PULSE DIAGNOSIS

Chapter 49


imagePULSE DIAGNOSIS



Chapter contents



INTRODUCTION


THE ‘NINE REGIONS’ OF THE PULSE FROM THE ‘YELLOW EMPEROR’S CLASSIC OF INTERNAL MEDICINE’


THE PULSE IN THE ‘CLASSIC OF DIFFICULTIES’


THE THREE SECTIONS OF THE PULSE


ASSIGNMENT OF PULSE POSITIONS TO ORGANS



THE THREE LEVELS


METHOD OF PULSE TAKING



FACTORS AFFECTING THE PULSE



ATTRIBUTES OF THE NORMAL PULSE



GUIDELINES FOR INTERPRETING THE PULSE



CLINICAL APPLICATION OF PULSE DIAGNOSIS



INTEGRATION OF PULSE AND TONGUE DIAGNOSIS



LIMITATIONS OF PULSE DIAGNOSIS




INTRODUCTION


Pulse diagnosis is the most difficult of the Chinese diagnostic arts: it is a very complex subject which must involve a deep level of understanding and a great deal of skill. An essential diagnostic tool for all practitioners of Chinese medicine, pulse diagnosis is truly an ‘art’; it has more right to that title than any other of the Chinese diagnostic skills. To acquire the skills of good pulse diagnosis requires great patience and to become proficient takes years of practice. It is a study that has no end: one will continue to develop one’s skills and understanding of pulse diagnosis throughout a lifetime of practice.


What is one feeling when taking the pulse? Basically, we are feeling the pulsation of Qi through the pulsation of Blood. Qi is a subtle energy and cannot be ‘felt’ (except by expert practitioners of Qi Gong) or ‘measured’; we therefore use the radial artery to feel the pulsation of the blood to give us an idea of the state of Qi. This is made possible by the strong link between Qi and Blood: Qi is the commander of Blood and Blood is the mother of Qi. Thus, through the pulsation of Blood, we can feel the state of Qi. That we use pulse diagnosis to feel the state of Qi is also shown by the fact that the pulse is felt on the radial artery where the Lung channel flows; because the Lungs govern Qi, that particular artery tells us about the state of Qi.


Pulse diagnosis is important for two reasons: it helps to identify the internal organ affected or the prevailing pattern and it reflects the whole complex of Qi and Blood.




The pulse identifies organ and pattern disharmony


Within the general picture of a disharmony, the pulse may be considered to be a manifestation like any other (e.g. thirst, dizziness, red face, etc.). The unique significance of pulse diagnosis, however, is that it, by itself, allows us to diagnose a pattern, even in the absence of other symptoms. For example, dizziness indicates a Kidney deficiency only if it occurs together with other Kidney-deficiency symptoms, such as tinnitus, lower backache and night sweating. However, a Deep-Weak Kidney pulse on both Rear positions by itself unequivocally indicates a Kidney deficiency.


In addition, the pulse may also indicate, by itself, a pattern with some certainty. For example, dizziness may be caused by Phlegm and, in order to diagnose this, it should be accompanied by other symptoms or signs of Phlegm such as a feeling of oppression in the chest, a feeling of muzziness in the head, a Swollen tongue, etc. However, a Slippery pulse by itself indicates Phlegm (excluding of course the case of pregnancy).




THE ‘NINE REGIONS’ OF THE PULSE FROM THE ‘YELLOW EMPEROR’S CLASSIC OF INTERNAL MEDICINE’


The practice of feeling the pulse on the radial artery was described in the ‘Classic of Difficulties’ (c. AD100); before that, the pulse was taken on nine different arteries: three in the head, three on the hands and three in the legs, as described in Chapter 20 of the ‘Simple Questions’: ‘There are three areas in the body, each area is divided into three which makes nine regions: these are used to determine life and death [i.e. prognosis], and in them, 100 diseases manifest, Deficiency and Excess are regulated and the pathogenic factors can be expelled.’1


The ‘nine regions’ are the arteries where the pulse is felt and which reflect the state of the Upper, Middle and Lower Burners; each of these three areas is divided into three regions identified with Heaven, Person and Earth to indicate Upper, Middle and Lower regions as indicated in Table 49.1.



Although this method of taking the pulse on nine different arteries and in nine different places was superseded by that of taking only the pulse of the radial artery, feeling the pulses of the nine regions may still be useful in clinical practice to confirm the Emptiness or Fullness of a particular area. For example, in a patient suffering from hypertension caused by the rising of Liver-Yang, it may be useful to check the pulses of the upper regions to determine the degree and severity of this pathology (the stronger, harder and fuller the pulses of the upper regions, the more severe is the rising of Liver-Yang).


Another example of the use of the pulses of the nine regions is in patients with circulatory problems in the legs; in this case, it may be useful to feel the pulses of the lower regions to establish the degree of severity of this problem (the weaker and emptier the pulses of the lower regions, the poorer is the circulation of Qi in the lower legs). Furthermore, this method may be particularly important if taking the pulse of a patient whose arm or leg has been amputated; in such a case the three pulses of the radial artery of the missing limb may be replaced by the nine regions from the ‘Simple Questions’.



THE PULSE IN THE ‘CLASSIC OF DIFFICULTIES’


The ‘Classic of Difficulties’ (AD100) established for the first time the practice of taking the pulse at the radial artery; this pulse was variously called Qi Kou (‘Portal of Qi’), Cun Kou (‘Portal of Inch [Front pulse position]’) and Mai Kou (‘Portal of Pulse’). The ‘Classic of Difficulties’ says:




The last part of this statement is interesting since the description of the pulse of the Portal of Inch as the ‘beginning and end point of the energy of the 5 Yin and 6 Yang organs’ seems to imply an understanding of the circulation of blood as a closed circuit.


There are two main reasons why the pulse is felt at the ‘Qi Portal’ position on the radial artery by the wrist in correspondence with the Lung channel. First of all, the Lungs govern Qi and this channel is therefore the best to gauge the state of Qi in the body. In fact, Chapter 1 of the ‘Classic of Difficulties’ says:




Secondly, Postnatal Qi and Blood are derived from food and water entering the Stomach. The Stomach extracts the essences of food, which go to the Lungs; from the Lungs, they go to the skin and the five Yin and six Yang organs and to all the arteries in the body; this is a reason why LU-9 Taiyuan is the Gathering point of all blood vessels. The ‘Simple Questions’ says in Chapter 11:




Chapter 21 of the same text says:




Thus, the section of radial artery on the Lung channel can tell us about the state of Qi and Blood of the whole body (Box 49.1).



BOX 49.1   WHY THE PULSE IS FELT ON THE RADIAL ARTERY (LUNG CHANNEL)




Dr J. H. F. Shen has an interesting further idea why the pulse is felt at the radial artery by the wrist. He compares the blood flowing in the radial artery by the wrist with a sea wave and the metacarpal bone of the thumb with a cliff: because the wave of blood in the radial artery crashes against the cliff and is pushed back, we can feel the pulse here. If the blood did not encounter this obstacle, it would flow through undeflected and we would not be able to interpret it in the same way (Fig. 49.1).




THE THREE SECTIONS OF THE PULSE


The three pulse sections are as follows:













Inch (Cun) Front
Gate (Guan) Middle
Foot (Chi) Rear


The second chapter of the ‘Classic of Difficulties’ explains how its author arrived at feeling the pulse at the three positions called Inch or Front, Gate or Middle and Foot or Rear (Cun, Guan and Chi):




The Foot and Inch sections of the pulse are the meeting point of the channels. The distance from the Gate position [LU-8, level with the radial apophysis] to the Foot position in the elbow represents the Foot-Interior and it reflects the Yin energies. The distance from the Gate position to the point Fish Margin [the thenar eminence] is the Foot-Exterior and it reflects the Yang energies. Hence, the distance of 1 inch is separated from the distance of 1 foot [from the Gate position to the elbow crease], so that the distance of 1 foot is represented by 1 inch. Hence the Yin energies are reflected within that 1-inch section of the foot-long section and the Yang energies are reflected within a 9-fen [nine-tenths of an inch] section of the Inch section. The total length of the Foot and Inch section extends over 1 inch and 9 fen; hence one speaks of Foot and Inch sections.6


In other words, the distance from the Gate-Guan (or Middle) position of the pulse (on LU-8 Jingqu) to the crease of the elbow measures one Chinese foot and reflects the Yin energies; the distance from the Gate-Guan position to the crease of the wrist is 9 fen (nine-tenths of an inch) and reflects the Yang energies. However, a 1-inch section is separated from the 1-foot distance from the Gate-Guan position to the elbow crease to represent the Yin energies; in other words, this 1-inch section is representative of the 1-foot section (Fig. 49.2).



The ‘Pulse Classic’ says something similar:




From the Fish Margin [the thenar eminence] to the prominent bone [the radial styloid process] moving one inch backwards [proximally], in the middle of this is the Inch Portal. From the Inch to the Foot, it is called Chi Ze and this position is called Foot. The position behind the Inch and in front of the Foot positions, is called Gate position: this is the boundary between the emerging Yang [at the Inch position] and submerging Yin [at the Foot position]. Emerging Yang occupies three divisions [positions] and submerging Yin also occupies three divisions [positions]. Yang originates at the Foot position and moves [or manifests] in the Inch position; Yin originates in the Inch position and moves [or manifests] in the Foot position. The Inch position governs the Upper Burner including the skin and hair up to the hands; the Gate position governs the Middle Burner including the abdomen and back; the Foot position governs the Lower Burner including the lower abdomen up to the feet.7


The ‘Classic of Difficulties’ says in Chapter 3: ‘In front [i.e. distal] of the Gate position Yang moves, the pulse here is 9 fen long and superficial … behind [i.e. proximal to] the Gate position Yin moves, the pulse here is 1 cun long and is deep.’.8


Thus, three sections of the pulse are identified: the Inch-Cun (Front) section reflecting the Yang energies, and the Gate-Guan (Middle) section and the Foot-Chi (Rear) section reflecting the Yin energies, (Box 49.2).



BOX 49.2   THE THREE POSITIONS OF THE PULSE




Three different types of finger pressure are applied to each section, making up the ‘nine regions’, which share the same name with but have a different meaning from those of the ‘Simple Questions’ listed above. This was the revolution brought to pulse diagnosis by the ‘Classic of Difficulties’: the same information that could be gained by feeling the pulse on nine separate arteries in the head, hands and legs, could now be gained by feeling the pulse at the radial artery only.


Chapter 18 of the ‘Classic of Difficulties’ describes the three different pressures applied to the pulse:




This passage establishes clearly the principle, adopted by all successive doctors, that the Inch section of the pulse corresponds to the Upper Burner and diseases from the chest upwards, the Gate section to the Middle Burner and diseases from the diaphragm tothe umbilicus, and the Foot section to the Lower Burner and diseases from the umbilicus to the feet (Fig. 49.3).




ASSIGNMENT OF PULSE POSITIONS TO ORGANS


I shall discuss the assignment of pulse positions to organs by examining the various pulse arrangements over the ages, and then trying to reconcile the discrepancies between the various arrangements.



Organ positions on the pulse


Besides attributing the three sections of the pulse to the Three Burners, Chinese pulse diagnosis goes much further in assigning each pulse position to the Qi of a particular organ. Through the centuries, Chinese doctors have disagreed over such assignment and many different opinions exist. Table 49.2 summarizes the assignment of pulse positions to various organs, according to six representative major classics:










It is worth reporting the actual passages concerning the correlation between organs and pulse positions from some of the classics to show how such correlation has never been so simple and mechanical as what tends to be taught today, that is, that we feel the ‘Yang organs at the superficial level and Yin organs at the deep level’.



Classic of Difficulties (Nan Jing, AD100)


Chapter 18 of the ‘Classic of Difficulties’ explains the correspondence of pulse positions to organs (or channels) in accordance with the five Elements in a rather complex statement:




The Hand Greater Yin [Lungs] and the Hand Bright Yang [Large Intestine] pertain to Metal; the Foot Lesser Yin [Kidneys] and Foot Greater Yang [Bladder] pertain to Water. Metal generates Water, Water flows downwards and cannot ascend. Therefore, these are felt at the position below the Gate position [i.e. Foot position]. The Foot Terminal Yin [Liver] and the Foot Lesser Yang [Gall-Bladder] pertain to Wood; Wood generates the Fire of the Hand Greater Yang [Small Intestine] and Hand Lesser Yin [Heart]. Fire blazes upwards and cannot descend. Hence, the Hand Greater Yang [Small Intestine] and Hand Lesser Yin [Heart] correspond to the position above the Gate [i.e. the Inch position]. The Fire of the Hand Heart Master [i.e. Pericardium] and Lesser Yang [Triple Burner] generates the Earth of Foot Greater Yin [Spleen] and Foot Bright Yang [Stomach], Earth governs the Centre and its position is therefore the central one. This is in accordance with the Five-Element Mother–Child mutual generating and nourishing relationship.10


Thus, the ‘Classic of Difficulties’ assignment of organs to pulse positions follows strictly the Generating cycle of the Five Elements as follows (Fig. 49.4):

















Left Right
Small Intestine/Heart Lungs/Large Intestine
Gall-Bladder/Liver Spleen/Stomach
Bladder/Kidneys Pericardium/Triple Burner


It is interesting to note that this strict assignment of organs to pulse positions according to the Five Elements and the assignment of the right Foot (Rear) position to the Pericardium and Triple Burner would suggest that the ‘Classic of Difficulties’ assigns channels rather than organs to the pulse positions. Thus, the arrangement of pulse positions in the ‘Classic of Difficulties’ is seen clearly from the acupuncturist’s perspective rather than the herbalist’s and this would confirm that the two main pulse arrangements, that is, one with the Small Intestine and Large Intestine on the Front and the other with them on the Rear position, reflect the different perspectives of the acupuncturist and herbalist, as discussed in more detail below.



Pulse Classic (Mai Jing, AD280)


The ‘Pulse Classic’ discusses the correspondence of pulse positions to organs (or channels) in Chapter 7. It says:




The Heart position is assigned to the left Cun [which is] distal to the Gate position. The Heart is the Hand Lesser Yin and is exteriorly–interiorly related to the Hand Great Yang, i.e. the Small Intestine. The Liver position is assigned to the left gate position. The Liver is the Foot Terminal Yin and is exteriorly–interiorly related to the Foot Lesser Yang, i.e. the Gall-Bladder. The Kidneys position is assigned to the left Foot position which is proximal to the Gate position. The Kidneys are the Foot Lesser Yin which is exteriorly–interiorly related with the Foot Greater Yang, i.e. the Bladder. The Lungs position is assigned to the right Cun position, distal to the Gate position. The Lungs are the Hand Greater Yin and are exteriorly–interiorly related to the Hand Bright Yang, i.e. the Large Intestine. The Spleen position is assigned to the right Guan position. The Spleen is the Foot Greater Yin which is exteriorly–interiorly related to the Foot Bright Yang, i.e. the Stomach. The Kidneys position is assigned to the right Foot position, proximal to the Gate position. The Kidneys are the Foot Lesser Yin which is exteriorly–interiorly related to the Foot Greater Yang, i.e. the Bladder. The Kidneys and Bladder meet in the Lower Burner at a point to the right of Guan Yuan [Ren-4]: to the left of this point are the Kidneys, to the right the Uterus also called Triple Burner.11


The last part of this statement is of note as it seems to assign both left and right Rear positions to the Kidneys and Bladder, while the Rear position reflects also the Uterus and Triple Burner. Most authors translate the end of the above passage as meaning that the left Rear position corresponds to the Kidneys and the right Rear one to the Uterus and Triple Burner; I personally think that ‘right’ and ‘left’ at the end of the above passage refer to right and left of Ren-4 Guanyuan. In conclusion, the pulse arrangement from the ‘Pulse Classic’ is:
















Left Right
Small Intestine/Heart Lungs/Large Intestine
Gall-Bladder/Liver Spleen/Stomach
Bladder/Kidneys Kidneys/Uterus/Triple Burner/Bladder


The association between Uterus and Triple Burner is interesting as it confirms the statement from Chapter 66 of the ‘Classic of Difficulties’, according to which the Original Qi stems from the space between the two kidneys (and therefore also the Uterus in women) and it spreads to the five Yin and six Yang organs via the intermediary of the Triple Burner.




The ‘Golden Mirror of Medicine’ (Yi Zong Jin Jian, 1742)


The ‘Golden Mirror of Medicine’ by Wu Qian assigns the pulse positions to the organs as follows:



















Left Right
‘External’/‘Internal’ ‘Internal’/‘External’
Shanzhong/Heart Lungs/Centre of thorax
Gall-Bladder/Liver Spleen/Stomach
Bladder, Small Intestine/Kidneys Kidneys/Large Intestine


Figure 49.5 is a reproduction of the diagram from the original text and Figure 49.6 is a translation of the same.13




The diagram from the ‘Golden Mirror of Medicine’ clearly shows that ‘external’ and ‘internal’ mean distal and proximal respectively: this means that the Yang and Yin organs within each position are felt at the distal and proximal ends respectively. This is discussed in greater depth below.



Modern China


The most common pulse assignment in modern China is as follows:



















Left Right
‘External’/‘Internal’ ‘Internal’/‘External’
Pericardium/Heart Lungs
Gall-Bladder/Liver Spleen/Stomach
Small Intestine/Bladder/Kidney-Yin Kidney-Yang/Large Intestine


Such assignment of pulse positions to organs is something that I have deduced from the various teachers I learned with in China as modern books do not usually present this information in a clear form. This is probably due to the fact that there has been considerable disagreement on this over the centuries and modern books tend therefore to gloss over this. For example, ‘Chinese Acupuncture and Moxibustion’ of 1987 does not even give any assignment of pulse positions to organs.14 Other texts often overlook the assignment of the Small and Large Intestine organs as this is the subject of more disagreement: for exam-ple, the ‘Fundamentals of Chinese Medicine’ (a translation of a Chinese text) of 1985 says: ‘The right Inch pulse is associated with the Lungs, and the right Barrier pulse is associated with the Stomach and Spleen. The left Inch pulse is associated with the Heart, and the left Barrier pulse is associated with the Liver and Gall-Bladder. The Kidney and Bladder are reflected in both Cubit pulses.’15



Reconciling different pulse arrangements


Although different pulse assignments may seem contradictory, there is a common thread running through them. It is generally agreed that the Front position reflects the Upper Burner, the Middle position the Middle Burner and the Rear position the Lower Burner. Generally, the main discrepancies occur with the assignment of the Yang organs and especially the Small and Large Intestine. Indeed, many doctors do not assign the Yang organs to the pulse at all (the ‘Yellow Emperor’s Classic of Internal Medicine’ does not).



Yin and Yang organ as reflected on the pulse


The commonly held assumption that the superficial level reflects the state of the Yang organs and the deep level that of the Yin organs has never been the only one in Chinese medicine. In fact, the different levels (or different places) where the Yang and Yin organs are felt are often described as wai (external) and nei (internal) and ‘external’ and ‘internal’ may be interpreted in three ways:






The first interpretation is by far the most common today but it is important to realize that it is not the only one and also that the three interpretations are not mutually exclusive. Indeed, Dr J. H. F. Shen often uses the second and third interpretations when reading the pulse; this will be discussed later. Figure 49.7 illustrates the three different ways of interpreting ‘external’ and ‘internal’.



In any case, the relationship between Yin and Yang organs as reflected on the pulse needs to be interpreted dynamically and not mechanically; we should not simply assign the superficial level to the Yang organs and the deep level to the Yin ones, for example on the left Middle position the Gall-Bladder on the superficial level and the Liver on the deep level. As the relationship between the paired Yin and Yang organs is very close (except for the Small Intestine/Heart and Large Intestine/Lung, which will be discussed shortly), each individual pulse position should be first analysed as a whole, paying attention to the intensity and the level of the pulse, rather than mechanically feeling the ‘Gall-Bladder’ on the superficial level and the ‘Liver’ on the deep level as two separate entities.


Each pulse position can reflect different phenomena in different situations. For example, let us consider the left Middle position (Liver and Gall-Bladder): in a state of health, the Liver and Gall-Bladder will be balanced or, to put it differently, Yin and Yang within the Liver/Gall-Bladder sphere are balanced. In this case, the pulse will be relatively soft and smooth and not particularly superficial or deep and the Gall-Bladder influence on the pulse will not be felt. But if Liver-Yang is in excess and rises upwards affecting the Gall-Bladder channel (causing severe temporal headaches), the rising Qi will be reflected on the pulse, which will be Wiry (harder than normal) and more superficial (it will be felt pounding under the finger). In interpreting this pulse we can say that Liver-Yang is rising or, to put it differently, that the Gall-Bladder Qi is in excess.




Small and Large Intestine channels versus organs in pulse diagnosis


The Small and Large Intestine are probably the subject of the widest discrepancies in pulse diagnosis because they are sometimes placed on the Front and sometimes on the Rear position. This discrepancy may be explained by the fact that the connection between these two organs and their channels is somewhat looser than that of other organs. In fact, the Small and Large Intestine organs are in the Lower Burner while their channels are in the arms (the organs of the Upper Burner have their channels in the arm, whereas the organs of the Middle and Lower Burner have their channels in the legs). Furthermore, the functions of the intestinal organs do not correspond closely to those of their channels; in fact, although the arm points of the Small and Large Intestine can of course be used for intestinal problems, their chief clinical application is to treat problems of the neck, shoulders, face and head as well as external invasions of Wind.


Thus, the same pulse quality in the specific example of the Front position could mean two different things in different situations. For example, if the right Front position (Lung) is quite superficial, slightly big and slightly Rapid, this could indicate an emotional upset affecting the Lungs. Here, the pulse reflects the state of the Lungs. But on another occasion exactly the same type of pulse may indicate something quite different when, for example, the patient has an acute, large, purulent tooth abscess. In such a case, the pulse reflects the state of the Large Intestine channel (where the abscess is) rather than a problem with the Lung organ. On the other hand, problems with the Large Intestine organ (rather than channel) more often manifest on the Rear position of the pulse and often on both sides. For example, in patients suffering from ulcerative colitis nearly always the Rear position of both sides is very Wiry, reflecting the Heat and stagnation in the Large Intestine. Thus, from these two examples (tooth abscess and ulcerative colitis) we can see how the contradictory assignments of the Large Intestine to the right Front and right Rear positions can both be right.



Clinical significance of pulse diagnosis irrespective of organ positions


We should not make too much of the different pulse positions assumed by different doctors and we should not view the relationship between pulse positions and organs mechanically. In fact, it would be perfectly possible to make a good, clinically significant pulse diagnosis without referring to the Internal Organs at all. This is because the pulse gives us an idea of the relative strength of Qi in the Three Burners, at the three levels and on left and right sides.


The pulse essentially reflects the state of Qi in the different Burners and at different energetic levels which are dependent on the pathological condition. We need to interpret the pulse dynamically rather than mechanically. The most important thing is to appraise how Qi is flowing, what is the relationship between Yin and Yang on the pulse (i.e. is there Deficiency or Excess of Yin or Yang), at what level is Qi flowing (i.e. is the pulse superficial or deep), and whether the body’s Qi is deficient and whether there is an attack by an external pathogenic factor.



The pulse gives us clinically relevant information, even without reference to organ positions.

Related posts:

  1. OBSERVATION OF THE GENITALIA
  2. MENSTRUAL SYMPTOMS
  3. DIAGNOSIS BY HEARING
  4. OBSERVATION OF THE COMPLEXION COLOUR

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

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