Chapter contents
3.1 Nei Jing23
3.2 Nan Jing25
3.3 Mai Jing26
3.4 Bin Hue Mai Xue27
3.5 Historical perspective: regional pulse assessment and the Cun Kou pulse 27
3.6 Historical problems in contemporary practice 29
3.7 Pulse classics and contemporary practice 30
The development of CM theory generally is reflected in the development of pulse theory. This is clearly seen in the Nan Jing, which documented the further development of pulse knowledge but which reflects the broader change in treatment generally, justifying why stimulation of an acupuncture point on the foot has systemic effects on the circulation.
The classics constitute an important source of information for our understanding of when and how certain pulse assumption systems developed and their related claims to clinical relevancy. They equally provide an important point of reference for the many difficult issues that affect the use of pulse diagnosis in the contemporary context: indeed, the information they contain may be seen as directly contributing to these issues (discussed in Chapter 4). This is because, unlike contemporary biomedical practices, where new ideas and developments supersede the outdated or disproved theories, in CM, both the old and new are retained. In the words of Unschuld, the new is seen as merely adding to the old. This means that the contemporary practice of pulse diagnosis often remains linked with its literary past.
There are four major literary texts available in English which document the development and use of pulse diagnosis in Chinese medicine:
• Nei Jing
• Nan Jing
• Mai Jing
• Bin Hue Mai Xue.
3.1. Nei Jing
One of the earliest references to pulse palpation in CM as a systemised diagnosis technique emerges from the The Yellow Emperor’s Classic of Medicine or Nei Jing, one of the oldest and additionally described as one of the most important Chinese medical texts, compiled in 300–100 bce. The Nei Jing is arranged as two distinct books, the Suwen and the Lingshu, the former being the primary source of information on pulse diagnosis. The Nei Jing is seen as an eclectic book of writings, representing the collation of knowledge representative of a range of different lineage medical teachings extant at its time of writing, and in particular that of systematic correspondences (Hsu 2005) (Box 3.1).
Box 3.1
Nei Jing
• Collated between 300 and 100 bce
• Incorporates the ‘vessel texts’ from the Mawangdui scrolls
• Details the medicine of systematic correspondences
• Introduced the concept of discrete circulations associated with both Qi and Blood influences, and discussed the normal pulse
• Documents a range of different arterial pulse sites linked with different systems of pulse assessment including:
– Cun Kou (wrist), Ren Ying and Fu Yang pulses
– channel/artery assessment
– Nine Continent pulse diagnosis.
In the context of the radial artery and pulse assessment, the sites of the radial artery were briefly discussed in Chapter 17 of the Nei Jing, described as three positions located above the radial artery, used to ‘detect [the] subtle quality of pulse patterns’ (Lingshu, treatise 74: Ni (trans) 1995: p. 68). These positions, situated at the wrist, adjacent to the radial styloid process and proximal to it, were named Cun, Guan and Chi respectively and were divided into deep and superficial levels of depth. These positions were viewed as representing different regions of the body and some of the positions were linked to specific organs. This meant that a change in the pulse character at the site meant a corresponding change occurring in the related organ.
For using the pulse diagnostically, the Nei Jing introduced two important concepts; that of circulation and the normal pulse . The first of these concepts, circulation, was described as the movement of substances (a vapour called Qi, in various forms, and Blood) throughout the body in 12 linking vessels, located in different regions of the body (Unschuld 1986). The concept of the ‘normal’ pulse was also introduced and this was used as a standard with which to compare the features of an abnormal pulse.
For example in reference to pulse rate the normal pulse was described as:
In man,
during one exhalation, the vessels exhibit two movements.
During one inhalation, the vessels exhibit two movements too.
Exhalation and inhalation constitute one standard breathing period.
If the vessels exhibit five movements,
this is an intercalation [of a fifth movement] because of a deep breathing.
That is called a ‘normal person’.
Suwen (Unschuld 2003: p. 257)
Therefore distinguishing health by the pulse required comparison of the patient’s pulse with the normal pulse frequency, deviation in the patient’s rate from the normal rate representing illness.
Even this oldest of CM texts borrowed from yet older writings incorporating two distinctly recognisable manuscripts termed the ‘vessel texts’ from the Mawangdui scrolls (Harper 1998, Hsu 2005). These texts include a series of case studies compiled by Chunyu Yi, a Chinese physician, in which Hsu notes in her study of the scrolls that there is ‘sufficient detail to recognize in them a particular form of pulse diagnostics, a form that in many aspects was later discontinued’ (2005: p. 11). In particular, Hsu mentions Chapter 10 of the Lingshu as recording the vessel texts ‘in a strongly modified form, yet in places also verbatim’.
Further evidence of the Nei Jing as a compilation of writings, rather than as a discrete text, is seen in the reference to the use of pulse diagnosis in various forms, including:
• Nine Continent pulse diagnosis: Pulse sites on the head, lower and upper limb
• Channel assessment by regional pulses: Arterial pulses congruent with each of the channel pathways occurring in all regions of the body
• Heaven, Humanity and Earth: Three permanent pulses located at the carotid, radial and dorsalis pedis arteries.
In this sense, pulse assessment in the Nei Jing was undertaken from a range of anatomical regions and not exclusively from the wrist.
3.1.1. Nine Continent pulse diagnosis
The Nine Continent system is specifically named for the use of nine arterial sites: three arteries located in the upper region (the head), three in the central region (upper limb) and three in the lower region (lower limb) of the body. The system is premised on the microcosmic arrangement of the macrocosm reflected within the body with components of Heaven, Earth and Humanity simultaneously assigned to the upper, middle and lower regions. The Nine Continent system provided information about:
• The region of the body that was affected
• Generic information about replete (excess) and vacuous (deficient) conditions, but not necessarily information about the specific nature of the illness
3.1.2. Channel assessment by regional pulses
This system of pulse assessment was based on the physiological association between superficial arterial pulses occurring in the same anatomical region in which an acupuncture channel transgressed. In this way, each of the channels was linked to an artery so the pulsation in the related artery came to reflect the strength of the associated channel. For example, the popliteal artery located behind the knee was linked with the Bladder channel (Zu Tai Yang). Changes in the presence and strength of the popliteal artery meant a change in the functional strength of the bladder channel.
The Nei Jing notes each of the channels as having movement; a distinct pulse associated with its location. In this sense, the coursing movement of the artery was inseparable from the path of the channel: the artery, the pulse and the channel were as one (a linked vessel); an interdependent relationship of function and form, embodied in the concepts of Qi and Blood. Hence, the assessment of the pulse or form reflected the state of the channels or function. For the early Chinese medical practitioner the axiom Qi leads the Blood and Blood nourishes the Qi was clearly apparent in the coupling and movement of the pulse sites and channel locations. In this way, each artery/channel was viewed as having a discrete circulation.
3.1.3. The three constant pulses
The three pulse sites were unique amongst all other pulse sites mentioned in the Nei Jing in that a pulsation could always be felt in these locations, irrespective of the presence of illness. What this means for the other regional pulse sites is that their related pulses were not always necessarily present — they were in fact, transient. Indeed, it is this factor that allowed the ancient Chinese medical practitioner to use the regional arterial pulses for diagnostic/medical purposes. (The nascent recognition of a united circulation could be seen arising from the three permanent pulse sites. Thus, the Nan Jing’s argument for a single site for assessment was an obvious conclusion.)
Wiseman & Ye (1998: p. 470) term these three sites as:
• Rén yíng (man’s prognosis): The carotid artery located in the neck — associated with the stomach channel (stomach Qi, sea of grain)
• Cùn kôu (inch opening): The radial artery located in the wrist and reflects the lung Qi (rules the Qi)
• Fū yáng (instep Yang): Dorsalis pedis artery in the feet (could also be the tibial artery according to p. 85 of the Jia Ji Jing) (penetrating vessel, sea of blood).
However, although the Nei Jing incorporated pulse palpation into the diagnostic framework, the pulse characteristics and qualities were described in obscure and difficult concepts that had little clinical relevancy for diagnosing disease (Unschuld 1986). It was in this environment that the central message of the Nan Jing’s approach to pulse diagnosis was delivered.
3.2. Nan Jing
The Nan Jing, translated as The Classic of Difficult Issues, was produced in response to the ‘difficult issues’ raised, or left unanswered, in the Nei Jing, so constituting an important text in the development of CM diagnostic theory (Box 3.2).
Box 3.2
Nan Jing
• Collated in the 1st or 2nd century ce
• Introduced the concept of a single linked circulatory system
• Focuses solely on the use of a single pulse position: the Cun Kou position on the wrist
• Associated the Zang and Fu organs with a particular pulse position and level of depth.
Collated some time in the 1st or 2nd century ce, the first 22 chapters provide instructions on the practical application of pulse assessment, describing a number of palpatory techniques and methods of assessment. The Nan Jing author(s) introduced innovative conceptual ideas for applying the pulse techniques, noting two extraordinary divergences from preceding pulse knowledge. The first was that the circuitous route or cyclic ebb and flow of the ‘Qi and Blood influences’ in the individual channels/vessels logically inferred that these were in fact a single linked circulatory system rather than several discrete circulatory systems as noted in the Nei Jing . Further, if the Qi and Blood flow were linked, then it was only necessary to examine movement at one area along the flow (Unschuld 1985). The ‘inch-opening’ or Cun Kou pulse in the radial artery at the wrist was chosen as the site for assessment because it was thought to be the point at which all the vessels intersected. These ideas were profound to the thinking of Chinese medical practitioners as the time, as noted by Unschuld:
The message offered by the Nan-ching must have been quite convincing in at least one respect. Vessel diagnosis concentrating on the wrists was adopted not only by many physicians (who were criticized by Chang Chi — or by a later commentator to his preface — for an all too simplistic practice both of diagnosis in general and of wrist diagnosis as well) but also by the leading pre-Sung authors of medical works with sections on diagnosis that have been transmitted to us from pre-Sung times
With the publication of the Nan Jing in the 2nd century ce, the regional assessment of the pulse/channel, described extensively in the Nei Jing, was radically challenged with the novel concept of a single or linked circulatory system embodied in the wrist pulse site posited in the book’s ‘first difficult issue’. In doing this, the Nan Jing
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