Pulse Diagnosis

Historical Evolution of Pulse Diagnosis

• Bian Que (also known as Qin Yue Ren) - 6th Century BCE

  • He is considered the historical forerunner of pulse theory.

• Pulse Studies and the Inner Classic

  • This foundational work describes the shape of each pulse, provides interpretations for various pulse images, and documents measurements of the pulse taken at numerous locations across the body.

• The Classic of Difficult Issues ($25-220 \, CE$)

  • This text introduced the concept of specific pulse positions that are still utilized today.

• Zhang Zhong-Jing

  • He elevated pulse diagnosis to the same level of importance as pattern identification (Pattern ID).

  • He is responsible for classifying pulse images into Yin and Yang categories.

  • He introduced the concept that seasons influence the quality of the pulse.

• The Pulse Classic (Compiled by Wang Shu-he)

  • This was the first full-length treatise dedicated entirely to the pulse.

  • It identified and defined $24$ specific pulse types.

• Li Shi-Zhen (1564 CE)

  • He wrote "Bin Hu’s Teachings on Pulse Diagnosis," which remains the most commonly used book on the subject.

  • The text introduces the underlying physiology and mechanisms behind different pulse images.

  • He expanded the categories to discuss $27$ distinct pulse types.

Foundational Principles and Clinical Distinctions

• Contradictions Between Pulses and Signs

  • Pulses and clinical signs do not always match and can contradict one another.

  • A pulse may be "false" while the physical signs are "true."

  • Alternatively, signs may be "false" while the pulse is "true."

  • In many cases, the signs and the pulse simply reflect different facets of the same underlying pattern.

• The Three Positions (Cun, Guan, Chi)

  • Cun (Heaven): The position closest to the wrist crease.

    • Left Wrist: Represents the Heart (HT) and Small Intestine (SI). SI is located more superiorly (superficial); HT is located deeper.

    • Right Wrist: Represents the Lung (LU) and Large Intestine (LI). LI is superior (superficial); LU is deeper.

  • Guan (Human): The middle position.

    • Left Wrist: Represents the Liver (LV) and Gallbladder (GB). GB is superior; LV is deeper.

    • Right Wrist: Represents the Spleen (SP) and Stomach (ST). ST is superior; SP is deeper.

  • Chi (Earth): The third position, furthest from the wrist crease.

    • Left Wrist: Always represents the Kidney (KD) and Urinary Bladder (UB), specifically Kidney Yin.

    • Right Wrist: Usually represents the Kidney (KD) and Urinary Bladder (UB), associated with Kidney Yang. Sometimes it represents the Pericardium (PC) and San Jiao (SJ), where SJ is superior and PC is deeper.

• Imperial vs. Ministerial Fire

  • The HT/SI is designated as Imperial Fire.

  • The PC/SJ is designated as Ministerial Fire.

  • The variation in the Right Chi position is explained by the flow of Qi: Imperial fire leads into Ministerial fire. If Heart fire is strong, it moves to the Ministerial fire, which then distributes it throughout the body. This Ministerial fire becomes Kidney Yang; therefore, they are different manifestations of the same energy.

Physiology of the Viscera in Pulse Manifestation

• The Heart: Governs the blood and vessels. It produces the pulsation and propels blood. The Heart also stores the Shen (Spirit). The pulse reveals how the Shen is responding to internal and external stimuli, helping the individual relate to the outside world.

• The Lung: Assembles or "faces" the $100$ vessels. Because the Lung governs Qi, and Qi is the "commander of blood," the Lung Qi is responsible for distributing blood throughout the body.

• The Spleen: Controls the blood, preventing it from spilling out of the vessels. The Spleen also controls the limbs; during movement (standing/walking), the Spleen moves blood to the necessary areas, storing it more superficially.

• The Liver: Stores blood deep within the body and regulates the Qi dynamic to ensure it is smooth and unimpeded. It regulates the total volume of blood in the body.

• The Kidney: Stores Essence and serves as the root of Yang Qi. Essence can be transformed into blood.

• Gu Qi Formation: Gu Qi (Food Qi) separates into clear and turbid parts. The middle jiao uses the heavier portion of the clear Qi to fuse it into essence, which is then sent to the heart.

Characteristics of a Normal Pulse

• Depth: It is neither floating nor deep.

• Rate: Approximately $4-5$ beats per breath of the practitioner ($70-90 \, bpm$).

• Size: Neither large nor small.

• Length: Neither long nor short.

• Nature: Even, moderate, and harmonious.

• Natural Variations:

  • Age: Babies typically have a rate of $120-140 \, bpm$.

  • Gender: Men typically have larger pulses; women often have weaker or thinner pulses.

  • Seasons:

    • Spring: Wiry pulse.

    • Summer: Surging (or slippery) pulse.

    • Fall: Empty and floating pulse.

    • Winter: Sinking or deep pulse.

Essential Pulse Qualities: Stomach Qi, Shen, and Root

• Stomach Qi: The Stomach is the origin of the body's Qi and Blood of "acquired constitution" (nutrition). Presence of Stomach Qi in a pulse is signaled by force and spirit. It should feel calm, leisurely, harmonious, and moderate.

• Shen: Indicated by a pulse that is gentle and mild but still possesses force and a consistent rhythm.

• Root (Kidney): If Kidney Qi is sufficient, the pulse has "root." This is felt at the deep level in the Chi (3rd) position. An anchored pulse indicates that even if a person is ill, recovery is possible because Kidney Qi is not exhausted.

Identification of Specific Pulse Types

• 1. Floating Pulse

  • Description: Pronounced at the surface; deficient at lower depths.

  • Indications: External Attack (if accompanied by chills, fever, and body aches).

  • Variations:

    • Floating and Tight: Wind-Cold or Tai Yang Excess (fever, intense chills, no sweating).

    • Floating and Fast: Wind-Heat.

    • Floating and Empty/Rootless: Chronic disease or major blood loss (Right Qi deficiency).

    • Scattered Pulse: Floating and diffuse without root.

    • Scallion Stalk: Floating and empty in the middle.

• 2. Deep Pulse

  • Description: Can only be felt at the deep level.

  • Indications: Usually an interior pattern.

  • Note: In exterior febrile diseases, a pulse may temporarily be deep if Yang Qi is obstructed.

• 3. Weak Pulse

  • Description: Deep, forceless, thin, and small. Requires firm pressure to feel.

  • Indications: Qi and Blood Deficiency; Yang Deficiency. Often seen post-childbirth or in chronic cough/blood loss.

  • Hidden Pulse: A variation that is even deeper and less forceful than the weak pulse.

• 4. Deep Wiry / Full Pulse (Confined Pulse)

  • Description: Deep, forceful, and tense. It feels "tied to the bone."

  • Indications: Internal stagnation (Cold pain, phlegm retention, food/Qi stagnation, interior excess heat, or calculus obstruction).

• 5. Fast (Rapid) Pulse

  • Description: $90-139 \, bpm$ ($6$ beats per breath).

  • Racing Pulse: Anything greater than $139 \, bpm$.

  • Indications: Heat in the Upper Jiao (especially Lungs).

    • Fast and Forceful: Excess Heat.

    • Fast and Thin: Deficiency Heat.

    • Fast, Forceless, and Large: Qi Deficiency.

• 6. Slow Pulse

  • Description: $40-60 \, bpm$ ($3$ beats per breath).

  • Indications:

    • Slow and Weak: Yang Qi Deficiency.

    • Slow and Forceful: Obstruction of Qi Dynamic (cold, phlegm, or blood stasis).

    • Slow in Pregnancy: Uterine deficiency cold (insecure fetal qi).

• 7. Moderate Pulse

  • Description: Smooth, flowing, and resilient. Slightly slower than normal with a subtle softness.

  • Indications: If no symptoms are present, it is healthy (indicating Stomach Qi).

    • Slightly less forceful: Qi deficiency.

    • Slightly more forceful: Dampness ($Moderate \rightarrow Slippery$ is a continuum; slippery pulses do not have the softness of a moderate pulse).

• 8. Slippery Pulse

  • Description: Smooth and resilient; compared to "pearls rolling in a dish" or "fish swimming." It is a "whooshing" of Qi and Blood.

  • Indications: Excess Heat, Phlegm, Food Stagnation, or Damp-Heat. It is normal in pregnancy and in healthy athletes.

  • Variations: Slippery and Fast (Damp Heat); Slippery and Large (Internal Excess Heat).

• 9. Rough or Choppy Pulse (Opposite of Slippery)

  • Description: Compared to "a knife scraping bamboo." Thin, slow, short, and rough; "vomiting silkworm."

  • Indications: Lacks Stomach Qi.

    • Forceful: Blood Stasis (severe, potential tumor/bleeding; often with a purple tongue).

    • Forceless: Qi and Blood Deficiency (insufficient blood to fill the vessel).

• 10. Wiry Pulse

  • Description: Long, straight, and tense, like a guitar string. The most common pulse.

  • Indications: Liver patterns, stagnation, pain, and phlegm-cold.

  • Specific Conditions: Shao Yang disease (mid-depth wiry with alternating chills/fever).

  • If Wiry and Empty: Ascending Yang due to Yin deficiency or LV/SP disharmony.

• 11. Tight Pulse

  • Description: Similar to wiry but harder and vibrates sideways "like a twisted rope."

  • Copper Wire Analogy: Wiry is like a copper wire without insulation; Tight is like a copper wire with insulation.

  • Indications: Cold or excess pain. Floating and tight indicates cold at the surface; deep and tight indicates cold at the deep level.

• 12. Empty / Deficient Pulse

  • Description: Large (wide) and forceless. Palpable on the surface but feels empty under pressure.

  • Indications: Qi and Blood deficiency (especially Lung Qi). Empty and fast indicates Yin deficiency.

• 13. Soggy / Soft Pulse

  • Description: Similar to empty but thin. "Like cotton cloth floating in water."

  • Indications: Qi Deficiency (Spleen/Stomach) and Dampness. Unlike the Empty pulse, the Soggy pulse specifically indicates dampness.

• 14. Full / Excess Pulse

  • Description: Forceful, large, long, and slightly wiry. Strong coming and going; palpable at all three depths.

  • Indications: Exuberant excess, fire evil, or terminal bowel constipation. Can be normal for constitutionally robust patients.

• 15. Surging / Flooding Pulse     Description: Similar to full but stronger coming than going, like waves beating against rocks.     Indications: Yang Ming / Qi level heat (The "Four Bigs": big sweat, thirst, fever, pulse). If it suddenly flares up from a weak pulse, it indicates severe damage to Right Qi and impending death.

• 16. Thin Pulse

  • Description: Thin and straight like a thread. Strongest at middle depth.

  • Indications: Qi and Blood Deficiency.

    • Thin and Fast: Yin Deficiency (very common).

    • Thin and Faint: Yang Deficiency.

    • Thin and Wiry: Liver Yin Deficiency.

• 17. Faint Pulse

  • Description: Extremely fine, soft, and barely perceptible.

  • Indications: Severe acute deficiency, collapse of Yang (accompanied by cold sweat and cold limbs), or acute loss of fluids.

• 18. Long Pulse

  • Description: Straight and long like a pole; extends beyond the Cun and Chi positions.

  • Indications: Resilient/no symptoms = normal. Long and wiry = arteriosclerosis or stagnation.

• 19. Short Pulse

  • Description: Lacks root; usually only felt in the Guan position.

  • Indications: KD Essence deficiency.

    • Forceless: Qi/Blood deficiency or hemorrhage.

    • Forceful: Phlegm or food stagnation.

• 20. Irregular Pulse

  • Description: The pulse skips beats.

  • Variations:

    • Irregularly Irregular: Random skips; signals damage to heart muscle or zang organs.

    • Regularly Irregular: Consistently missing a beat; more dangerous, indicating significant heart muscle damage.

General Classifications and Guidelines

• Excess Type Pulses: Wiry, Tight, Full, Long, Surging, Slippery, Rapid, Floating, Rough (forceful), and potentially Irregular.

• Deficiency Type Pulses: Weak, Thin, Faint, Short, Empty, Soggy, Slow, Deep, and Rough (forceless).

• Dampness Markers: Soggy, Wiry (if rheum), Moderate and forceful, Slippery (specifically Damp-Heat).

Pulse Correlations and Positions

• Standard Testing Guideline:

  • Right Wrist: Lung (1st), Spleen (2nd), Kidney Yang/Ming Men (3rd).

  • Left Wrist: Heart (1st), Liver (2nd), Kidney Yin (3rd).

• Bonus Guideline (by 3 Jiao and Yin/Yang Organ):

  • Right: Lung (Cun), SP/ST (Guan), KD/LI (Chi).

  • Left: Heart (Cun), LV/GB (Guan), KD/UB/SI (Chi).

Clinical Philosophy

• Never treat a patient outside of their constitution. Identify the patient's "normal."

• If a patient feels great but the pulse/tongue appears "bad," treat based on what maintains their well-being rather than chasing a "perfect" pulse.

• If the patient feels bad, use the pulse to identify the pathology and guide healing.