An Introduction To Pulse Diagnosis: by Julian Scott

JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
AN INTRODUCTION TO PULSE DIAGNOSIS

By Julian Scott
Pulse diagnosis comes under the heading of the fourth method of diagnosis "to feel"; and as such, it is generally regarded as the least important method of diagnosis; "To see, to hear, to ask" being considered superior. This is not to say that, as a method, it is unimportant. Far from it; a practitioner would be neglecting his duty if he did not take the pulse; but it suffers from some shortcomings which will be discussed. There is much confusion concerning pulse diagnosis, and it is hoped that this article will clear away some misunderstandings and go some way towards reconciling points of view which may appear to be opposed, but which are in fact complementary. HISTORICAL INTRODUCTION The legendary doctor Bian Que who lived during the Warring States period is accorded the distinction of being the first to use pulse diagnosis in the "Records of the Historian" by Su-Ma-Qian. The earliest extant descriptions of pulse taking are in the Nei Jing, which was also compiled in the Warring States period, but it almost certainly includes material from traditions that go back much further, possibly even prior to Bian Que. The other early text is the Nan Jing "The Classic of Difficult Questions" which has some chapters concerning pulse diagnosis. Both the Nei Jing and the Nan Jing emphasise the overall quality of the pulse, although in the Nei Jing there is a brief reference to the three different positions on the radial artery, relating them to the internal organs, much as they are used today. The Nei Jing also mentioned a different system of pulse taking, according to nine different positions on the body, relating them to "Heaven, Earth and Man". This may be a survival of a system of analysis by subdivision into three parts, which was superseded in the Warring States period by the subdivision into two parts characteristic of Yin-Yang. This subdivision into three parts actually survives in Chinese medicine today in the San Jiao or "Three burning spaces", but nowhere else. The positions where the pulse should be taken to find out the relative strengths of Heaven, Earth and Man are as follows: HEAVEN Heaven Earth Man Heaven Earth Man Heaven Earth Man Both sides of forehead, near Taiyang (Extra) point Both sides of cheek at Daying ST-5 In front of ears near Xiaguan ST-7 On the radial artery at Jingqu LU-8 On the hand at Hegu L.I.-4 On the ulnar artery at Shenrnen HE-7 On the leg at Wuli LIV-10 On the leg at Taixi KID-3 On the leg at Jimen SP- 11
EARTH
MAN
There is no further reference to this system in the Nan Jing, so it might be thought that as a system it had died out, having been superseded by the system of taking the pulse at
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the radial artery (known also as Cun Kou). However, the famous doctor Zhang ZhongJing writing in the 2nd Century AD referred to a system where the pulse was taken at the radial artery, the carotid artery (at Renying, ST-9 point) and the leg artery (at Fuyang BL-59 point) and criticised those who took little notice of the pulse at these last two regions. He felt that misunderstandings would occur if these positions were not used. This view is still held today, in that if no pulse at all can be felt at all three positions, in a patient who suddenly falls unconscious, then the prognosis is poor. Pulse qualities through the ages Some modern texts refer to "the 27 pulse qualities" while other texts refer to 28. If we look back through the ages, we find that different texts have widely different numbers of pulse qualities. The reason for this is not that there is any real disagreement as to the meaning of different pulse qualities but that certain combinations of pulse qualities were sufficiently important to be given a separate name. The number of pulse qualities mentioned in different texts is given in the table below. TEXT Nei Jing Shang Han Lun Mai Jing Hua Sou Li Shi Zhen Zhang Lu PERIOD Warring States, Before 300 BC Later Han, About 150 AD About 250 AD Yuan, 12th Century Ming 1576 Qing NUMBER OF PULSE QUALITIES MENTIONED 21 23 24 30 27 32
Pulse position through the ages Of greatest interest is how to take the pulse at Cun Kou, the radial artery. Over the centuries different writers have ascribed different meanings to the three different positions on each wrist. In the first table we give a selection of interpretations of pulse positions, starting with the Nei Jing, and ending with Dr. J.F. Shen who is currently practising in New York. Two versions appear in bolder type than the others, because these two are commonly used throughout China and the Chinese speaking world. A superficial glance shows that there are many different interpretations, and it may at first be thought that there is genuine disagreement. As we proceed through this article, we shall find that the areas of disagreement are small and are much less than the areas of agreement. It is a tribute to the accuracy of pulse diagnosis that, over the length and breadth of China, and stretching back over 2' thousand years, there is so much agreement. Viewed in this perspective, we can admit that it would be surprising if some of the hundreds of thousands of doctors who have used this method did not have some contribution to make or have some different emphasis. In the table below there is a feature which is somewhat glossed over, and this is the question of where one should look if there is more than one organ at a position. The Nei Jing states that organs are to be found in the "Lateral or Outer" (Wad) position while the parts of the body are
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to be found at the "Medial or Inner" (Nei) position. There is of course discussion as to whether this really means medial and lateral or whether it means deep and superficial. This example is followed by later texts; but by the Ming dynasty this interpretation was rejected, and in the Bin Hu Mai Xue by Li Shi-Zhen it is expressly stated that the two organs are to be found at the same place. So for example it is stated that the Guan position on the left relates to the LIV and incorporates the GB. There is no reference to superficial or deep levels, and both organs can be found both at the superficial level and deep level. As we proceed through the text, we find that this is the natural outcome of combining the theory of pulse positions with the theory of pulse qualities - theories which had previously been separate.
BOOK Lateral/Outer Nei Jing Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi Cun Gua n Chi
HE LIV KID S.I. GB BL S.I. GB BL Pericardium GB SI/BL Pericardium GB BL/L.I. Shanzhong GB/Diaphragm BL/L.I.
LEFT Medial/Inner
Shanzhong Diaphragm Abdomen HE LIV KID HE LIV KID Yin HE LIV KID HE LIV KID HE LIV KID HE LIV KID
RIGHT Medial/Inner Lateral/Outer

Chest ST Abdomen LU SP KID LU SP KID Yang LU SP KID LU SP KID LU SP KID LU SP LU SP KID L.I. ST Mingmen L.I. ST SJ/BL Chest ST L.I. Shangzhong ST SJ/S.I./Mingmen Chest ST L.I.
Nan Jing
Mai Jing The Pulse Classic by Wang Shuo he 210-285 A.D. Bin hu Mai (1576) by Li Shi Zhen Jing Yue by Zhang Jing Yao (1561-1639) 1792 Yi Zhong
The Essentials of Chinese Acupuncture 1964 Dr Shen 1981
HE Diaphragm LIV/GB L.I./KID/Uterus
KID Left-LU-Right Diaphragm Oesophagus SP/ST Duodenum S.I./BL
INTRODUCTION TO THE PRACTICE OF PULSE TAKING A) SOME GENERALITIES 1. The purpose of taking the pulse The purpose of taking the pulse is to find the condition of the interior of the body, with special reference to the internal organs. This is very important, but often it is not clearly understood. Thus if there is some problem in the channels (meridians) this will not show on the pulse unless the related organ is also affected. So an injury to a limb or even arthritis from Bi syndrome will not show on the pulse, unless a related organ is also affected. As mentioned above, diagnosis by feeling is the fourth, and last, method of diagnosis. Having carried out the three other methods of diagnosis, there should be a clear idea of the condition of the patient, and so there should be a very clear idea of what pulse to expect. In fact it can be put even more strongly - do not take the pulse unless you know what to expect. It is said that if there is a discrepancy between the pulse and the symptoms in acute disease, then the prognosis is very poor. Only if it is known what pulse to expect can it be said with certainty whether the pulse and symptoms agree or not. 2. Strengths of pulse diagnosis The main strength of pulse diagnosis is that it can be used on all types of patient. In looking diagnosis, there is much variation in pigmentation between different races; in asking diagnosis, there is some subjectivity on the part of the patient as to the relative strength of pain etc. By contrast, pulse diagnosis is carried out by the practitioner, who brings his own frame of reference with him. Another strength of pulse diagnosis is an extension of this first: pulse diganosis can predict disease before it occurs. When disease is still so slight that the patient is unaware of it, the pulse may already be affected. The third strength of pulse diagnosis is also a weakness; the pulse is affected by a patient's emotions. If a patient arrives in a state of high emotion from some recent event, the pulse will show this, and give a false indication of the state of disease; on the other hand emotion is often closely related to disease and quick changes in emotion can often be detected on the pulse. 3. Weakness of pulse diagnosis The weakness of pulse diagnosis is that there are many factors which can influence the pulse and the practitioner has the task of making allowance for these factors. To this extent taking the pulse is subjective. The main influencing factors are: a) State of heart and blood vessels The pulse is due to blood circulating in the blood vessels and pumped by the heart. If these are affected in any way, there will be an overall alteration to the pulse. As an
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example we may take the slow heart beat characteristic of an athlete. If an athlete suffers from a fever, his pulse will be more rapid than his normal rate, but may nevertheless be slower than 76 beats per minute. As another example, there are two ways in which the arteries are commonly affected hardening of the arteries, and enlargement of the arteries due to too much exercise when young. The former will give a hard and wiry pulse throughout, while the latter will give a large and hollow pulse throughout. While these pulses certainly reflect something about the body's condition, they do not necessarily reflect the current condition of the internal organs, but rather tell something about the history of the patient. b) Qi of lung and stomach; exercise and diet The general level of the pulse is related to the general level of Qi in the body, but more especially to that of the LU and ST. So if a patient has recently taken vigorous exercise the pulse will be more rapid. Manual workers have large and forceful pulses, and often the pulse on the right side is larger with right handed workers, whether they are male or female. By contrast, the pulse of mental workers is relatively weak and slow. As for diet, alcohol will increase the speed of pulse; after a meal the pulse will be large and forceful, while prolonged hunger leads to a weak pulse. c) Qi of the 5 Zang It is said that if the pulse beats 50 times without any dropped beats, the Qi of the 5 Zang is flourishing. If one beat is dropped after only 40 beats, then one Zang is affected; if one beat is dropped after thirty beats two Zang are affected. Thus it is said that no pulse is properly examined unless at least 50 consecutive beats are taken. d) Emotions Emotions affect the pulse immediately. Thus overjoy or excessive anger can affect the pulse. The pulse may be a valuable indicator of emotions, but sometimes recent emotions are not related to longer term disease. e) Weather and seasonal variations In cold weather the pulse will normally be deep and slow, while in hot weather (or central heating) the pulse will normally be superficial and rapid. According to Li Shi Zhen the following seasonal variations of pulse are normal: In Spring the pulse should be wiry In Summer the pulse should be overflowing In Autumn the pulse should be fine like a hair
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In Winter the pulse should be deep and strong like a stone. (The descriptions of seasonal changes in the Nei Jing are slightly different. In the UK with its relatively mild seasons, these variations are not as pronounced as in China, which has a more extreme climate.) ______________________________________________________________________________ B) HOW TO TAKE THE PULSE 1. Preparation Some preparation is needed before taking the pulse, both to prepare the practitioner and to prepare the patient, so that a reliable recording can be obtained. The practitioner must first of all be calm, but more important, should already have a clear idea of what the pulse should be before he takes it. He should have already carried out the three other forms of diagnosis, to look, to hear and to ask. In some cases the diagnosis will be so clear from these steps that pulse taking is unnecessary, and in fact may even be misleading. The other preparation that the practitioner should make is to try and determine how much allowance should be made for external factors such as hurry, emotional condition, weather etc. The preparation for the patient is to give the patient time to settle down and relax so that the pulse truly reflects the state of the internal organs, and does not relate to the conditions of the past few hours. It is this factor which leads to the recommendation in the Nei Jing that the pulse should be taken at dawn. Clearly it is not practical to carry out pulse diagnosis only in the first hours of the day. On the other hand a valid reading will not be obtained at the end of a gruelling day's work. 2. Position Li Shi-Zhen says "At the beginning of a diagnosis, let the patient extend his arm placing his palm upwards and relaxing it". In principle, the wrist should be at the level of the heart when taking the pulse. There are two common ways in which this is obtained firstly with the patient sitting up, with the hand on the table on a pillow; secondly with the patient laying down. The former position is the most convenient, and is generally thought to give a truer reading. It is the position adopted in China whenever possible. If the patient is not well enought to sit up, then the pulse is taken with the patient laying down. With the patient's hands outstretched on the table, the index, middle and ring fingers are placed on the Cun, Guan and Chi positions respectively. The fingers should be at right angles to the direction of the artery, and all three fingers should lightly rest on the pulse at the same time. Some doctors advise taking the patient's right pulse with the doctor's right hand. However all the Chinese doctors I have spoken to stress that this is not essential. The most important thing is to be comfortable while taking the pulse. Thus if the patient is sitting to one side of the doctor, then the doctor will only use one hand for diagnosis. This gives reliable readings.
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3. Where to take the pulse There is little point in changing the words of Li Shi-Zhen "Behind the wrist there is a high bone (the styloid process of the radius). It marks the Guan position. In front of the Guan position is the Cun position, which belongs to Yang and behind the Guan position is the Chi position which belongs to Yin". In practice the styloid process lies in between the Guan and Cun positions. As a measure of scale, the distance between the Cun and Chi positions is about one Cun of the patient. WHAT THE PULSE POSITIONS MEAN Referring back to the pulse positions through the ages, the reader may justifiably feel confused and wonder whether there is any purpose at all in taking the pulse; and if so, should Ll ShiZhen's method be used or that of the Nei Jing, or a mixture of the two. In the next section we will give a reconciliation of the different points of view, but now we give important rules to bear in mind when taking the pulse. 1. 2. 3. The pulse relates to the Zang rather than the Fu. The pulse relates to the three jiao i.e. the upper part, the middle part and the lower part of the body. The superficial, middle and deep levels relate to Qi, Blood and Jing respectively.
If these factors are borne in mind, then a clear understanding of the pulse can be reached. 1. Zang rather than Fu Why does the pulse represent the Zang rather than Fu e.g. why does the middle pulse on the left hand side relate more to the LIV than the GB? The reason is that as far as internal medicine is concerned, most of the functions of the body are related to the Zang rather than the Fu. So for example the functions of the LIV are to store blood, ensure free flowing of Qi, dominate the tendons and open into the eye, while the function of the GB is merely to store bile and to assist in the function of digestion. The functions of the LIV are more important and far-reaching than those of the GB, and are more likely to go wrong. However, even when there is real dysfunction of the GB, there will also be dysfunction of the LIV. At this stage it must again be emphasised that the pulse does not relate to the channels (meridians). So although in many ways the GB channel is more important than that of the LIV, having more points and being longer, as far as the internal workings of the body are concerned, it is to the LIV that the important functions of the body are ascribed. Some of these attributions may seen arbitrary and at variance with other systems of medicine, but it has to be accepted that this is the way Chinese medicine has been written. Chinese medicine is a coherent and logical system, provided that the meaning of the terminology is clearly understood. The transplanting of Western ideas of the working of the organs into Chinese medicine is about as successful and fruitful as transplanting the organs themselves.
2. The three jiao The distal pulse (Cun) relates to the upper part of the body, the intermediate pulse (Guan) relates to the middle part of the body and the proximal pulse (Chi) relates to the lower part of the body. The upper part of the body refers to the chest and the area above the diaphragm. The middle part of the body refers to the area between the diaphragm and the navel, and the lower part of the body refers to the area below the navel. The left hand pulse relates to the left hand side of the body and the right hand pulse to the right side. So if there is an injury to left side in the chest area resulting in stagnation of Qi, the left hand distal pulse may be a little tight. More commonly, the energy in one Jiao is full or empty, and this will reflect in the pulse in the corresponding position on both sides being full or empty. So if the upper Jiao is empty, it is common for both the distal pulses to be empty. If the middle Jiao is full (a common occurrence) then both the middle pulses will be full. These descriptions appear to be in conflict with the earlier definition that the pulse positions relate to the Zang. Indeed there really is conflict here, because the pulse at the different positions can relate either to the Zang or to the three Jiao. How can one tell whether the pulse relates to the Zang or to the Jiao? The answer is that often it is not possible to tell merely by taking the pulse, and other factors will have to be taken into account. Thus if the distal pulses are both empty, it may mean that both the HE and LU are injured and weak; or it may mean that there is relatively little energy in the upper part of the body, but that there is nothing wrong with the organs. A definite distinction cannot be made on the basis of the pulse alone, and reference would have to be made to other forms of diagnosis. 3. Superficial Intermediate and Deep levels To a certain extent this rule anticipates a later section where we discuss the qualities of pulses. Strictly speaking, a superficial pulse is a clearly defined pulse quality, as is the deep pulse. However, it is well to introduce the idea at an early stage as it helps to clarify many points. The Qi, Blood and Jing are the three main forms of energy in the body. Qi is relatively yang and flows externally and performs work functions. Jing (often translated as "essence") is relatively Yin and is the embodiment of the Yin functions of the organs. (See J.C.M. No.7 "The Origin of Qi and Blood.) Blood is intermediate between Qi and Jing, having both a cooling function and an active function. Qi being Yang relates to the superficial level; Jing being Yin relates to the deep level. Blood being intermediate relates to the intermediate level. It is anticipating the later sections, but some examples will illustrate these principles. When there is attack of pathogenic energy such as wind-cold (as commonly seen in influenza), the body's energy goes up to the superficial level in order to fight the pathogenic energy. Correspondingly the pulse is superficial. As another example we can take the pulse which appears when there has been excessive bleeding in the body. This pulse is hollow, which means that there is some strength at the superficial level and some strength at the deep level but that the intermediate level is weak. Immediately after bleeding there is less blood in the body, but the Qi and Jing have not had time to be affected. So we see
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that the intermediate pulse which relates to blood is relatively empty, while the superficial and deep pulses, relating to Qi and Jing are unaffected. Reconciliation of different interpretations We can proceed now to the difficult task of reconciling the apparently differing pronouncements of famous doctors. First of all we discuss the question of superficial and deep. In nearly all cases it will be seen that if there is a difference of opinion, it either reflects a difference of emphasis, or else it relates to a real ambiguity in the information that the pulse supplies. Pulse position - the organs First of all we would draw the reader's attention to the pulse positions that have remained the same through the ages i.e. the pulse positions that are common to all writers. It will be seen at a glance that the position of the Zang, and that of the ST are nearly the same in all writers. So we see that the HE, the LIV and the KID appear at the Cun, Guan and Chi positions on the left hand side, and that the LIV and SP appear on the Cun and Guan on the right hand side, with the ST also at the Guan position, We mentioned earlier that the Zang were more important than the Fu in that they had many more functions; so we see that there is really an enormous measure of agreement between writers over the ages, and that any differences are relatively small. Pulse positions - Intestines and San Jiao The two systems which we compare in most detail are those shown in large boxes in the diagram, namely those of Wang Shuo-He as given in the Mai Jing (pulse classic) and those of Li Shi Zhen as given in Bin Hu Mai Xue. We chose these two systems to compare because both are in common use at the present time. There are other systems in use but they are usually variations or combinations of these two. It will be seen on comparing these pulse systems that the most important discrepancy concerns the placing of the pulse relating to the intestines. In my view this reflects a real problem in the body, which causes confusion among generation after generation of students, namely that the intestine organs, the Fu, are in the lower part of the body, while the related channels are in the upper part of the body. This can give rise to all sorts of confusing situations, such as when the upper part of the body is empty, but the lower part is full. In this case we can have the intestine organs being full, as they are in the lower part, while the channels are empty as they are in the upper part. (An example illustrating this will be given later on.) So the two systems give different positions, because there is a real problem where to look for the intestine pulses. Should one expect the Cun pulse to relate to the intestines because the corresponding channels are in the upper Jiao; or should one expect the Chi positions to relate to the intestines because the intestine organs are in the lower Jiao? The solution adopted usually depends on the practitioner. Acupuncturists, whose stock-in-trade is manipulating the channels, usually prefer the system of Wang and look for afflictions in the intestine channel in the Cun position. Herbalists, whose potions go directly to the internal organs, usually adopt the
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system of Li, and maintain that disorder of the intestines appear in the Chi position. However, to insist that one system is correct, while the other is wrong, is bigotry. This raises again the question of how to tell whether a full pulse in the Cun position relates to the LU or HE organs, or to the L.l. or S.l. channels. Again there is no direct way that this can be told from the pulse, and other systems of diagnosis have to be used. Usually there is no confusion, for problems in the LU organ can be distinguished at a glance from problems in the L.l. channel. Superficial and deep The Mai Jing seems to indicate that the pulses of the Fu are to be found at the superficial level, while the Zang are at the deep level. Li Shi-Zhen on the other hand, insists that the pulses of the organs to be found at one position are at the same depth. Thus he says that the middle pulse on the right hand side relates to the SP and incorporates the ST. Both these points of view are current in Chinese Medicine to this day. There is a third view which is held by the Vietnamese school (as represented by N. Van Nghi) that the superficial pulse relates to the Zang, while the deep pulse relates to the Fu i.e. exactly the opposite of the system in the Mai Jing. This point of view has the support of the Nei Jing, which uses the character Wai, (usual translation "outer") for the position of the Zang. However the mainstream of Chinese Medicine seems quietly to ignore this uncomfortable statement in the oldest of books, and we should do so also. The question that remains is whether it is right to regard the superficial part of the pulse as relating to the Fu and the deep as relating to the Zang. In my view it is unwise to grant uncritical acceptance of a model which is just a little too elegant. If we return to the rules stated earlier we see that the superficial relates to Qi and the deep relates to Jing. Now most of the functions of the Fu require Qi. Their main task is to transport the food in various stages of decomposition and to expel the dregs, while performing some separation. By contrast, the function of the Zang is to store Jing. So we see already that the superficial part of the pulse, since it relates to Qi, will tend to relate to the Fu, while the deep part of the pulse, since it relates to Jing, will tend to relate to the Zang. As an example, we can take affections of the lower part - if external cold attacks the BL, giving symptoms of cystitis etc. The pulse in the lower left Chi position will be superficial. On the other hand, if the patient is also very weak and lacking in KlD-Jing, the deep pulse will be empty. One can find many examples of pathological conditions where a problem of Qi soon shows as a problem in the Fu, while a problem of Jing soon shows as a problem in the Zang. However, this is by no means always the case. One can take as example the syndrome of Wind-Heat attacks the LU. This is a superficial syndrome and affects the Qi, and so the pulse is superficial, especially in the Cun position on the right hand. The symptoms are clearly LU symptoms with severe cough, sore throat etc. In this case, there is no possibility of ascribing the superficial pulse to the L.l. Left and Right The main problems which occur here are where to place the intestines, the BL and Ming Men. Some writers put them on one side, and some on the other. Here the discrepancy represents a genuine ambiguity in the body. Thus if there is long term constipation giving a fullness in the L.l., this fullness may show on either side. Similarly an attack of
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damp-heat in the BL may show in a full tight pulse on either side. Again, to make a definite distinction only by examining the pulse is not possible, and recourse should be had to other methods of diagnosis. As for the position of Ming Men, this is so clearly related to the function of the KID that it would be splitting hairs to look for a difference in the pulse position. Ming Men is related to KID Yang which is traditionally placed on the right side. In practice, if one KID pulse is deficient, so is the other. PULSE QUALITIES In some schools in The West, more attention is paid to the different pulse positions. In China more attention is paid to the overall quality. In fact the first thing that is learnt is a simple differentiation of the basic qualities, and differentiation according to position only comes later. In my experience this approach is valid, for there are usually more similarities in the pulse at different positions than there are differences. For example it will be immediately obvious whether the overall pulse quality is strong or weak, even though there are some differences in each position. This view is supported by all the texts through the ages, starting of course with the Nei Jing, which rarely mentions pulse positions, but frequently mentions overall pulse qualities. In practice, the most refined diagnosis comes from combination of qualities and positions. Basic principles of pulse qualities "The theory of the pulse is very complicated, but is based upon the four principle pulses - floating, deep, slow and rapid. Once they are understood, by elaborating them the entire subject can be clarified." So speaks Li Shi-Zhen in his pulse book. There can be no better way of starting pulse diagnosis than with these qualities, and some other basic qualities. We have seen that the superficial level relates to Qi and the deep to Jing. If the pulse at the superficial level is stronger than that at the deep level, it is called Floating pulse. This can arise either due to excess at the Qi level, or due to deficiency at the Jing level. How can this situation occur? Excess at the Qi level can come when there is excess of a Yang pathogenic factor, especially some exterior disease. In this case the pulse will be Floating and Strong. By contrast, if the Floating pulse is due to deficiency of Jing, this will be a Weak and Floating pulse. Normally Jing will be associated with the Yin levels of the body. The same principle may be applied to the Deep pulse, which may be Deep and Strong, due to excess of some Yin pathogenic factor (such as penetration of cold-damp) or Deep and Weak due to absence of Yang Qi. Fast and Slow Turning to the main qualities of Fast and Slow, the Fast pulse relates to hot conditions while the slow pulse relates to cold conditions. Hot conditions are usually classified into full heat and empty heat (Yin Xu). The full heat will have a full and rapid pulse while the empty heat will have an empty and rapid pulse.
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It is appropriate at this point to mention pulses with some irregularity in rhythm. This pulse is related to blockage of Qi in some part of the body. Frequently the irregularity is seen as a faster pulse on the patient's in-breath, and slower pulse on the patient's outbreath. This usually relates to obstruction of Qi in the upper part of the body. CLASSIFICATIONS OF MAIN PULSE QUALITIES Speed Fast Slow Depth Floating Related to hot conditions. Full heat is fast and forceful - Yang Excess Empty heat is Fast and weak - Yin deficiency (xu) Relates to cold conditions Full cold is slow and forecful - Yin Excess Empty cold is slow and weak - Yang deficiency (xu) Excess at Qi level or deficiency at Yin level. To be seen in superficial disease (Yang excess disease) when the Wei Qi is fighting the pathogenic factor at the superficial level. Floating and strong. To be seen in interior disease due to Yin deficiency or Jing deficiency. Floating and weak. In the hollow pulse, the intermediate level (which relates to blood) is weaker than the pulse at the superficial and deep levels. Usually some internal bleeding problem. Excess at the Yin level or deficiency at Qi level. To be seen in deep disease (disease has penetrated deeply to the internal organs) deep and strong. To be seen in diseases due to deficiency of Yang energy - deep and weak. Relates to Shi (full conditions, when the body is basically strong but has been attacked by external pathogenic factor. Relates to Xu (empty) conditions when the body is weakened by long term disease etc. Relates to cold and stagnation
Hollow Deep
Strength Strong Weak Quality Tight Wiry
Relates to LIV. The stagnation is more severe and amounts to obstruction. Slippery Relates to phlegm Rough Relates to deficiency of Qi and Blood
Strong and Weak While we are discussing the basic qualities, one so basic that Li does not even mention it is the differentiation between the strong and weak pulse. We have already implied that strong relates to a Shi or full condition while weak relates to a Xu or empty condition. It is not difficult to recognise full and empty pulses, the only exceptions are the Drumskin pulse which is superficial and weak. It can sometimes feel like a strong pulse because at
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the most superficial layer there appears to be strength; but only the slightest pressure is enough to reach a layer where the pulse is very weak. The Hidden pulse is opposite, with a strong pulse at a very deep layer. It can be confused with a Weak pulse, for it is only felt on quite strong pressure; until this pressure is applied, there is little to be felt. Qualities of Tight, Slippery, Wiry and Rough These basic qualities refer to the feel that the pulse has under the finger, and are correspondingly hard to describe. The Tight and the Wiry pulse are similar in nature, with the tight pulse only slightly Wiry. I will not attempt any further description of these pulses than is given in the table of pulse qualities - the best way is to find a patient who has very clear signs of LIV Yang rising, and feel their pulse. It will be a Wiry pulse. It is quite similar to the pulse felt in patients with hardened arteries - though this pulse is Wiry, Hard and Long. The Slippery pulse again is hard to describe, and the best way to observe this is to find a patient who suffers from catarrh. Their pulse will either be rather Soft, or else it will be Slippery. The Rough pulse is a pulse that is irregular in amplitude and rhythm. CLASSIFICATION OF MAIN PULSE QUALITIES Introduction to 27 qualities Once these basic qualities are firmly fixed in the mind, it is time to proceed to an examination of the 27 pulse qualities given in the table. It seems a large number of pulse qualities, but it will be seen that the new qualities are either combinations of qualities given so far, or extreme cases of the qualities given so far. Brief notes are given in the table by way of explanation. We also give a few little "boxes" showing some symptoms that might be expected if that pulse quality is found at a particular position. These symptoms need not be memorised, for they can be deduced - we take as an example the first box, the Slippery pulse. The Slippery pulse relates to phlegm or heat. If it is found in the Cun position on the left hand, it means that the phlegm and heat is affecting the HE or giving rise to the symptoms given. An explanation for the other symptoms in the boxes is left as an exercise to the reader. Pulse qualities and their meanings
English name Floating Deep Pinyin Fu Chen Other translations and description Superficial See text for description See text for description Meaning Pathogenic Wind Yin Xu Qi disease Pathogenic Qi within Qi obstructed Yang Xu Organ disease Oedema (1)
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Slow Fast
Chi Shuo
60-70 82 = fast 96 = very fast 120 = serious (or nervous) "Like a pearl rolling in a basin" "Rough". "Like bamboo scraped with a knife". Irregular amplitude and/or rhythm. (4) Like a rope with one end fastened and the other going round. (5) Like a pencil (6) Only appears in middle of doctor's finger Full, long and hard a) Empty-Soft. Floating and big. Slow and soft movement b) Really empty Fills whole area beneath fingers (9)
Slippery Choppy
Hua Ce
Tight Long Short Full Empty
Jiu Chang Duan Shi(7) Xu (8)
Overflowing
Hollow
Kou
"Scallion", "Onion stalk". Strong at top, empty in middle, strong at bottom
Small Wiry
Wei Xian
"Minute" (11) Hardly discernible "Taut". "Bow-string". (see text)
Cold within Yang Xu HE injured by exercise (2) Heat Yang abundant Yin Xu Qi or Blood Xu Shock, weak nerves (3) Phlegm Heat Pregnancy Pathogenic Qi Blood and Jing weak Qi obstructed Cold and Damp Pain Pathogenic Cold "Infection" Shi Qi rebellious and fire Wind-stroke (very long) Xu, especially of Yuan Qi Shi condition Blood Xu Summer Heat Jing Xu and cold pathogenic Qi: dangerous Pathogenic Wind, especially Wind-Heat Blood Xu (if weak) Deficiency of fluids If after long disease, the prognosis is poor Hollow + Weak = loss of blood Hollow + Strong = about to bleed Hollow + Soft = Qi stagnant Hollow and Strong in whole pulse = a) high blood pressure, ( 10) b) diabetes Lost Yang with Qi and Blood injured Very serious LlV-Wind Phlegm Pain Shi Cold Extreme Qi and Blood Xu (12) Qi accumulation Yin Xu KID empty Jing exhausted Marrow exhausted Yang decayed Often seen in protracted disease, not dangerous KlD-Qi destroyed: always a sign of danger
Drumskin Hard Soft
Ge Lao Ruan (13) Ruo San
"Leather". Superficially taut, soft on pressure. See text Long, wiry, hard "Weak Floating". Cotton floating on water
Weak Scattered
Thin or fine and soft If middle depth is selected, pulse becomes hollow; if deep is selected, undiscernible
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Thin
Xi
"Fine" "Thready"
Hidden Big Unsteady
Fu Da Dong
Hidden or sunken beneath muscle; near bone. Deeper than Deep pulse "Broad", Twice as broad as overflowing pulse but not so full and large Rapid, slippery, shaking. Fluctuates between light and heavy.
Hasty Knotted Irregular
Cu Jie Dai
Halting at times Fast and interrupted Slow and interrupted Stops after set number
Decayed Qi Yin Xu - often with Yang symptoms Damp Debility Disease has penetrated to zang Wind-Cold on exterior; pathogenic cold on interior Internal pathogenic heat Yang Ming fever developing Pain Fright, deep fear Qi and Blood wild Sweating in Yang Ming fever (15) In healthy person, overwork before puberty Fire Obstruction of Qi Obstruction, accumulation Congealed cold Zang injured HE nerve troubled If stops after 2 or 4 - dangerous
(1) Deep "Oedema" is my addition. It is normally related4. Choppy to Qi obstructed or Yang Xu. (2) Slow In Western medicine a normally slow heart beat is often regarded as beneficial to health. In Chinese medicine it may be regarded as a sign that the heart has been enlarged by too much exercise when young. This may lead to tiredness and lethargy in later life. (3) Fast The patient's pulse is often faster the first time they come for treatment, as they do not know what to expect. (4) Choppy Also described as small, minute and short with irregular rhythm. It is a Xu pulse and is associated both with deficiency of Qi and blood and also with obstruction. In this case the obstruction occurs because there is not enough energy to move the obstruction - in contrast to the LIV sort where the obstruction is withstanding enormous pressure. (5) Tight The tight pulse is slightly wiry. The wiry pulse relates to LlV-type obstruction. In the tight pulse we see obstruction manifested in pain, or due to cold. According to Dr. Shen, the tight pulse is associated with "infections" in the Western sense of the word. When the pulse is tight at the middle depth only, it may mean heat in the blood. (6) Long The long pulse refers to the length under the finger in the direction of the artery. In a very long pulse, it seems rather that there is a pencil being moved up and down in the
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artery. It contrasts with the short pulse, where the length in the direction of the artery is small i.e. the pulse can only be felt in the middle of the finger. In a healthy person, the long pulse indicates a strong constitution. In a healthy person, the short pulse indicates a delicate constitution. (7) Full The character Shi is the same as Shi for excess or full condition. (8) Empty The character Xu is the same as Xu for deficient or empty condition. (9) Overflowing The overflowing pulse spreads out sideways from the artery like a river that is bursting its banks. The prognosis is poor if this pulse appears after a prolonged disease, for this pulse relates to a full condition after a long disease. This is an example of the pulse and the symptoms going the opposite way. (10) Hollow "True high blood pressure" relates to high blood pressure that is continuous, as opposed to blood pressure that raises at times of high emotion, but then falls again. (11) Small This pulse is extremely small. (12) Drumskin This pulse sometimes appears in patients who are extremely weak inside, but screw themselves up to carry out their daily work - living on their nerves. They are very likely to suffer from needle shock, as they suddenly relax. (13) The character also means soggy. This pulse can also appear when there is internal damp. In this case it is soft but not weak. (14) Scattered A dangerous pulse when it appears from natural causes. Often related to some internal poisoning, often a sign of cancer. Not such a serious pulse when the poisoning can be directly related to taking Western medicines. The scattered quality will go when the patient stops taking the medicines for a while. (15) Unsteady "Yang Ming fever" relates to differentiation of syndromes according to the 6 Jiao. Article to appear. Quality Slippery Position Cun Guan Chi Left side Heat in HE Vomiting LIV-Heat Dizziness Frequent bloody cloudy Right side Catarrh Vomiting Middle Jiao Stuck: Heat Gurgling intestines
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Choppy
Cun Guan Chi
urine Palpitations Pain in HE LlV-Blood Xu Knee and back pains Head hot Heart pain Epigastrium full and painful Back and sides painful Pain under umbilicus Overfull HE Hardened arteries True high blood pressure LIV swollen by anger + Hollow: diabetes Prostate trouble Heart pains Lumps LIV dispersing power gone Back and leg pains Hernia Empty KID Easily forgets Cramps Jing/Blood wasted Palpitations Swellings Yin exhaustion
KID fire rises tinnitus Weak cough LU-Qi weak SP weak No appitite KID Fire weak or injured Cold Asthma Hypogastrium painful Hernia Cold accumulation Full LU Water in LU ST swollen by working after meals Headaches Chest and rib pains Cold and Full Pains in abdomen Abdominal pains Dysentery Qi weak sweating SP weak
Tight
Cun Guan Chi
Overflowing
Cun Guan Chi
Wiry
Cun Guan Chi (12)
Soft
Cun Guan Chi
Scattered
Cun Guan Chi
Sweats
Yang exhaustion
Summary of the qualities After studying the qualities in the table, we find that we can analyse them according to the main qualities of depth and quality and strength, and arrange them in the following way:
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TAUT SOFT
Strong Tight Wiry Flooding
SUPERFICIAL Weak leather Full Scattered Soft minute
Strong Firm hidden
DEEP Weak thin weak
The pulse and pregnancy The pulse may change in pregnancy. Sometimes it is a pathological sign; sometimes it is not. It is said that if the pulse becomes slippery in pregnancy, this is not a pathological sign. According to Li Shi-Zhen, if the left pulse at the Chi position is more slippery and rapid then the child will be a boy; if the right pulse at the Chi position is more slippery and rapid then the child will be a girl. However he qualifies it saying "This idea is ancient. It is not always correct but is often a helpful indication". ______________________________________________________________________________ Concluding remarks 1. When first taking the pulse, it is not possible to remember the 27 qualities and have them available for instant access. In order to develop this facility, ask the following questions, firstly about the overall pulse, and then about the individual positions. 1. Fast or slow? 2. Superficial or deep? 3. Strong or weak? 4. Wiry, slippery, rough? In answering the questions, you have made the basic diagnosis. 2. As far as pulse positions are concerned, remember that the positions relate primarily to Zang or solid organs and the three Jiao, and that some of the Fu or hollow organs can appear at different places. Do not be too rigid in sticking to one system of diagnosis. Some case histories 1. Master B. 6 years old, was brought to me by his mother, who said that he had been listless, pale and eating very little. The G.P. had said not to worry, but she was nevertheless concerned. In this case the patient was very shy and refused to put out his tongue for inspection. In the absence of a clear symptom picture, and tongue diagnosis, the pulse gave the most reliable information. The pulse was slightly Slippery and Small in all positions except the right Guan position which was Full and Slippery. His stools were more or less normal, and he complained of an ache in the region of the stomach.
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From this I deduced that the patient's condition was retention of phlegm in the ST. This diagnosis was confirmed in a dramatic way a few moments later, when, as a result of treatment, he vomited phlegm over my trousers. After this performance the pulses were less Slippery and much better balanced i.e. the right Guan pulse was nearly normal. This illustrates that the pulse can change extremely rapidly if the condition of the organs change. 2. Mr. R. 28 years old suffered from epilepsy. He had much evidence of sputum, on his tongue and from his nose. His abdomen was swollen and his body covered with hair. His pulse was slightly Rapid, and Soft (soggy), characteristic of heat and dampness. As a result of an extended course of treatment, his nose cleared, his abdomen became so much Jess distended that he had to buy new trousers, and the excess body hair disappeared. The pulse however was almost unchanged. This showed that although his symptoms were much improved the basic condition of the organs was still the same, and that he could easily revert to the condition he was in before. 3. Miss S. 26 years old complained of lethargy. On examining the pulse, it was found to be slightly Rapid, Full and Wiry in the left Guan, and Tight on both sides, between the Guan and Cun. The Tight quality appearing on both sides suggested obstruction of Qi somewhere in the chest region. (Not in an organ, which would have had a Tight quality on one side only). The Wiry and Rapid left Guan pulse indicates LlV-Yang rising. I asked her if she had a tight feeling in the chest. She answered that she had had this tight feeling since losing her temper a week previously. 4. Mrs. B. 48 years old had a recurring condition of cystitis. For many years she had contracted cystitis every two or three months that had necessitated the use of antibiotics. Both Chi pulses were very Small and Soft and Deep, indicating that she had very weak KID energy. During the time that she had cystitis, the left Chi pulse was still very Small but Tight and superficial. Thus in her case the left Chi pulse related to the bladder, and the superficial and tight quality related to the attack of cold. 5. Mr. N. 23 years old complained of a painful shoulder. He enjoyed playing all sorts of sports, but found he could not do so because his shoulder became so painful the day after using it. The pain occurred along the L.l. channel. He had tried physiotherapy and other manipulative techniques but with no lasting results. On taking his pulse I found that both the Cun positions were Empty, and the right Chi position Full and a little Tight. Once glance at his physique showed that his condition was good, so that any disorder in the Chi pulse would not relate to the KID, but must relate to the Fu. Since the main symptom he complained of was along the L.I. channel, it pointed to some obstruction of Qi in the L.I. organ. After some questioning it appeared that he had been kicked in the abdomen in a football match some years previously, but had thought nothing of it. His abdominal muscles were completely tense and knotted, but as treatment progressed these muscles relaxed and it was possible to feel the knot deep down, from the obstruction of Qi in the L.I. This case is specially interesting, for the Right Cun pulse relates to the L.I. channel and the right Chi pulse relates to the L.I. organ. The obstruction of Qi in the L.I. organ is a full condition in the Lower Jiao. Consequently the right Chi pulse is too Full; the symptoms of the arm are all empty conditions and result from the channel not being nourished by the organ. The Qi is
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obstructed in the organ and is unable to reach the channel. As a result, the Cun pulse is weak. Further reading This article is merely an introduction to pulse diagnosis. The principles have been elaborated and worked out in the 27 qualities. The basis is very simple, but to diagnose accurately from the pulse requires much experience. There is no particular magic or mysterious process in building up this experience, beyond careful observation and thought. There are a number of texts available in English which will help in further study. The text of Li Shi Zhen's Bin Hu Mai Xue is now available in a translation by Hoc Ku Huynh of P.O. Box 202-K, Haymarket, NSW Australia. (Also available from Felicity Moir, 17a Kensington Park Gardens, London W.ll. Cost 19.00) For a description of pulse qualities, and their meaning when they appear in different positions see "The Web that has no Weaver" by Ted J. Kaptchuk. This book also contains useful diagrams illustrating the pulse qualities. For an unusual approach based on years of clinical experience see "Chinese Medicine" by Dr. J.H.F. Shen published by Educational Solutions Inc., 80 Fifth Avenue, New York, N.Y. 10011.
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JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984