PULSE QUALITIES

Chapter 50


imagePULSE QUALITIES



Chapter contents



INTRODUCTION


FEELING AND IDENTIFYING THE PULSE QUALITY


THE EIGHT BASIC PULSE QUALITIES



EMPTY-TYPE PULSES



FULL-TYPE PULSES



PULSES WITH IRREGULARITIES OF RATE OR RHYTHM



THREE NON-TRADITIONAL PULSE QUALITIES



CLASSIFICATION OF PULSE QUALITIES



TERMINOLOGY


THE PULSE POSITIONS IN DETAIL



PULSE QUALITIES INDICATING DANGEROUS CONDITIONS


THE INFLUENCE OF DRUGS ON THE PULSE



INTRODUCTION


The pulse ‘qualities’ described in Chinese books over the centuries have varied but they have been standardized today into 28 or 29 qualities. In theory, there is no special reason why we should be restricted to using only those terms; for example, there is no ‘Hard’ pulse quality, but this is a term that often comes to mind when feeling a particular pulse. However, it is important to train oneself to use the set terminology of pulse qualities in order to establish a common ground of communication among practitioners and between teachers and students; for example, a practitioner or student might describe a pulse as ‘squidgy’ in his or her own terminology (in fact, the term ‘squidgy’ describes the Soggy pulse quite well) but this would not be much use to other practitioners or students.


It cannot be stressed strongly enough that the pulse qualities, with their description and clinical significance, should be memorized. Only by memorizing the pulse qualities can students then communicate with the clinical teacher; only when both the students and the clinical teacher are clear as to what a Wiry pulse feels like and means, can they communicate with each other, and students correlate the theoretical description of a Wiry pulse with their own feeling of the pulse.



FEELING AND IDENTIFYING THE PULSE QUALITY


It should be stressed that the pulse ‘quality’ can be felt and identified only if we move the fingers constantly by ‘rolling’ them distally and proximally, ‘pushing’ them medially and laterally, and ‘pressing’ down and releasing upwards as described in the previous chapter. We cannot feel and identify the pulse quality if we keep the fingers absolutely still because the fingers need to feel, probe and explore the shape and size of the pulse and this can be done only by moving the fingers in all four directions around a given pulse position (i.e. distally, proximally, medially and laterally). For example, we can deduce that a pulse is Long or Short only if we gently roll the finger distally; we can deduce that a pulse is Slippery only if we feel ‘around’ it by moving the fingers medially and laterally; we can deduce that a pulse is Floating-Empty only if we press the fingers down and then release them to explore its depth.



Remember: the pulse qualities cannot be felt by keeping the fingers absolutely still. The fingers must feel all around the pulse position, i.e. distally, proximally, medially, laterally and at different levels.



The pulse qualities discussed are as illustrated in Table 50.1. The order in which I have arranged these 29 pulse qualities is different from that traditionally used in Chinese books. The first 8 qualities are the traditional, basic ones, that is, Floating, Deep, Slow, Rapid, Empty, Full, Slippery and Choppy. The other 21 qualities are arranged in three groups:







In addition to the above 29 traditional qualities, I shall also discuss three new qualities, mostly owed to Dr Shen’ experience: Irregular, Stagnant, and Sad.


For each pulse quality, I shall discuss the following:






I have paired the eight basic qualities (Floating/Deep, Slow/Rapid, Full/Empty and Slippery/Choppy) each with its opposite. These pulse qualities are considered to be the eight basic ones because they correspond closely to the eight principles; that is, Floating and Deep correspond to Exterior and Interior, Slow and Rapid to Cold and Heat, and Full and Empty to Excess and deficiency. The Slippery and Choppy qualities are added to this group of eight basic qualities because they are extremely common, the former indicating Phlegm or Dampness and the latter Blood deficiency. These two pulse qualities are paired also because to a certain extent they are at different ends of a scale in terms of how they feel under the finger.


Box 50.1 summarizes the eight basic pulse qualities.



BOX 50.1   THE EIGHT BASIC PULSE QUALITIES





THE EIGHT BASIC PULSE QUALITIES



Floating



Pulse description


This pulse is felt on very light pressure; in extreme cases it is felt with no pressure at all. As its name implies, it has a ‘floating’ quality and it is relatively resistant to pressure. We can think of a large plank of wood in water: we can push it down with some resistance but it comes back up. In other words, there is a difference between a pulse that is felt clearly on the surface (as it should be if Yang-Qi is normal) and a pulse that is Floating: the Floating pulse is more resistant to finger pressure than a pulse that is normal at the superficial level. Especially in summertime, it is normal for the pulse to be relatively more superficial but that does not make it a Floating pulse. Bearing in mind the three levels of the pulse as discussed in the previous chapter, the Floating pulse is felt very clearly (and somewhat excessively) on the superficial level, which corresponds to the Qi and Yang energies.


The traditional description of a Floating pulse was like ‘feathers being ruffled by the wind’. The ‘Classic of Difficulties’ in Chapter 18 says: ‘When the pulse is Floating, it is felt moving above the muscle.’1



Clinical significance


Generally speaking, the Floating pulse indicates the presence of a pathogenic factor on the Exterior of the body: it is therefore associated with exterior symptoms caused by invasion of Wind. Indeed, the presence of aversion to cold, fever (or being hot to the touch) and a Floating pulse is enough to diagnose an invasion of an external pathogenic factor. Thus the Floating pulse is one of the main clinical signs of invasion of Wind. In fact, the ‘Discussion of Cold-induced Diseases’ says: ‘A Floating pulse, stiffness and pain of the neck and aversion to cold are signs of the Greater-Yang pattern [invasion of Wind].’2


The reason that the pulse becomes floating in invasions of external pathogenic factors is that when the body is attacked by external evils the Defensive Qi is attracted to the surface of the body and the space between skin and muscles, to fight the external pathogenic factors. Thus, the increased Yang-Qi on the surface of the body is reflected in a more Yang pulse (i.e. Floating). However, if the patient has weak Defensive Qi and does not react well to the invasion of pathogenic factors, the pulse may not be Floating.


The Floating pulse is not found only in exterior conditions but also occurs in interior ones. I shall therefore discuss the clinical significance of the Floating pulse, distinguishing between exterior and interior conditions; this will be done under ‘Combinations’.


Under the following conditions, a Floating pulse is normal and does not indicate a pathology:






Box 50.2 summarizes the clinical significance of a Floating pulse.



BOX 50.2   FLOATING PULSE: SUMMARY OF CLINICAL SIGNIFICANCE





Combinations


The clinical significance of the Floating pulse combined with other pulses must be differentiated according to interior or exterior conditions.



Exterior conditions

In exterior conditions the pulse should be Floating by definition and is clearly accompanied by exterior symptoms such as an aversion to cold and the presence of fever. The Floating pulse of exterior conditions can be combined with other qualities as follows.









Interior conditions

The Floating pulse can be found in interior conditions and it is, indeed, relatively common. In interior conditions, exterior symptoms such as an aversion to cold and the presence of fever are obviously absent. Thus, if we feel a Floating pulse, we should first establish whether the patient’ condition is exterior or interior; this is easily done because an exterior condition presents with an acute onset of aversion to cold, fever, body aches, sore throat, etc. In the absence of such symptoms the condition is interior and we must therefore interpret the significance of the Floating pulse differently.


The Floating quality of the pulse in interior conditions is not as pronounced as in exterior ones; in exterior conditions the pulse is clearly floating like a piece of wood in water as described above and is rather resistant to pressure, whereas in interior conditions the Floating quality of the pulse is less pronounced and is not so resistant to pressure.



The Floating quality of the pulse in interior conditions is not as pronounced as in exterior ones.



A Floating pulse in an interior condition associated with an emptiness at the deep level of the pulse generally indicates a potentially serious problem often with severe Blood, Yin or Essence deficiency. Thus, a relatively Floating pulse that is Empty at the deep level in interior conditions may be associated with anaemia, chronic asthma, cirrhosis of the liver or cancer.


In addition, if the pulse is generally Weak and Deep but Floating in one particular position, there may be a problem (often organic rather than just energetic) with the organ corresponding to that position. For example, if the pulse is generally Weak and Deep in all positions except in the Heart position, where it is Floating, this may indicate heart disease.


The Floating pulse without strength in interior conditions may also be associated with prolapse of the stomach, in which case the pulse would also be Fine or Soggy.


Box 50.3 summarizes Western conditions that may be indicated by a Floating pulse.



BOX 50.3   WESTERN DISEASES POTENTIALLY INDICATED BY A FLOATING PULSE




If, in the absence of exterior symptoms, the pulse is Floating in all positions and, although it feels relatively hard on the superficial level, it disappears on pressure, this indicates that the person is overworking and pushing himself or herself to the limit; Dr Shen calls this condition ‘Qi wild’.


The clinical significance of the Floating pulse in interior conditions needs to be interpreted according to its combinations as follows.



Floating-Empty

This is a relatively common pulse in interior conditions and it indicates Yin deficiency. The Floating-Empty pulse is felt clearly and easily on the superficial level with very light pressure but, with a deeper pressure, the pulse feels empty. However, the Floating-Empty pulse is not as floating as the Floating pulse of exterior conditions.


The emptiness of the pulse at the deep level clearly reflects the deficiency of Yin. On the other hand, its floating quality at the superficial level reflects the rising Yang that derives from Yin deficiency. The Floating-Empty pulse reflects a relatively advanced condition of Yin deficiency when this gives rise to Floating Yang and possibly Empty-Heat. There are of course other pulse qualities that may indicate Yin deficiency such as Fine, Leather or Minute.











Deep








Slow



Pulse description


In antiquity, the pulse was defined as slow in relation to the breathing cycles of the doctor. Thus a pulse was described as slow if it beat three times or less during the time it takes the doctor to breathe in and out, and as rapid if it beat five times or more during the same time. Obviously this method relies on the doctor’ being in good health: it would not work if the doctor suffered from asthma! Although this method is not used any longer, the concentration on one’ own breathing focuses and relaxes the doctor’ mind.


In modern times, the definition of a Slow or Rapid pulse is related to the pulse rate, which must be correlated to the age of the patient as follows:




























Age Rate
0–1 120/140
1–3 110
4–10 84/90
11–15 78/80
16–35 76
36–50 72/70
50+ 68


Any pulse rate below the above values is therefore a Slow pulse. Of course these values should not be adhered to rigidly: for example, a pulse rate of 74 b.p.m. in the 16—35 years age range would be only very slightly slow and have no clinical significance.



Clinical significance


A Slow pulse almost always indicates a Cold pattern. A different interpretation of a Slow pulse is that it denotes a problem in the Yin organs, as opposed to the Rapid pulse, which indicates a problem in the Yang organs; however, this is a broad generalization and it is not that clinically relevant. The ‘Classic of Difficulties’ in Chapter 9 says, ‘Rapid pulse indicates problems in the Yang organs, the Slow pulse problems in the Yin organs’.3


The clinical significance of the Slow pulse depends on whether it is Full or Empty: a Slow and Full pulse indicates Full-Cold, whereas a Slow and Empty pulse indicates Empty-Cold deriving from Yang deficiency. A condition of Full-Cold can last only a relatively short time (a matter of weeks or months) as interior Cold will eventually injure Yang and lead to Yang deficiency and therefore Empty-Cold. For this reason, in clinical practice Empty-Cold is more common than Full-Cold because we generally see patients with chronic conditions.


If the pulse is very slow, beating only twice for each breath cycle, it is called a Harmful pulse; if it beats only once per each breath, it is called the Destroyed pulse. Both these pulses, and especially the second one, indicate extreme depletion of the Internal Organs and are always associated with serious conditions.



Common Cold conditions manifesting with a Slow pulse

Common conditions which present with a Slow pulse are Stomach-Qi deficiency, Spleen-Yang deficiency, Heart-Yang deficiency, Kidney-Yang deficiency, deficiency of Gathering Qi (Zong Qi), Lung-Yang deficiency, Cold in the Stomach, Cold in the Uterus, abdominal masses, Cold-Phlegm and Damp-Cold.


A Slow pulse in chronic conditions may also indicate a deficiency of the Original Qi (Yuan Qi).


Box 50.5 summarizes the clinical significance of a Slow pulse.



BOX 50.5   CONDITIONS COMMONLY MANIFESTING WITH A SLOW PULSE





Contradictory manifestations characterized by a Slow pulse and Heat symptoms

Very occasionally the Slow pulse occurs in combination with Heat symptoms; one of the reasons for this contradiction may be Damp-Heat as the Dampness itself may slow the pulse down.


Of course, a contradiction between a Slow pulse and Heat symptoms may simply be due to the coexistence of Cold and Heat patterns. For example, the combination of Kidney-Yang deficiency with Damp-Heat in the Bladder is relatively common. Another possible common combination is that of Kidney-Yang deficiency with Liver-Yang rising.


In menopausal women, a simultaneous deficiency of Kidney-Yin and Kidney-Yang is very common; if the Kidney-Yang deficiency is more pronounced the pulse may be Slow, but the Kidney-Yin deficiency will cause some Empty-Heat signs such as hot flushes and night sweating.


In the context of acute febrile diseases of the Warm-Disease type, the pulse can be Slow with the pattern of Damp-Heat at the Defensive-Qi level.


A Slow pulse with Heat symptoms may also indicate the condition of True Cold and False Heat, but this is quite rare. Yet another possible explanation of a Slow pulse with Heat symptoms is when the Heat is so intense that it obstructs the circulation of Qi and makes the pulse Slow; however, this is also quite rare.


Box 50.6 summarizes conditions with contradictory pulse and Heat symptoms.



BOX 50.6   SITUATIONS GIVING RISE TO CONTRADICTORY SLOW PULSE AND HEAT SYMPTOMS





The Slow pulse and jogging

Dr Shen relates a Slow pulse always to a Heart disharmony and poor circulation and, paradoxically, it is often seen in people who jog a lot: according to Dr Shen, excessive jogging (in his opinion more than 4 miles a day) leads to a dilation of the blood vessels which eventually becomes permanent and therefore slows the circulation down so that the pulse becomes Slow.


A Slow pulse is relatively common in Western patients who are joggers. Indeed, when we feel a Slow pulse, the first question we should ask is whether the patient jogs regularly. However, this is not necessarily a ‘false’ sign that should be discounted because it reflects the fact that excessive jogging injures Yang and leads to internal Cold. Therefore, although the Slow pulse should be taken into consideration, it is important also to bear in mind that it may be ‘disguising’ the presence of Heat.




Combinations















Rapid




Clinical significance


The Rapid pulse always indicates Heat, which may be Full or Empty according to whether the pulse is Full or Empty. Typical examples of a pulse that is Rapid and of the Full-type are Rapid-Wiry, indicating Liver-Fire, or Rapid-Slippery, indicating Phlegm-Fire.


Examples of a pulse that is Rapid and of the Empty-type are Rapid-Fine, indicating Yin deficiency with Empty-Heat, or Rapid and Floating-Empty, also indicating Yin deficiency with Empty-Heat. It is important to stress that, in Yin deficiency, a Rapid pulse indicates the presence of Empty-Heat rather than Yin deficiency itself; this is manifested by the pulse being either Fine or Floating-Empty. This is equivalent to the situation in tongue diagnosis when, in Yin deficiency, a Red tongue body indicates the presence of Empty-Heat rather than the presence of Yin deficiency itself, which would be manifested by the absence of coating.



Yin deficiency is indicated by a Floating-Empty pulse; it is only when it is also Rapid that Empty-Heat is indicated.



As mentioned above under the Slow pulse, the ‘Classic of Difficulties’ relates the Rapid pulse to problems of the Yang organs, and the Slow pulse to problems of the Yin organs. Of course, this is a broad generalization which suffers from exceptions (e.g. Liver-Fire may manifest with a Rapid pulse).


Common conditions which present with a Rapid pulse include Stomach-Heat, Heat in the Intestines, Lung-Heat, Liver-Fire, Heart-Fire, Yin deficiency with Empty-Heat, Phlegm-Heat, Damp-Heat and invasion of Wind-Heat. The Rapid pulse is also seen in the Lilium Syndrome described in Chapter 3 of the ‘Synopsis of Prescriptions from the Golden Cabinet’.4


Box 50.7 summarizes the common clinical manifestations of a Rapid pulse.



BOX 50.7   COMMON CONDITIONS MANIFESTING WITH A RAPID PULSE




In fevers, whether of internal or external origin, the pulse should be Rapid; if it is not, this is a serious sign.



In fevers, if the pulse is not Rapid this is a bad sign.



However, there are a few situations when a Rapid pulse does not indicate Heat because the clinical manifestations do not point to Heat. When we feel a Rapid pulse, it is important to check this against the tongue and the inside of the lower eyelids: in true conditions of Heat, the tongue will be Red and the inside of the lower eyelids will also be red.


The following are examples of situations when the Rapid pulse does not correspond to Heat.





• The pulse can become Rapid following an emotional upset, such as a shock or an outburst of anger. Thus if we see a patient whose clinical manifestations do not point to Heat and the pulse is Rapid, we should always ask whether they have had an emotional upset recently (within hours or days). The ‘Simple Questions’, in Chapter 17, says, ‘A Rapid pulse may indicate that a person has suffered a sudden fright and the pulse will revert back to normal in three to four days.’5


• The pulse can become Rapid when a person suffering from Qi and Blood deficiency works very hard, pushing himself or herself to the limit. In such a case the pulse becomes Rapid manifesting an attempt by the body’ Qi to cope with such demands: Dr J. H. F. Shen describes this situation as ‘Qi wild’ when the pulse is also Overflowing. The ‘Complete Book of Jing Yue’ confirms this by saying that one of the causes of a Rapid pulse may be exhaustion (Xu Lao).6 If the pulse is Rapid and Big but also Empty, this may indicate severe exhaustion of Essence and Blood which occur also without Empty-Heat.


• The pulse can become Rapid in advanced cases of cancer, even in the absence of a Heat pattern. In a patient suffering from cancer this is often a bad sign indicating a poor prognosis and, potentially, a rapid spread of the cancer.


• The pulse can become Rapid in extreme Qi deficiency, again reflecting an attempt by the body’ Qi to cope with its demands.


• The pulse can become Rapid in Yin Fire. The concept of Yin Fire was introduced by Li Dong Yuan in his famous ‘Discussion on Stomach and Spleen’ (Pi Wei Lun, 1249). According to Li Dong Yuan irregular diet, overwork and emotional stress weaken the Stomach and Spleen and the Original Qi (Yuan Qi). When the Original Qi declines, the Minister Fire becomes pathological and rises from the space between the Kidneys to harass the Heart and Pericardium; Li Dong Yuan called this Yin Fire (not to be confused with Empty-Heat). The pathological Minister Fire (i.e. Yin Fire) ‘displaces’ the Original Qi because they both occupy the same space in between the Kidneys; for this reason Li Dong Yuan says that the Yin Fire is a ‘thief’ of the Original Qi. Thus in this kind of pathology there may be some Cold symptoms and signs arising from a deficiency of the Original Qi (such as cold feet, a feeling of cold and a Pale tongue) and some Heat manifestations from the rising of the Yin Fire (such as a feeling of heat in the face and a Rapid pulse). Arousal of the Yin Fire is treated not by clearing Heat but by tonifying the Original Qi with sweet and warm herbs; the representative formula for this is Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction (Tonify Qi and Ease the Muscles in the Three Treasures).


    As Yin Fire derives from a deficiency of the Original Qi, if the latter predominates, the pulse may be Slow rather than Rapid.


• A Rapid pulse may also simply indicate nervous tension without any Heat. This is usually found in people who are constitutionally nervous: these patients will most probably have a Heart crack on the tongue.



Box 50.8 summarizes those situations when a Rapid pulse does not correspond to Heat.



BOX 50.8   SITUATIONS WHEN THE PULSE IS RAPID FOR REASONS OTHER THAN HEAT




The following factors may also cause the pulse to become temporarily Rapid in the absence of Heat: vigorous physical exercise, heavy meals, alcohol, smoking, tea, coffee, fright, emotional upsets, certain herbs such as Ma Huang Ephedrae sinicae or Ren Shen Radix Panax Ginseng and anaemia.






Empty




Clinical significance


The Empty pulse indicates Qi deficiency at its beginning or middle stages; in chronic Qi deficiency, the Empty pulse will usually become Weak (see below). Since most of the patients we see suffer from chronic conditions, the classic Empty pulse is relatively rare. When discussing the clinical significance of the ‘Empty’ pulse, it is important to be precise about one’ terminology: there is a difference between the classic ‘Empty’ pulse as defined above, indicating purely Qi deficiency, and an empty-type pulse, which encompasses a broad range of deficient pulses, such as Weak, Fine, Choppy, etc. It is therefore important, especially in training clinics, not to use the word ‘Empty’ in a loose sense but only to indicate a precise pulse quality.



Remember: do not confuse the specific ‘Empty’ pulse quality with a generic, loosely defined ‘empty-type’ of pulse.



The Empty pulse is most common on the Lung position and in chronic conditions it may indicate Lung exhaustion (Fei Xu Lao).


If the pulse is Empty and relatively Floating and without strength in all three positions, especially of the left, it indicates Blood deficiency.


If the pulse is Empty and slightly Rapid in acute exterior syndromes, it indicates invasion of Summer-Heat.


Box 50.9 summarizes the clinical significance of an Empty pulse.



BOX 50.9   EMPTY PULSE: SUMMARY OF CLINICAL SIGNIFICANCE






Differentiation of similar pulses









Full




Clinical significance


The Full pulse simply indicates the presence of a Full pattern; its precise clinical significance can be deduced only from its combination with other qualities. When discussing the clinical significance of the ‘Full’ pulse, it is important to be precise about terminology: there is a difference between the classic ‘Full’ pulse as defined above, indicating purely a Full condition, and a full-type pulse, which encompasses a broad range of full pulses, such as Wiry, Slippery, Tight, Big, Overflowing, etc. It is therefore important, especially in training clinics, not to use the word ‘Full’ in a loose sense but only to indicate a precise pulse quality.


A proper identification of the Full pulse is essential to determine the correct principle of treatment in chronic conditions which are usually characterized by the simultaneous presence of Full and Empty patterns. In such cases, we must have a clear idea in mind as to what our treatment strategy should be, that is, tonify the body’ Qi or expel pathogenic factors. When we are confronted by these alternative treatment strategies, the pulse quality is extremely important in our deciding which one to choose; if the pulse is Full it is usually better to concentrate our attention on expelling pathogenic factors, even if the condition is chronic. Postviral fatigue syndrome is a case in point. In this condition there is nearly always deficiency, usually of Qi, and Excess, usually of Dampness, and I often base my decision whether to tonify Qi or resolve Dampness on the pulse quality: if it is Full or of the full type, I start by resolving Dampness rather than tonifying Qi. The same principle applies to any chronic conditions manifesting with simultaneous deficiency and Excess.


Box 50.10 summarizes the common conditions presenting with a Full pulse.



BOX 50.10   COMMON CONDITIONS MANIFESTING WITH A FULL PULSE








Slippery




Clinical significance


The Slippery pulse indicates primarily Phlegm or retention of food; it may also indicate Blood stasis. Generally speaking, the Slippery pulse is full by definition indicating the presence of Phlegm; however, it may also be combined with empty-type pulses reflecting the simultaneous deficiency of Qi and the presence of Phlegm (which usually derive from Qi deficiency).


Although the Slippery pulse is traditionally associated with Phlegm, it may also be seen in cases of chronic Dampness; for example, it is very common in chronic cases of postviral fatigue syndrome with clear manifestations of Dampness.


It is normal for the pulse to become Slippery during pregnancy and, indeed, it indicates a healthy pregnancy. Conversely, if the pulse is not Slippery during pregnancy, it is not a good sign and it may indicate impending problems; in such cases, the woman should be treated even in the absence of symptoms. In particular, there are certain pulse qualities which are undesirable during pregnancy, such as Choppy, Choppy-Wiry, Fine, Weak, Leather and Hollow, all of which may indicate the possibility of miscarriage.


According to some Chinese sources, a Slippery pulse that is Slowed-Down and relatively soft indicates health.


Common conditions manifesting with a Slippery pulse include a whole range of diseases characterized by Phlegm in all of its manifestations (i.e. Phlegm-Heat, Cold-Phlegm, Damp-Phlegm, Wind-Phlegm, etc.). In the organs, Phlegm can be retained primarily in the Lungs, Stomach and Heart (non-substantial Phlegm misting the Mind). Phlegm in the Lungs is extremely common and a good example of a Slippery pulse is that felt in a patient with acute or chronic bronchitis.


Conditions other than Phlegm, such as Damp-Heat or retention of food, may also lead to a Slippery pulse.


According to Dr Shen, when a Slippery quality is felt only in one position, it does not necessarily indicate Dampness or Phlegm. For example, he attributes the following clinical significance to a Slippery quality in individual positions:




Related posts:

  1. OBSERVATION OF THE GENITALIA
  2. MENSTRUAL SYMPTOMS
  3. DIAGNOSIS BY HEARING
  4. MENTAL AND EMOTIONAL SYMPTOMS

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Apr 15, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on PULSE QUALITIES

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