Floating pulse (fu mai)
    • It is already palpable when slight pressure is applied, in exerting stronger pressure it becomes deeper.
    • Main diseases: superficial diseases mainly caused by the Wind Evil. A floating and weak pulse suggests old diseases caused by emptiness.
  • Deep pulse (chen mai)
    • When pressed slightly it is unpalpable, only when exerting stronger pressure it can be felt.
    • Main diseases: inner diseases mainly caused by the Dormant Evils. Sometimes it also occurs in diseases due to the Cold Evil and emptiness.
  • Slow pulse (chi mai)
    • There are not even four beats during the time of one inspiration and expiration.
    • Main diseases: mostly diseases caused by the Cold Evil.
  • Rapid pulse (shu mai)
    • There are more than six beats during the time of one inspiration and expiration.
  • Slippery pulse (hua mai)
    • A palpable pulse, from which the physician has a sensation of smoothness and fluency. It is a pulse which need not manifest any disease. It often occurs in pregnant women and manifests abundance of Blood.
    • Main diseases: caughing up sputum, overeating.
  • Rough pulse (se mai)
    • It is the counterpart of the slippery pulse, manifesting lack of Blood, hindrance in Qi and injury of Jing.
  • Full pulse (shi mai)
    • It has large and strong beats.
    • Main diseases are those with the symptom of fullness.
  • Empty pulse (xu mai)
    • It has a weak, fine, slow pulse not easily palpable.
    • Main diseases are those with the symptom of emptiness.
  • Wiry pulse (xian mai)
    • It is a palpable pulse from which the physician gets the sensation of elasticity as when touching the strings.
    • Main diseases: liver diseases, all sorts of pains and malaria.
  • Weak pulse (ru mai)
    • It is already palpable when pressed slightly. It is very weak and the physician gets a sensation of softness as if touching cotton wool soaked with water.
    • Main diseases are those with the symptom of emptiness or caused by the Damp Evil.
  • Overflowing pulse (hong mai)
    • It is strong when pressed, when a deeper pressure is applied it becomes a slightly weaker.
    • Main diseases are caused by the excess of the Fire Evil.
  • Fine pulse (xi mai)
    • When pressed it is as fine and thin as a thread.
    • Main diseases are caused by lack of Qi and Blood.
  • Weak pulse (ruo mai)
    • When pressed it is not palpable, when a deeper pressure is applied, it is fine.
    • Main diseases are caused by lack of Qi and Blood.
  • Slowed-down pulse (huan mai)
    • It has four beats within the time of one inspiration and expiration. Mostly it is the pulse of healthy people. If associated with a disease it is caused mainly by the Cold or Damp Evils and the disease has a good prognosis.

The Use of the Pulses in Diagnosis

Various causes of the diseases bring about different pathological changes which are manifested by different pulses. Diseases caused by the Wind Evil mostly have a floating pulse, those caused by the Cold Evil have a slow pulse, those caused by the Fire Evil a rapid pulse and those caused by the Damp Evil a weak and slippery pulse, etc.

There exist certain relations between the diseases and the pulses. Thus if in the spleen disease the pulse is slippery, it means that wood is destroying earth. After a great loss of Blood the pulse should be weak, if on the contrary it is overflowing, it suggests deterioration of the disease.

It must be decided whether the disease is a genuine or a false one. If a patient has a fever, his cheeks are burning and his breathing is difficult, it should signify a disease caused by the Fire Evil, but if at the same time the pulse is deep and weak, it is actually the so called false Fire Evil.

If the patient is shivering with cold and his pulse changes from the floating into a rapid one, it means the disease is penetrating inside. In Yang diseases a Yang pulse should occur while in Yin diseases a Yin pulse should be found. If in a Yang disease a Yin pulse appears, it suggests the deterioration of the disease. If in a Yin disease a Yang pulse appears, the prognosis is mostly a good one.