Bob Flaws L.Ac.This book is a basic introduction to pulse examination as it is used in Traditional Chinese Medicine or TCM. Although in Chinese, TCM is simply referred to as zhong yi or Chinese medicine, I do regard what is usually called TCM in the West as a particular style of Chinese medicine. Many of the adherents of this style would simply say that TCM encompasses all that has been found to be worthwhile and clinically valid over the 2000 years of recorded Chinese medical history and that is why it is simply called Chinese medicine. Be that as it may, here in the West, there are a number of styles of Oriental medicine currently being taught and practiced. Therefore, I think it useful to distinguish this style for what it is. Hence, before attempting to understand the role and practice of pulse examination within this style, I believe it is important to understand something about this style in general.
TCM as a Style
The hallmark of TCM as a style of Chinese medicine is its emphasis on treatment based on pattern discrimination (bian zheng lun zhi). This means that, although TCM practitioners first make a disease diagnosis (bian bing), treatment is based more on the pattern discrimination than on that disease diagnosis. In other words, the overall guiding treatment principles for the case at hand are based on the pattern discrimination, not on the disease diagnosis. It is these principles which guide the selection of the Chinese medicinal formula or main acupuncture points. Once these main principles are stated and a basic treatment protocol is erected based on these principles, medicinals or acupuncture points are then added to the base protocol depending on their empirical efficacy for the particular disease under treatment.
For instance, a patient may be suffering from headache. In TCM, headache (tou tong) is a disease category. If the patient also says that her headache comes at the end of every menstruation, is worse at night or when fatigued, tends to be generalized, typically lasts until she goes to bed but is usually gone when she wakes the next morning, and if her facial complexion is a sallow yellow, she has palpitations or dizziness, lack of warmth in her four limbs, a scanty appetite, loose stools with her period, pale nails, a pale tongue, and a fine and weak or relaxed pulse, her TCM pattern discrimination is one of blood vacuity due to spleen vacuity. In that case, the main treatment principles are to fortify the spleen and nourish the blood. The guiding formula in that case might be either Ba Zhen Tang (Eight Pearls Decoction) or Gui Pi Tang (Restore the Spleen Decoction) depending upon the exact signs and symptoms. If Gui Pi Tang were chosen, then Radix Ligustici Wallichii (Chuan Xiong) might be added to specifically upbear blood to nourish the sea of marrow and therefore address the specific complaint of headache.
If treated by acupuncture, the basic formula might consist of Zu San Li (St 36), San Yin Jiao (Sp 6), Pi Shu (Bl 20), and Ge Shu (Bl 17). The first three points all fortify the spleen, remembering that it is the spleen which is the root of latter heaven or postnatal qi and blood engenderment and transformation. Ge Shu is the hui or so-called reunion point of the blood. It specifically acts to nourish the blood. If the major complaint or disease were palpitations, then Shen Men (Ht 7) might be added to this basic formula. However, because the disease under treatment is headache, Bai Hui (GV 20) might be added with moxibustion in order to upbear yang qi, based on the premise that it is the qi which moves the blood and that the blood follows the qi.
It is said in TCM:
Yi bing tong zhi
Tong bing yi zhi
One disease, different treatments;
Different diseases, one treatment.
This means that any disease may present a number of different patterns. In the case of headache, there are wind cold external invasion pattern headaches, liver yang hyperactive above pattern headaches, phlegm dampness obstructing the clear portals pattern headaches, blood vacuity pattern headaches, and essence insufficiency pattern headaches, to name the most common ones. Although two patients may each suffer from headache, if their TCM pattern discrimination is different, they will receive a different treatment. Another two patients may present with two completely different diseases. One may be suffering from headache and the other from insomnia and yet, as long as they present the same overall TCM pattern, their treatment may be essentially the same.
Therefore, in TCM, a correct pattern discrimination is vitally important. It is the guide and foundation to successful, individualized treatment. When treatment is given on the basis of a correct TCM pattern discrimination, it restores balance without iatrogenesis or side effects. In addition, a TCM pattern discrimination contains within itself an explanation of why the person is manifesting the signs and symptoms they do. Each pattern is the result of certain disease causes (bing yin) and disease mechanisms (bing ji). If one understands those disease causes and mechanisms, then one can take steps to alter or abolish them. One can change their diet and lifestyle accordingly and even change deleterious mental/emotional habits. Thus a TCM pattern discrimination is both enlightening and empowering in a way that a simple disease diagnosis typically is not. Hence, TCM pattern discriminations are the means by which practitioners of Chinese medicine can follow the injunctions in the Nei Jing (Inner Classic) to emphasize prevention over mere remedial treatment.
How Patterns Are Discriminated
TCM patterns are discriminated by means of the four examinations (si zhen). These are visual examination (wang zhen), inquiry (wen zhen), listening and smelling examination (wen zhen), and palpation (qie zhen). It is by means of the combination of these four methods of examination (si zhen he can) that a TCM pattern is identified. However, most modern TCM clinical manuals describe this combined summation and analysis in terms of main symptoms (zhu zheng), examination of the tongue (she zhen), and pulse examination (mai zhen). In other words, in clinical practice, patterns are based on three broad groups of information: 1) signs and symptoms, 2) tongue examination, and 3) pulse examination. It is the comparison and corroboration of these three groups of information which differentiate one pattern from another, and it is extremely important that no one sign or symptom means anything except in relationship to all other signs and symptoms gathered by the four examinations.
For instance, the pattern of spleen qi vacuity and spleen yang vacuity have many of the same signs and symptoms. In both patterns there are scanty appetite, loose stools, abdominal distention, fatigue, lack of strength, and a pale tongue with a thin, white coating. However, in the case of spleen yang vacuity there are also chilling of the limbs, a cold body, and a slow pulse. But this does not mean that chilled limbs are always a symptom of yang vacuity. There may be chilled limbs due to liver depression/qi stagnation. In this case, the four chilled limbs are referred to as the four counterflows because yang qi is depressed internally and cannot flow uninhibitedly out to the extremities. One knows this because the tongue in this case is a dark reddish and may have a yellowish coating, while the pulse is wiry and rapid, not slow.
Thus it is vitally important to keep in mind that no one sign or symptom always means any one thing. It only means something when taken in consideration of all other signs and symptoms, including the tongue and pulse examinations.
The TCM Methodology
This basic TCM methodology of moving from a major complaint to the patient’s individual signs and symptoms, tongue, and pulse, thus constituting the pattern discrimination, thence to the statement of treatment principles, and only then to the selection of a guiding formula or protocol and its individualized modifications is exemplified in the organization of most modern Chinese TCM clinical manuals. In such clinical handbooks, information is typically given under the following headings and in the following order:
Disease name:
Treatment based on pattern discrimination:
Pattern name:
Main symptoms:
Tongue & coating:
Pulse images:
Treatment principles:
Formula:
Additions & subtractions based on symptoms:
Just as most Chinese clinical manuals and textbooks are organized in this manner, it is important that clinicians follow this methodology or progression when making a pattern discrimination and then erecting a treatment plan. This is a very step by step methodology, and if one omits a step, then the whole process may go awry. It is especially important to write down the TCM pattern discrimination and the treatment principles before writing down the names of Chinese medicinal formulas or acupuncture points. I have explained this process at greater length in both my Sticking to the Point: A Rational Methodology for the Step by Step Formulation & Administration of a TCM Acupuncture Treatment and How to Write a TCM Herbal Formula.
The Importance of Pulse Examination
As seen above, pulse examination is one of the main methods of establishing a TCM pattern discrimination. Pulse examination in modern TCM primarily means the feeling of the pulse of the radial arteries at the styloid processes of both wrists. This is commonly called the cun kou or inch opening. It is believed by practitioners of Chinese medicine that the pulses felt here can be read as a simulacrum of the flow of qi, blood, and body fluids of the entire body. The first chapter of the Nan Jing (Classic of Difficulties) opens with the following question:
All the twelve channels have [sections where the] movement [in these] vessels [can be felt]. Still, one selects only the cun kou in order to determine whether the five viscera and six bowels [harbor a] pattern of death or life, of good or evil auspices. What does that mean?1
The answer of why one can determine the health and disease of the entire body by feeling the pulses at the cun kou on the wrists that the Nan Jing gives is this:
The cun kou constitutes the great meeting point of the [contents passing through] the vessels. It is the [section of] the hand tai yin [channel where the] movement [in that] vessel [can be felt]. When a [normal] person exhales once, [the contents of] the vessels proceed 3 inches. When [a normal person] inhales once, [the contents of] the vessels proceed [another] 3 inches. Exhaling and inhaling [constitute one] breathing [period]. During this period, [the contents of] the vessels proceed 6 inches. A person, in the course of one day and one night, breathes altogether 13,500 times. [During that time, the contents of] the vessels proceed through 50 passages. [That is,] they circulate through the body [in the period needed by] the [clepsydra’s] dripping water to move down by 100 markings. The constructive and defensive [qi] proceed through 25 passages [during a] yang [period], and they proceed through 25 passages [during a] yin [period]. This constitutes one cycle. Because [the contents of the vessels] meet again, after 50 passages, with the cun kou, [this section] is the beginning and the end of [movement of the contents of the vessels through the body’s] five viscera and six bowels. Hence, the pattern [of death or life, good or evil auspices harbored by the body’s five viscera and six bowels] may be obtained from the cun kou.2
Whether or how one chooses to accept this explanation aside, it is a fact that practitioners of Chinese medicine have been diagnosing and treating patients on the basis of pulse examination carried out at the inch opening for at least 2000 years. On the other hand, most Western students of TCM find pulse examination very confusing and difficult to master. It seems somehow very mystical and arcane. Although most Western practitioners express a strong belief and interest in pulse examination, few, I think, feel very confident of their abilities in this domain.
This Western ambivalence toward and pervasive lack of mastery of pulse examination is, I believe, exacerbated by a somewhat similar attitude toward pulse examination current in the Peoples’ Republic of China at least in the 1980s. When I was a student in China during that time, the importance of pulse examination was deliberately played down by many of my teachers and clinical preceptors. Based on conversations, it seems they felt that pulse examination was hard to validate by Western anatomy and physiology and, therefore, was a bit of an embarrassment to people who were desperately trying to become modern and scientific. At that time, I never had a teacher tell me a pulse was anything other than wiry, slippery, fast, slow, floating, deep, or fine. One of my teachers only took the pulse with two fingers and never expressed her readings in terms of the three basic positions of the pulse. When queried about this, she said that it is scientifically impossible for the pulse to have different qualities or images in different positions. Ergo, one does not have to worry about positions.
What I mean to say is that, although pulse examination comprises at least one third of the diagnostic criteria for making a TCM pattern discrimination, many modern Chinese teachers and the majority of the modern Chinese TCM literature of which I am aware, tend not to be very sophisticated in their explanation and use of pulse examination. Rather, it seems that many modern Chinese TCM practitioners relegate pulse examination to a minor, confirmatory role. While Western practitioners believe that pulse examination is mystical, and therefore difficult to learn, many modern Chinese practitioners believe it is mystical, and therefore not worth learning.
However, this is not my experience. I believe that mastery of pulse examination is vitally important for making a correct TCM pattern discrimination. And I believe that pulse examination is, perhaps, even more important for Western practitioners than for our Chinese counterparts. This is because it is my experience that our patients are sick in more complex ways than many Chinese patients. In China, most young practitioners do not go into private practice working in isolation from senior practitioners with lifetimes of experience. It is my experience that young practitioners in China are given relatively simple cases to treat, and, should they come across a complicated, difficult case, they can always ask a senior practitioner to help parse out the pattern discrimination. Western practitioners, on the other hand, tend to go immediately into private practice, and that after insufficient clinical education as an undergraduate. Typically, there is no one else in the clinic to ask about a difficult case. In addition, we as Western practitioners tend to see a disproportionate number of difficult cases which are either not self-limiting or have not been successfully treated by modern Western medicine and often other types of alternative medicine as well. This is because, here in the West, we are so often practitioners of last resort. Further, because of the modern Western diet, the adverse effects of certain modern Western medical treatments, the ill effects of pollution, and the pervasive stress of our modern society, most of our patients suffer from complex, chronic conditions which frequently and I might even say typically do not display the nice, neat, simple patterns contained in beginners’ TCM textbooks.
In my experience, all too often, our patients present, not with one textbook pattern or another, but with a combination of three, four, or even five patterns. When the disease mechanisms at work in such complex patterns interact with each other, they produce complicated mixtures of signs and symptoms, including complicated and sometimes even seemingly contrary pulse images. Thus it is also my experience that if one wants to parse out such complicated patterns, one must be able to feel more than just the several pulse images enumerated above. In addition, one must also understand how each pulse is created and the secondary and tertiary meanings of all of the pulse images. In other words, it is my experience that a simplistic approach to pulse examination is not sufficient for the practice of TCM in the West.
The Obstacles to Mastering the Pulse
The good news is that pulse examination is not that difficult to master. In my experience, there is a trick that makes pulse examination actually quite easy and straightforward. However, before revealing that secret, I would like to quote Manfred Porkert from The Essentials of Chinese Diagnostics on what he calls “three kinds of obstacles to mastering pulse diagnosis:”3
- Inadequate endowment
- Wrong intellectual perspective
- Inapt pedagological approach
Manfred Porkert describes inadequate natural endowment under two sub-headings: 1) inadequate physical endowment (i.e., lack of sufficient sensitivity in the fingertips and the capability to concentrate) and 2) inadequate intellectual gifts (i.e., inability to distinguish, coordinate, and synthesize the observed data). In terms of this first obstacle to mastering Chinese pulse examination, it is up to the Deans of Admission and Academic Deans at Western schools and colleges of acupuncture and Oriental medicine to ensure that all students enrolled at such schools are endowed with these capabilities.
By “wrong intellectual perspective,” Porkert is referring to preconceived notions regarding Chinese pulse examination by Western health care practitioners who are often skeptical about it. If one refuses to believe that one can diagnose health and disease by feeling the pulse of the radial arteries at the wrists, then of course, one will not seriously study this art with an open mind and will not plumb its depths. This is not usually a problem at most Western schools of acupuncture and Oriental medicine. Students at such schools typically enter with a willingness to study and consider as at least provisionally true the basic theories and practices of Chinese medicine.
However, it is the last obstacle – an inapt pedagological approach – which Porkert says is responsible for most failures in mastering Chinese pulse examination. In fact, it is Porkert’s opinion that:
Most of the failures in mastering pulse diagnosis – I should say at least 80 percent – are due to this formidable obstacle, or to approaching it too lightly.4
According to Porkert, Chinese pulse examination is a skill. However, it is an essentially intellectual skill. He goes on to say that in the acquisition of any skill, the gathering of certain intellectual information must precede physical training. This means that intellectual data must be presented before physical instruction and that it is that intellectual data which actually constitutes the indispensable basis for the effective acquisition, assimilation, and integration of physical experience. In other words and in terms of Chinese pulse examination, unless one has learned all pertinent TCM theory and the intellectual, i.e., verbal, descriptions of all the major pulse images, one cannot feel and interpret the pulses correctly.
To exemplify this point, several years ago, in going back through my case records, I noticed that I had often written down that this or that patient’s pulse was fine and floating. At the time, I had just finished reviewing the textbook definitions of the 28 pulses and these were fresh in my mind. I immediately recognized that what I had described as a fine and floating pulse is the soggy (ru) or soft (ruan) pulse. I had been feeling fine and floating pulses for years. However, until I realized that a fine and floating pulse is a soggy pulse, I was not able to make the diagnoses that go with a soggy or soft pulse. My fingers were not suddenly feeling anything physically different. My new-found ability to feel the soggy pulse was entirely an intellectual capability, a verbal epiphany, not a physical one.
The Secret of Chinese Pulse Examination
In my experience, the secret of Chinese pulse examination is exactly this: One cannot feel a pulse image unless one can consciously and accurately state the standard, textbook definition of that pulse image. If one does not know that the soggy pulse is floating and fine, one cannot write down that diagnosis even though one may be able to feel that the pulse is floating and fine. Therefore, I wholeheartedly agree with Porkert when he says:
Applied to the training and mastery of pulse diagnosis…the problem is not that the students cannot feel what must be felt, but that they usually are at a loss to describe, hence to assimilate, to permanently learn and keep what they have physically perceived… This, precisely, is the critical issue: there is no point in attempting practical training in pulse diagnosis unless all pertinent theory and, more important, the complete iconography of the pulse has previously been absorbed intellectually. In other words, no student of pulse diagnosis should attempt practical training unless he has not only memorized, but understood by frequent rehearsal, every single term and technical relationship instrumental to Chinese pulse diagnosis… Only on this condition will he be able to immediately describe and express with precision and stringency what he feels when actually putting his fingers on a patient’s arms. And only on this premise will he be able to recall, reflect and communicate to his colleagues what he feels.5
Porkert goes on to state:
If this essential condition has been met, practical mastery of pulse diagnosis in normal medical practice is – at worst – a question of several months; with proper guidance it should take only weeks to gauge, correct and refine one’s sensitivity so that the error rate drops to insignificance within one month. If, on the contrary, this warning is ignored, even with the best intentions, a student may not master quite basic notions even with years of trying… Trying to make sense of the subtle differences felt at the pulse sites without the most strict reference and conscientious attention to the intellectual tools prepared for this very purpose in the course of almost 2000 years is like attempting to interpret an EKG while spurning all knowledge of what is taught about this technique in medical colleges by physics, physiology and clinical medicine.6
I have to admit that this is exactly the case with me and my experience of Chinese pulse examination. I first read Porkert’s book in 1983 when it was first published in English. At the time, I remember reading the above passages. I did not just read them, I even underlined them. However, I did not actually take the trouble to memorize the exact Chinese definitions of all the major pulse images until several years ago. Although I was able to feel the slow and fast, deep and floating, slippery, wiry, and fine pulses, as long as I could not say either out loud or to myself the word for word definitions of the other 20 or more pulses, I could not feel them in clinical practice. Once I realized this fact and went back and memorized these definitions, I was immediately able to feel all the major pulses as long as I kept these definitions currently in mind. In addition, I have taught this approach to several groups of Western students and, within two days, they were immediately able to feel and consciously identify twice as many pulses as they had been previously able.
In other words, this method works. I know it works because it works for me. I also know it works because I have seen it work for others as well. Having studied several Oriental arts in my life, it is my experience that mastery comes from mastering the basics. Unless there is a solid foundation, one cannot build high into the sky. Beginners think that masters have some special secrets to which they are not yet privy, but that is rarely the case. Mastery always means mastery of the basics. Unfortunately, all too often it is human nature to be impatient with the basics and to try to jump to some seemingly higher, more exciting plane. In terms of Chinese pulse examination, mastery of the basics primarily means the memorization of the definitions of the major pulse images or what Manfred Porkert calls the iconography of the pulse.
This is not a big book on the pulse. Certainly there is more that can be said about Chinese pulse examination. However, it is my heart-felt plea that Western students of acupuncture and Oriental medicine not just read this book but take the time to memorize the factual material it contains. At the very least, if you want to be able to feel the main 27-29 pulse images, you must memorize their definitions. As Manfred Porkert points out:
Chinese pulse diagnosis does not presuppose any exceptional, little known, paranormal endowment or ability in the person applying it. All that is required is a solid grounding in its coherent theory and a trained and well-kept hand.7
For many modern Western students, memorization is a dirty word. It seems so boring and prosaic. It seems to lack mystery and imagination. But believe me, if you want to be able to do Chinese pulse examination, just do it.
This article is an excerpt from a book titled The Secret of Chinese Pulse Diagnosis by Bob Flaws, $17.95, ISBN 0-936185-67-8, from Blue Poppy Press. To order directly call 1-800-487-9296
References
1. Nan Ching (The Classic of Difficulties), trans. by Paul U. Unschuld, University of California Press, Berkeley, CA, 1986, p.65.
Jim Strohecker
Tom Ferguson MD
Daniel Redwood DC