Complex CM pulse qualities and associated pulse parameters

Blood/plasma loss may occur suddenly such as acute haemorrhaging due to trauma or gastrointestinal bleeding such as a perforated stomach ulcer. Fluid loss may occur due to excessive vomiting, sweating, diarrhea, dehydration or excessive urination. Hypovolemic shock is a type of circulatory shock that refers to the decreased blood volume resulting from blood or plasma loss. Circulatory shock causes inadequate blood flow around the body. There are usually three stages of circulatory shock (Guyton and Hall 2006: pp. 279-285, Tortora & Grabowski 2000, McCance & Huether 2006):

From a CM perspective the different stages of hypovolemic shock may be the mechanism underlying the traditional CM pulse qualities such as the Faint pulse or the Scallion stalk pulse, relating to sudden acute blood loss (see individual CM pulse qualities for more information).

Chronic blood loss may occur over time due to heavy menstrual bleeding, abnormal uterine bleeding, gastrointestinal bleeding, nosebleeds, hematemesis, hemoptysis, bleeding from haemorrhoids or cancer. Chronic blood loss may mean that blood loss is occurring at a faster rate than haemoglobin can be replaced, resulting in smaller red blood cells containing less haemoglobin (Guyton & Hall 2006: p. 426).

According to McCance & Huether (2006: p. 942)‘haemorrhage that is chronic (occult) produces adaptations that are less prominent and the individual experiences an iron deficiency anaemia when iron reserves become depleted.’

Dietary restraints on eating sources of iron or the poor absorption of appropriate nutrients for the production of blood will also affect blood quality. While plasma volume remains unchanged, the number or size of red blood cells (RBCs) may be adversely affected, leading to a decrease in blood viscosity.

Each of the above situations impacts upon either the number of RBCs, plasma volume or haemoglobin-carrying capacity of the RBCs and therefore affects the circulatory system in varying degrees, hence the appearance of certain CM pulse qualities (see section 7.5.3.7 for more detailed information). These processes may be reflected within the CM pulse qualities such as the Fine, Faint or Scallion Stalk pulse qualities.

The Liver is traditionally associated with assisting the free spread of Qi throughout the body, and its movement is considered to have an expansive nature. In addition, the Liver has a major role to play in the storage of blood, providing sufficient blood to circulate through the blood vessels and channels, while returning at night to be stored in the Liver. The patterns of disharmony associated with the Liver therefore involve obstruction of this normal free flow and spreading of Qi and blood.

Liver disharmonies associated with the Stringlike (Wiry) pulse include Liver Qi stagnation, Liver Yang rising, Liver Fire, internal Liver Wind and Liver Blood stasis (Box 7.4).

Yang Qi is responsible for maintaining the normal tension of the arterial wall. If Liver Yang becomes hyperactive this can lead to increased tension in the pulse.

A number of authors agree that the Stringlike (Wiry) pulse can be seen in Phlegm patterns (Deng 1999, Li (Flaws trans) 1998, Lu 1996, Lyttleton 2004, Maciocia 2004). Phlegm is formed by a number of different processes (see Clavey (1995) for a comprehensive discussion on the aetiology and symptomatology of Phlegm) and may occur due to Heat or Fire within the body, causing body fluids to dry up and congeal. Alternatively, Liver Qi stasis can eventually turn to fire, again drying fluids. Flaws (1997: p. 53) describes Yin obstruction (due to Damp, Phlegm, food or blood causing obstruction or stasis) as being capable of impeding the free flow of Qi.

Phlegm/Damp is able to enter and ‘choke the circulation both inside and outside of the blood vessels’ (Clavey 1995: p. 177) impeding the flow of blood. This can be equated with hypertension in a biomedical context, where there is sclerotic loss of vascular elasticity and therefore increasing hardness of the arterial wall.

Clinically this can be seen in conditions such as epigastric fullness, nausea, vomiting, coughing with production of phlegm. Phlegm/Damp may also result in gynaecological problems such as amenorrhoea and infertility and this may present as a Stringlike (Wiry) pulse, particularly if Liver Qi stagnation is the contributing cause (Lyttleton 2004).

The Stringlike (Wiry) pulse may be seen in any condition where there is pain. From a CM perspective, pain indicates obstruction of Qi or blood or both. Therefore the lack of free flow is reflected in the increased arterial tension in the pulse. Pain evokes a systemic response, activating the sympathetic nervous system. This will tend to override other pulse variables, with increased arterial tension the predominating change in pulse parameters. Clinically, this pulse may be seen in abdominal or epigastric pain, dysmenorrhoea, headaches and musculoskeletal problems, irrespective of the cause.

Rogers (2000) describes this pattern as Wood energy attacking Earth energy, while Lu (1996) and Deng (1999) briefly mention the pattern of Liver encroaching on Spleen due to an underlying vacuity of the Earth energy. The aetiology is premised on the Five Phase (Wu Xing) arrangement of the organs involving the Ke cycle. The Ke cycle is the controlling cycle and within this cycle the Liver is responsible for keeping in check the functions of the Earth, particularly the Spleen. When the Spleen and Stomach Qi become deficient, or the Wood overexerts its controlling function, this results in digestive problems that present with both Wood and Earth type symptoms. For example, irritable bowel syndrome presenting with alternating diarrhoea and constipation and exacerbated by stress is a classic presentation of the Wood attacking the Earth pattern. Flaws (1997) suggests that a commonly seen pattern is Liver Qi stasis, occurring in conjunction with both Spleen damp and Blood vacuity.

A number of authors (Li, Flaws (trans) 1998, Deng 1999, Lu 1996) describe malaria as presenting with a Stringlike (Wiry) pulse. Malaria is a febrile condition and in CM is usually recognised as having an exogenous Cold origin that has entered the body and is located between the interior and exterior. This is equivalent to the Shao Yang stage of Six Divisions (associated with the Gallbladder and Triple Energiser channels). Typical symptoms include fever, chills and severe headaches.

Pain is a common symptom associated with obstruction of Qi and/or blood flow. The associated signs and symptoms will depend on the location of the pain and the specific organ affected. The nature of the pain, for example sharp, distending, stabbing or dull, assists in identifying the pattern of disharmony.

Three organs are particularly vulnerable to direct invasion by pathogenic Cold: the stomach, the large intestine and the uterus (Maciocia 1989). This can result in strong pain due to the obstruction caused by the contracting nature of Cold on Qi and blood flow.

Clinically, the Tight pulse may be seen in conditions such as sudden stomach pain, abdominal distension and fullness, diarrhoea, loss of appetite or dysmenorrhoea (menstrual pain). Exposure to environmental cold or excessive consumption of cold, raw food such as ice cream, fruit, salad or cold drinks may contribute to the formation of this pulse. In women, exposure to Cold during menstruation, such as swimming or wearing inadequate clothing in cold weather, are also seen as potential causative factors (Lyttleton 2004: p. 17).

This may be seen in an external invasion of Wind Cold and may occur following exposure to cold weather. Pathogenic Cold has a contracting effect on the blood vessels, causing an increase in arterial tension. As an EPA, it would be expected that the pulse would also be felt relatively strongest at the superficial level of depth, providing the body’s Zheng Qi is strong.

Clinically, this may be seen as an acute onset of a cold or flu-type viral infection. Common signs and symptoms include strong body aches, aversion to cold, chills and fever, no thirst or sweating and a sore throat.

Food retention may occur when Stomach Qi is deficient or not descending properly or there is excessive food intake. This can cause obstruction of Qi and blood leading to pain, hence the formation of the Tight pulse.

From a CM perspective, the acute loss of blood results in an artery that feels ‘empty’ due to the decreased volume of circulating blood and is therefore easily occluded. Yang Qi, which is normally anchored and stabilised by Yin blood, moves upwards and outwards causing the pulse to become strongest at the superficial level of depth. Yang Qi becomes relatively hyperactive, having lost the calming aspect of the Yin, leading to an increase in arterial wall tension. This leads to the distinctive arterial wall.

Major blood loss can lead to ‘Qi deserting with the Blood’ (Wiseman & Ellis 1996: p. 151) and may be accompanied by decreased blood pressure, cold sweats or even sudden loss of consciousness.

Vacuity of Blood can occur via the chronic loss of blood due to bleeding from the gastrointestinal tract (for example, ulcerative colitis, stomach ulcers, Crohn’s disease or coeliac disease), chronic nosebleeds, abnormal uterine bleeding, haemoptysis or blood in the urine. Although the daily loss may be small in quantity, consistent loss of blood may lead to the body being unable to produce enough blood (haemoglobin to compensate adequately for the continual loss.

Blood vacuity may also occur due to problems with the organs that are involved in blood production such as the Spleen, Heart or Kidneys, so that sufficient blood is not produced. As these organs are also important in the production of Qi, concurrent Qi vacuity signs and symptoms may be present. The Liver helps to replenish blood, so Liver disharmony may also affect the quality of blood.

Chronic illness of any kind can affect the production of both Qi and blood, so that blood and Qi are not replenished. Kidney Yin vacuity can lead to vacuity of Kidney Essence, which in turn affects blood production and nourishment.

The Scallion Stalk pulse may be seen in patients following blood loss, usually due to an acute situation. This may result from physical trauma or non-trauma-related blood loss such as acute gastrointestinal bleeding, for example a perforated ulcer. This may cause hypovolemic shock, referring to the decrease in blood volume due to loss of blood (hypovolemic shock also refers to the loss of plasma that may occur due to severe burns, intestinal blockage or the excessive loss of body fluids due to profuse sweating, vomiting, diarrhoea or urination) (see Box 7.6 for further information).

The term ‘shock’ refers to ‘an inadequate cardiac output that results in a failure of the cardiovascular system to deliver enough oxygen and nutrients to meet the metabolic needs of body cells’ (Tortora & Grabowski 1996). As previously discussed in section 7.4.2, there are three stages of shock. The Scallion Stalk pulse may possibly arise following either a small amount of blood loss or with increased blood loss (Box 7.7).

If blood loss is less than 10% of total volume then this is known as nonprogressive shock and compensatory mechanisms are initiated in the period after the blood loss to return blood volume back to normal (see Box 7.8). This includes the absorption of fluids from the interstitial spaces and intestinal tract. Although this is helpful in increasing the plasma volume back to normal (which takes 1-3 days), it does not compensate for the loss of red blood cells, which may take 3-6 weeks to return to normal. Therefore, following nonprogressive blood loss the red blood cell concentration is low while plasma volume returns to normal fairly quickly. This results in posthaemorrhagic anaemia and may help explain why the pulsation is more easily occluded as the blood flow is less dense (lower proportion of red blood cells) and has a decreased viscosity (‘thinner’ in consistency). This has a number of effects: a decrease in peripheral resistance so blood flow is increased; peripheral vasodilatation to increase blood flow through the tissue because of decreased oxygen supply to tissues due to decreased red blood cell concentration. These both result in more blood returning to the heart and an increased cardiac output. This may cause the pulse to be more readily palpated at the superficial level of depth, have a wider diameter than usual and be more readily occluded.

If blood loss is more severe, dropping by more than 15% of total volume, then the normal compensatory mechanisms are not sufficient and urgent medical intervention to replace fluids lost is required to return blood volume to normal. This is known as progressive shock, and cardiac output falls dramatically, which is worsened by the instigation of positive feedback cycles. Due to the decreased cardiac output, the heart muscle becomes ischaemic, leading to even lower output and blood pressure. This in turn adversely affects the activity of the vasomotor centre in the brain that controls vasoconstriction. This leads to generalised vasodilatation of blood vessels. The pulse is forceless due to the decreased cardiac output, the arterial width is increased due to vasodilatation and is easily occluded due to the lack of volume in the arterial system and hence, the Scallion Stalk pulse manifests.

The increased arterial wall tension that results in the distinctive pliable arterial wall of the Scallion Stalk pulse (as previously discussed in section 7.3.5) occurs due to tension in other parts of the arterial wall structure, not from contraction of vascular smooth muscle. In fact, the artery wall is in a state of vasodilatation because of the blood loss.

The Guangzhou College notes (1991) state that the Hollow (Scallion Stalk) pulse has been shown to appear experimentally when blood loss is both rapid and heavy (>400 ml) and when the usual compensatory reflexes of vasoconstriction have not resulted in strong contraction of the blood vessels (no specific research study has been cited).

Chronic blood loss may result in anaemia, occurring over a period of time due to the body’s inability to absorb enough iron from the intestinal tract (mainly the small intestine) to replace the lost haemoglobin. This can result in the production of smaller red blood cells containing insufficient haemoglobin. A loss of 2-4 ml of blood per day is enough to cause iron deficiency anaemia (McCance & Huether 2006: p. 934). Chronic disease such as chronic inflammatory disease, HIV/AIDS, hepatitis and chronic renal failure may also result in anaemia due to alterations to iron metabolism, red blood cell life span, and blood cell production in the bone marrow (McCance & Huether 2006: Ch. 26).

Chronic blood loss may occur due to occult bleeding such as gastrointestinal tract bleeding from ulcers, inflammatory bowel disease, coeliac disease, carcinoma or a range of other gastrointestinal complaints. In addition, menorrhagia (heavy menstrual bleeding) or abnormal uterine bleeding may also contribute to blood loss.

Alternatively, there may be inadequate dietary sources of iron resulting in anaemia due to general decreased food intake, specific dietary restrictions (for example, restrictions on meat) or problems with iron absorption such as coeliac disease or other inflammatory intestinal disease.

As noted by Guyton and Hall (2006), anaemia has a systemic effect on the circulatory system. In anaemia, it is the lowered proportion of red blood cells to plasma volume that results in a decreased blood viscosity. This in turn has a positive effect on the peripheral resistance to blood flow, resulting in an increased amount of blood flowing through the tissues and returning to the heart. The increased blood flow to the heart results in increased cardiac output, which is further enhanced by vasodilatation of peripheral blood vessels due to decreased oxygen supply to tissues (hypoxia). The rate of blood flow also increases. In other words, the cardiovascular system, particularly the heart, has to work much harder to continue to supply the body with sufficient oxygen and nutrients and transport metabolic waste products to be eliminated.

Over time this can have a detrimental effect on the heart, leading to eventual cardiac failure if the underlying cause of anaemia is not addressed. In severe anaemia, the cardiac output may be raised to as much as three or four times normal levels (Guyton & Hall 2006: p. 427).

From a CM perspective, such physiological changes are represented in the pulse by:

Recent research has shown that Helicobacter pylori, bacteria commonly implicated in digestive dysfunction such as duodenal and stomach ulcers, may also lead to iron deficiency anaemia (Russo-Mancuso et al. cited in McCance & Huether 2006: p. 934). H. pylori has been shown to impair iron absorption (Ciacci et al. cited in McCance & Huether 2006: p. 934). This has an interesting correlation with CM theory, where impaired functioning of the Spleen and Stomach, integral to digestive functioning, can also lead to the impaired production of both blood and Qi.

This acute pattern of an EPA of Cold occurs on top of an underlying vacuity of body fluids or blood loss. The causes of this blood or body fluid loss are varied and have been discussed previously in the section on the Scallion Stalk pulse. The Drumskin pulse could be interpreted as a further development of the Scallion Stalk pulse, due to the complication of an EPA of Cold.

If the Drumskin pulse is seen in a relatively new illness, this is seen as less critical and therefore has a good prognosis.

From a biomedical perspective, the Drumskin pulse (similarly to the Scallion Stalk pulse) has increased arterial tension but not only due to vasoconstriction (smooth muscle contraction). Due to the loss of blood there is compensatory vasodilatation (relaxation of vascular smooth muscle), so tension/stress in the arterial wall is transferred to other structures within the wall. The additional complication of pathogenic Cold stimulates the body’s attempts to maintain warmth, thereby activating vasoconstriction of the arterial walls which has an additive effect on the tension already in the arterial walls, hence the extremely ‘hard’ presentation of the artery on palpation.

The Drumskin pulse may be seen in patients with an acute profuse loss of Yin fluids due to haemorrhage, excessive sweating, diarrhoea or vomiting.

The Drumskin pulse may also appear in the course of chronic illness. This is seen as a critical worsening of the disease, indicating the increasing severity of vacuity of blood, body fluids or Kidney Essence, and therefore is considered to have a bad prognosis. The mechanism is similar to the previous pattern.

The Scattered pulse is a sign of severe disease, reflecting a severe vacuity of Qi, Blood, Yin and Yang. This may be due to chronic illness that, over time, consumes these substances, reflecting increasing vacuity of the organs involved in the transformation and transportation of Qi and blood, including the Spleen, Stomach, Lung, Kidney and Heart.

The Kidneys are considered to be the source of both Yin and Yang for the entire body, providing both the motive and nourishing aspects that support health. Therefore if Kidney function is affected, over time this can affect the functioning of all organs.

Yuan Qi provides the motive force for all the functional activity in the body. If this is exhausted, then Yang Qi will also be adversely affected. Yang Qi maintains the normal arterial wall tension. If Yang Qi is deficient then the arterial wall loses definition, blurring the boundaries between the artery and surrounding tissue.

A forceful pulse is defined as having a large pulse pressure wave or amplitude, with the change in pressure occurring rapidly so that the pulse strikes the finger strongly and displaces a wide surface area on the fingertip (Fig. 7.4). It is defined as being forceful in at least two of the three traditional pulse positions and with the pulse likely to be apparent in the beyond Chi and/or beyond Cun pulse positions.

A pulse that is forceless is defined as either:

The perception of pulse force is also affected by the proportion of time the heart is in systole and diastole, which affects the volume of blood ejected into circulation by the heart (stroke volume). It is also affected by pressure indices affecting the end-systolic volume in the ventricles and so strength of heart contraction.

The activation of the sympathetic or parasympathetic nervous system affects the heart, leading to changes in cardiac output (see Box 7.13 for further information).

Changes in body temperature due to either environmental conditions or disease can affect both the heart rate and, to a degree, the contractility of the heart. Changes in body temperature alter the rate of electrical discharge in the heart (Stables & Rankin 2005: p. 225).

A moderate increase in body temperature can increase the strength of cardiac contractility, therefore increasing the perceived force of the radial arterial pulsation. However, if this is prolonged it has an adverse effect on cardiac metabolic functioning resulting in eventual impaired cardiac function and therefore weaker contractions.

If the heart rate is greatly increased, both systole and diastole are shortened. Systole duration increases to the detriment of the diastolic duration. As a result, the left ventricle will not be filled sufficiently, adversely impacting on the cardiac output and also resulting in a weaker pulsation.

Cardiac output is regulated in proportion to metabolic activity. Guyton & Hall (2006: p. 237) note that cardiac output declines with age, however they add that this is probably reflective of declining activity with age. This is associated with decreased skeletal muscle mass and therefore reduced oxygen and blood flow requirement reflected in a decreased cardiac output.

The Replete pulse indicates the presence of a strong pathogenic factor, usually Heat or Fire, generally resulting in the stagnation of Qi.

In the presence of pathogenic Heat, the appearance of the Replete pulse indicates that the antipathogenic Qi (Upright or Zheng Qi) is strong. The excessive force is a reflection of the struggle between the pathogen and the body’s Zheng Qi as it attempts to overcome the pathogen. It would also be expected that the hyperactivity of Yang could also cause an increase in pulse rate, resulting in the appearance of the Rapid pulse.

The Replete pulse is formed as a result of the body’s fight against the pathogenic factor, with blood and Qi overfilling the artery. Pulse force defines the Replete pulse and is determined by a combination of the strength of Yang Qi and the Yang nature of pathogenic Heat. Therefore the pulse has an increase in overall intensity, reflecting the summative accumulation of Yang Qi.

This Firm pulse can be seen when pathogenic Cold enters the body and directly lodges in the interior. This may affect the internal organs such as the stomach, the intestines or the uterus, which are considered to be particularly vulnerable to an attack of external Cold directly passing to the interior of the body (Maciocia 2004). Alternatively, this may be due to consumption of excessively cold food (such as ice cream) or cold drinks. Cold in the stomach may present with abdominal pain and vomiting of clear fluids, Cold in the intestines usually presents with lower abdominal pain and diarrhoea, and Cold in the uterus may result in pain during menstruation.

Pathogenic Cold can also enter the meridian system. An example of this is an invasion of pathogenic Cold into the Liver channel, which may present clinically as a hernia.

Lu (1996) also notes that the Firm pulse may be seen in convulsions caused by Wind.

The Firm pulse may also arise as a result of the internal stagnation of Qi or blood so that neither Qi nor blood is able to reach the exterior. Stasis may be caused by retention of food, or may be due to pathogenic factors such as Cold or phlegm. Improper diet or emotional disturbance may adversely impact on the Liver and Spleen, leading to Qi stasis that, over time, results in the stasis of Blood.

The Firm pulse is commonly associated with abdominal masses due to either Qi or Blood stasis (Lu 1996). Qi stasis can result in the formation of masses of indefinite shape that can form or dissipate at irregular intervals, influenced by the state of Qi flow. The location of the pain is not fixed. Such masses are known as ‘conglomerations’ and are usually associated with disease in the Fu (Yang) organs and problems with Qi. ‘Concretions’ are also caused by stasis and have a definite form and fixed location, usually associated with problems of the Zang (Yin) organs and blood (Wiseman & Ye 1998: p. 92). Blood stasis type pain is usually fixed, stabbing and more severe in nature.

A deeply located pulse can indicate:

In the case of Qi stasis, the increased arterial tension indicates disturbance to the normal Qi flow, and a resulting hyperactivity of Yang that is unable to move outwards.

In the case of pathogenic Cold, the increased arterial tension is due to the contracting nature of Cold. It also reflects the obstruction of normal flow of Qi and blood by the Cold, which has a tendency to constrain Yang.

The increased force and wide arterial diameter seen in the Firm pulse imply the presence of a pathogenic factor and reflect the resulting obstruction of Qi and/or blood.

Blood and Qi have a mutual relationship; blood is considered to be the mother of Qi, and Qi engenders blood (Wiseman & Ye 1998). Blood vacuity is often accompanied by Qi vacuity signs, therefore the signs and symptoms accompanying the Vacuous pulse may include both blood and Qi vacuity signs: generally these include lethargy, shortness of breath, spontaneous sweating, pale complexion, low voice, dizziness, ‘floaters’ in eyes and pale tongue. Specific signs and symptoms will of course depend on the specific organs involved.

Qi, particularly the Yang aspect, works to maintain arterial wall tension; when Qi is vacuous the tension in the arterial wall is not maintained and the arterial diameter widens. Blood vacuity results in the decreased viscosity of the blood due to the decreased numbers of red blood cells. This results in decreased oxygen supply to the tissues and the resultant hypoxia causes the peripheral blood vessels to dilate in order to increase the blood flow through the tissues and back to the heart. This contributes to the increase in arterial diameter.

Clinically, the Vacuous pulse may be seen in heat exhaustion or heat stroke. This would be expected to have an acute onset and may occur during periods of extreme climatic heat. An EPA of summer Heat causes excessive heat in the body, consuming Qi and Yin fluids. This causes dehydration and causes the pulse to become forceless and easily occluded due to a decreased fluid volume in the arteries (decreased plasma volume). Li (Flaws trans 1998: pp. 81-82) describes the accompanying signs and symptoms as spontaneous sweating, very rapid pulse and fright palpitations (Box 7.17). He advises to ‘nourish the constructive, boost the Qi’, referring to the need to rehydrate, replenish fluids (an essential part of blood) and strengthen depleted Qi.

The elderly and very young are the most susceptible to this type of pattern, as both groups are prone to difficulties with thermoregulation.

Heat exhaustion/heat stroke is characterised by fluid and electrolyte loss, especially sodium, causing dehydration. There is a consequent reduction in arterial volume (loss of plasma) and a corresponding decrease in blood pressure.

From a CM perspective, the loss of Yin fluids deprives Yang of its stabilising anchor. As a result, Yang ‘floats’, moving upwards and outwards; the pulse becomes superficial, forceless and wide. The loss of both fluid and Qi results in the lack of pulse force and its easy occlusion. The vacuous Yin means that Yang becomes relatively hyperactive and may also result in a Rapid pulse.

The severe vacuity of Qi and blood is usually due to chronic disease. This is known as ‘vacuity desertion’ (Wiseman & Ye 1998). The appearance of the Faint pulse denotes a critical worsening of a disease. Such severe vacuity usually indicates long-term hypofunctioning of the organs and may be caused by chronic lifestyle issues such as overexertion, insufficient sleep, poor diet and emotional disharmony.

From a CM perspective, this could refer to any acute situation where the separation of Yin and Yang occurs. This may be seen with high fever or massive blood and fluid loss such as haemorrhage, profuse sweating or severe vomiting and diarrhoea. The extreme and sudden loss of Yin means that Yang is no longer nourished and supported, leading to the collapse of Yang. (This is could be associated with hypovolemic shock.) This is reflected in signs and symptoms such as cold limbs, profuse beadlike sweating, no thirst, loose stools or incontinence of urine or stools, or unconsciousness.

While the Weak pulse reflects a dual vacuity of Qi and blood, Yang Qi vacuity is the predominating feature. Yang Qi vacuity signifies hypoactivity of physiological functioning, exhibiting signs and symptoms that reflect the damage to the warming and moving aspects of Yang Qi. Cold signs and symptoms accompany the Weak pulse, such as aversion to cold, cold extremities, pale complexion, lethargy, loose stools, a desire for warm drinks, increased urinary output and spontaneous sweating.

If the Weak pulse occurs in someone who is young, Lu (1996) considers this to be a sign of a weak constitution, inherited from parents. This constitutional weakness may predispose the individual to increased attack by EPAs. In this case, the pulse may not present as the Floating pulse in response to the presence of an EPA because of the body’s already depleted Qi. Pre-Heavenly Essence or Jing represents the inherited energy from each parent at the time of conception and cannot be replenished.

Chronic illness causes the consumption of both Yin and Yang over time. The appearance of the Weak pulse is seen as a natural reflection of this underlying vacuity. This may be the result of organ hypofunction and can be seen in vacuity patterns of the Kidney (sore knees, tinnitus, aching bones) and Spleen (digestive problems, tiredness, muscle weakness).

Qi and blood are traditionally considered to diminish with the natural progression of age, and the Weak pulse is said to appear in older people as a reflection of this decline. However, a vacuity of Qi and blood is considered to be pathological, whether age related or not, and it would be expected that there would be accompanying abnormal signs and symptoms associated with Qi and blood, depending on which predominates.

The Soggy pulse may arise due to vacuity of Qi and the concurrent vacuity of either blood or Yin. Blood vacuity may arise due to loss of blood through abnormal bleeding from the nose, stomach or throat known as ‘flooding invertedly’ (Li, Flaws (trans) 1998: p. 107). Alternatively, Yin vacuity signs such night sweating and ‘steaming of the bones’ (tidal fever, restless sleep and agitation) may occur, a sign that the body’s nourishing and cooling abilities have been compromised.

Exogenous damp can enter the body through the pores of the skin, settling in the flesh. As Clavey (1995: p. 124) notes:

The Damp EPA enters the body whose physiological processes are already impaired by Qi and blood vacuity. Qi vacuity compromises the body’s ability to defend itself from external attack and may also enhance the effect of the pathogen. If the Spleen is affected this may impact on the body’s ability to further transform and move fluids throughout the body.

The Dampness trapped in the tissue both impairs and consumes Yang Qi, leading to a forceless pulse. It compresses the pulse, resulting in an arterial diameter that is narrow, already depleted by Qi and blood vacuity.

Other authors mention that the Soggy pulse is indicative of chronic Dampness such as ‘postviral fatigue syndrome’ (Maciocia 2004: p. 481).

An increase in the volume of body fluids can affect the flow wave and pulse contour, depending on where the increase in volume occurs in the arterial system or in the connective tissue.

Increased fluid volume can develop as a result of abnormal fluid transformation and transportation involving the Spleen, Lung and Kidney and the Triple Heater. Fluid retention can occur due to normal water loss being inhibited, for example the inhibition of sweating or urination, and this can result in excess fluid moving into the blood vessels, leading to increased blood volume. Alternatively, fluid can accumulate in the limbs as oedema, in the lungs as phlegm or in the abdomen causing distension.

Clavey (1995: p. 134) notes that the close relationship between blood and fluids means that accumulated fluids can also interrupt normal blood flow, impacting on other bodily functions. For example the Shui Fen (water separation) syndrome illustrates what happens when oedema disperses menstrual blood ‘separating it pathologically into water and Qi so that blood cannot flow into the uterine vessels, thus causing amenorrhoea’.

Conversely, increased production of fluids may not necessarily be pathological but may happen routinely as the result of normal increased metabolic demands, such as those occurring during pregnancy.

Decreased fluid volume may occur as the result of the damage or loss of blood, body fluids, Yin or Essence. This can influence the radial arterial pulsation in the following ways:

The Slippery pulse can be an indication of good health, signifying abundant Qi and blood filling out the blood vessels. This signifies that Yin and Yang are well balanced and harmonious. The Mai Jing notes (Wang, Yang (trans) 1997: p. 21):

The Slippery pulse is traditionally associated with a healthy pregnancy. It reflects the normal production of the extra blood and Qi that is required to supply the developing fetus with sufficient nutrients to grow and develop. This pulse is said to occur in the first trimester and is considered to be a healthy sign of a normally progressing pregnancy.

The Slippery pulse is also considered to be a diagnostic indicator of pregnancy. If the pulse is identified as Slippery and there is amenorrhoea (no periods) in someone whose periods are usually regular (Li, Flaws (trans) 1998: p. 76), then this may be a sign of pregnancy. In addition to the overall Slippery quality, an increased force in both Chi positions and the left Cun position is also deemed necessary by Maciocia (1998: p. 76). However, this theory in general should be used with some degree of caution, as the Slippery pulse can also occur in someone who is not pregnant, as the result of a pathological process such as pathogenic Damp, Phlegm or Heat.

The Slippery pulse is commonly associated with pathogenic Phlegm, Damp or Heat. These pathogens may occur individually or in varying combinations.

Retained food may be caused by the regular consumption of Damp-inducing foods and alcohol which impact adversely on the Spleen and Stomach. This leads to impaired digestive function, and the retained food may transform into phlegm. As noted by Clavey (1995: p. 184), this is termed ‘food phlegm’ and is linked to Phlegm-Damp.

The Slippery pulse may be seen at different times during the menstrual cycle. Maciocia (1998: p. 77) describes the normal pulse during menstruation as ‘somewhat Slippery, Big and slightly rapid’.

It may be expected that at other times during the menstrual cycle the building up of blood and Yin in expectation of potential fertilisation (around mid-cycle, approximately days 11-15) may be reflected in the Slippery pulse. At this time of the cycle Yin is described as being ‘at the peak of its cycle, the Chong vessel is full of Blood’ (Lyttleton 2004: p. 36). From a physiological perspective, oestrogen is at its peak. There appears to be some limited initial biomedical support for this, with research showing increased radial artery distensibility (related to the ability of the artery to expand and contract and peripheral vasodilatation) occurring around ovulation (days 13-15) (see Box 7.20 for more information).

The Rough pulse may be seen in body fluid loss, blood vacuity or the consumption of Kidney Essence (Fig. 7.12). Vacuity of Yin fluids leads to impaired blood flow through the arteries, resulting in an unsmooth flow of blood.

The Rough pulse is also related to the stasis of normal Qi and blood flow. Some authors consider this pulse quality to be a sign of unhealthy lifestyle, seen in physically unfit people with an erratic lifestyle and diet, leading to stagnant Liver Qi with Damp (Townsend & De Donna 1990). As a result, Qi stasis eventually leads to the sluggish flow of the blood. However, other types of blood stasis may occur as the result of obstruction due to pathogenic factors or retained food.

The terms ‘short’ and ‘scattered’ are sometimes utilised in the description of the Rough pulse. It is described as short by Maciocia (2004: p. 477) who notes that the pulse lacks ‘continuous movement between the three positions and does not feel like a wave’. However, this description is not a common component of other definitions for the Rough pulse.

‘Scattered’ is used in the traditional pulse definitions of the Rough pulse in the Mai Jing and The Lakeside Master’s Study of the Pulse. However it is poorly defined, if at all, and the possible interpretations of ‘scattered’ are too varied for this term to be of clinical use.

Hammer discusses the Choppy pulse as having ‘small ‘hills’ and ‘valleys’ as one rolls one’s finger along the pulse’ and ‘the varying heights are static’ (2002: p. 63). He further describes it as ‘like rubbing it [the finger] across a washboard’. Although these descriptions imply a variation in pulse wave height, he notes that the Choppy quality is ‘relatively stable and fixed in terms of the vertical movement and has little of the restive wave activity associated with Changing Intensity and Amplitude [a specific and separate pulse quality as defined by Hammer and his colleague, Dr Shen]’.

A common interpretation of the Rough pulse encompasses varying pulse force. However, Hammer identifies a distinctly separate pulse quality defined as a pulse having a change in intensity and amplitude (see above), and says that the Choppy pulse is not this type of pulse. It is therefore unclear whether the ‘hills’ and ‘valleys’ Hammer is referring to are a result of the actual arterial pulsation or alternatively, perhaps part of the physical structure of the artery wall, possibly referring to a tortuous arterial wall that is not smooth.

There are distinctive pulse qualities in biomedicine that could possibly be equated with the Rough pulse. For example, pulsus alternans is defined by pulse beats that alternate in strength. This can palpated as alternating increase and decrease in amplitude, hence a distinctive change in pulse amplitude despite having a regular rhythm. This is due to the alternating force of left ventricular contraction and is commonly indicative of severe impairment of left ventricular function. It can also occur during or after paroxysmal tachycardia (sudden increase in heart that may last from a few seconds to a number of hours). However, pulsus alternans can also be seen in individuals without heart disease for several beats following a premature or ectopic beat (a heart contraction that occurs before the normal contraction is expected (O’Rourke & Braunwald 2001: p. 1256). See section 6.6 for more information about ectopic beats and tachycardia.

It is possible that the Rough pulse was used to describe a number of pulses that exist but do not fit easily into any of the other standard CM pulse quality definitions. For example, a forceless pulse that has a slow rate of pressure increase, leading to a delayed systolic peak and subsequent slow collapse, correlates well with the description of the pulse as slow and going and coming with difficulty. This will also result in a forceless pulse due to the low volume (small pulse pressure), further fulfilling the descriptions of its decreased width. From a biomedical perspective, this is recognised as the pulsus parvus et tardus which often occurs with discrete obstruction to left ventricular output, for example occurring in aortic valve stenosis (O’Rourke et al 1992: p. 74).

This theory deals with externally contracted febrile disease. The Yangming stage is the second stage and is associated with the progression of an external Cold pathogen into the interior of the body, transforming into extreme Heat. This pattern is usually accompanied by severe thirst and agitation, high fever, profuse sweating and the Surging pulse.

The Six Division pattern identification was initially mentioned in the Nei Jing but was described in greater detail in the Shan Han Lun, the classic text on externally contracted febrile disease.

From a CM perspective, high fever is a sign of that the body’s Zheng Qi is strong and fighting off a very strong pathogen. Subsidence of the fever is a sign that the Zheng Qi is overcoming the pathogenic factor (Wiseman & Ellis 1996: p. 226).

The Surging pulse reflects the transformation of the Cold pathogen into Heat, the subsequent increase in Yang and the struggle with the Zheng Qi. It also reflects the damage to fluids by the strong heat. This may be the cause of the pulsation’s tendency to hit the fingers strongly at first (increased Yang Qi) but then drop off gradually, as the fluids have been damaged and cannot sustain support for the Yang Qi (Yang is exuberant but Yin is weak).

This theory also deals with externally contracted febrile diseases but is concerned with Heat pathogens and the effect of their progression into the interior of the body. In this particular pattern, an EPA of Heat transforms into severe heat and is very similar to the Yangming pattern described above. Signs and symptoms include high fever, severe thirst, agitation and profuse sweating. However, the Heat pathogen is able to transform into more severe heat much more rapidly than the previous pattern (Wiseman & Ellis 1996: p. 239).

As in the previous pattern, the Surging pulse is the result of the struggle between the Heat pathogen and the body’s Zheng Qi (Upright Qi).

This is a severe vacuity-type pattern that results from the consumption of Yin and the resulting hyperactivity of Yang. This version of the Surging pulse is usually found in patients with very weak constitution due to chronic illness (leading to consumption of Yin) or complicated by severe loss of blood (Lu 1996: p. 104). In such circumstances the appearance of the Surging pulse signifies a bad prognosis.

Townsend & De Donna (1990) ascribe ageing, poor diet and excessive consumption of alcohol or drugs as possible factors responsible for diminished Yin and the manifestation of the Surging pulse. The severe vacuity of Yin can no longer control the Yang, which becomes hyperactive.