Chapter contents
9.1 Qi and Blood balance 203
9.2 The Three Jiao 207
9.3 Eight Principle pulse diagnosis 212
9.4 Five Phase (Wu Xing) pulse diagnosis 214
9.5 Nine Continent pulse system 222
Chinese medicine is a diverse practice and this is apparent in the range of extant approaches used in assessing the radial arterial pulse. The subject of this book has focused on one of these approaches; the Cun Kou system. Although without a doubt one of the most regularly used and popular pulse diagnostic systems, it is by no means the only pulse assessment system used in clinical practice.
Similarly, the diversity of CM practice is also apparent in the clinical context where individual practitioners may utilise more than one system of pulse assessment. In this situation, the choice of pulse assessment used stems from two key factors:
• The style of CM practised by the individual practitioner
• The patient’s cause for treatment: some pulse assumption systems are best used in assessing clinical dysfunction and overt illness whereas others are suited to the assessment of specific types of illness or even for health management. As such, not every pulse assessment system is necessarily relevant to all aspects of CM practice.
For these reasons, this chapter outlines five other pulse assessment systems that are clinically relevant to CM practice. These also use the radial arterial pulse positions, Cun, Guan and Chi, and or aspects of parameter assessment as discussed in Chapter 6 and Chapter 7. The five pulse assessment systems discussed in this chapter include:
• Qi and Blood balance
• San Jiao (Three Heaters)
• Eight Principles (Ba Gang)
• Five Phase (Wu Xing)
• Nine Continent.
9.1. Qi and Blood balance
In the First Difficult Issue of the Nan Jing, the pulse is discussed as the interaction of the ‘constructive’ with the ‘protective’ or the tangible fluid form called Blood and interaction with the body’s Qi (Unschuld 1986: p. 66). Both Qi and Blood and the relative function and quality of these are inseparable from the understanding of pulse in CM. It is not surprising, then, that in addition to specific pulse qualities that assess the relative quality and interaction of Qi and Blood, there is also a distinct approach to assessing the relative balance of these substances as well. This is termed the Qi/Blood balance. Theory dictates that the overall pulse in the left wrist corresponds to Blood, while the right-hand pulse correspondingly relates to Qi (Box 9.1).
Box 9.1
Relative strength of left and right pulses
The system probably derives from both actual and theoretical claims associated with gender-related pulse differences. The Qi represents Yang and so within the theoretical construct of Yin and Yang the Qi side pulses should feel stronger on the right side for women to balance their inherently Yin nature. For men this is reversed. The Blood represents Yin, so the Blood side pulses should feel stronger in men to balance their inherently Yang nature.
Clinically, the theoretical construct in relation to gender-related differences between the left and right pulses does not appear to be supported. King et al (2006) found that differences do occur between left and right hand pulses, but these are not gender dependent, with the majority of individuals being stronger on the right-hand side or having pulses of equal strength on both sides. Further research into this area is required to substantiate the clinical relevance of this pulse assumption theory.
9.1.1. Relationship of the Qi and Blood to the Zang organs
Similar to the other systems of pulse diagnosis, the conceptual basis of assessing the Qi/Blood balance is based loosely on the Nan Jing arrangement of the Zang (Yin) organs at the Cun, Guan and Chi pulse positions on each side (Table 9.1). From this arrangement, the three zang associated with the left pulse positions relate to the strength of Blood and the three Zang associated with the right pulse positions relate to the strength of Qi.
| Left side pulses | Right side pulses | |
|---|---|---|
| Blood | Qi | |
| Heart (Moves Blood) | Cun | Lung (Da Qi/Zheng Qi/Air) |
| ↑ | ↑ | |
| Liver (Stores Blood) | Guan | Spleen (Gu Qi/food) |
| ↑ | ↑ | |
| Kidney (Kidney Yin-Blood matrix) | Chi | Pericardium (Kidney Yang-Motive force) |
| Prenatal Qi | Postnatal Qi | |
| Constitution | Digestion |
9.1.1.1. The right side pulse and the Zang organs
The relationship between the organs represented at the three pulse positions on the right side and Qi is as follows:
• The Cun position relates to the lungs and its function of deriving Da Qi from the air and storing Zheng Qi. The lungs are considered the ‘governor of Qi’ (Nei Jing).
• The Guan position relates to the Spleen and Stomach, which are responsible for deriving the nutritive or Gu Qi, with digestion playing an integral part of the Qi transformation process.
• At the Chi position the Triple Heater and Pericardium have theoretical connections to the Kidneys and are consequently viewed as an extension of Kidney Yang, the foundation of Qi in the body.
9.1.1.2. The left side pulse and the Zang organs
A similar relationship is noted for the associated Zang represented at the pulse sites on the left wrist.
• The Cun position is associated with the Heart which ‘rules the blood’, circulating it through the circulatory system.
• The Liver, which is associated with the Guan position, stores the Blood (and to some degree is responsible for the quality of the blood after production. For example, Liver heat produces Blood heat). It also plays a role in the distribution of Blood throughout the body, as needed via its role in enabling the smooth flow of Qi.
• At the Chi position are the Kidneys pulse, and in particular Kidney Yin, which stores the essence and has a relationship with the production and nutritive function of blood. Kaptchuk (2000) additionally recognises the role of the Kidneys to ‘store the essence, rule birth, development and maturation – the stuff of life and development’ (pp. 83-84). This represents the constitutional aspect of the individual.
Hence the left-hand pulse represents the Blood. The Blood pulse could be described as also representing the prenatal Qi. Consequently, the left side in Chinese medicine also has some relationship to the concept of ‘constitution’ proposed by the Shen system. The relationship is shown in Table 9.2.
| += “normal” strength; ++ = stronger than ‘normal’; −= weaker than ‘normal’; −− = very weak; ✓ = relatively stronger side. | ||
| Left side (Blood) | Right side (Qi) | Interpretation of findings |
|---|---|---|
| + (+1) | + + (+2) | This means Qi is stronger than Blood, which is of normal strength. This may signify hyperactivity of Qi or Qi stagnation |
| − (−1) | − − (−2) | This means that both Qi and Blood are weak, however, Qi is more deficient than Blood |
| + + (+2) | − (−1) | This means that Qi is weaker than normal, while Blood is stronger than would be expected. This could possibly mean Qi vacuity (deficiency) leading to Blood stasis (stagnation) |
| − − (−2) | − − (−2) | This signifies that both Qi and Blood are equally very deficient |
| + ✓ | + | This means that both sides are of “normal” strength, however the Blood side is slightly stronger. This can reflect simple variations in normal strength of Qi such as that associated with hunger or fatigue at the day’s end |
9.1.2. Applying the Qi/Blood pulse assumption system
This Qi/Blood pulse assumption system is founded on the precept of sufficient Qi to move the Blood volume and sufficient Blood to nourish the Qi. This symbiotic relationship ensures that there is good circulation of nutrients to all parts of the body, maintaining balance and good functioning.
This approach can be used in three ways:
• As a preventive health measure: When the individual, for all intents and purposes, is healthy; there are often no overt signs of illness. The approach is used to address any disharmony or imbalance of Qi or Blood before pathology presents, ideally addressing the imbalance to prevent disease.
• For assessing the Qi and Blood balance during illness: This is particularly relevant for conditions that are chronic in nature, especially when both Qi and Blood may be deficient, providing further diagnostic information to pinpoint the focus of treatment.
• For its prognostic value: If signs of distinct or absolute differences in strength are present, this system is also useful as a prognostic gauge of the severity of the illness. In this way, the greater the strength divergence between the left (Blood) and right (Qi) pulses, the more severe the illness. In this situation, the practitioner would be best served by using a more appropriate pulse assessment approach, such as the parameters or overall pulse qualities.
The process for evaluating the pulse in this system entails four stages:
Step 1 Assess the overall pulse strength within each side’s pulse
Assessment of the Qi/Blood balance primarily focuses on the parameter of strength, similar to assessment of the force of overall pulse qualities described in Chapter 7. Separately on each side, all three radial pulse positions are palpated simultaneously at each of the three levels of depth. For example, at the superficial level an ‘assessment’ is made by the practitioner as to the overall strength of the pulse palpating the Cun, Guan and Chi positions simultaneously. This procedure is repeated at the middle and deep levels of depth. The strength at all three levels of depth is then averaged to arrive at the overall strength for that side’s pulse. The procedure is repeated for the other side’s pulse.
Step 2 Assess the relative strength of the overall pulse between the two sides
Once a baseline ‘measure’ for each side’s overall pulse strength is obtained, the system, as with all comparative applications of pulse assessment, requires the strength between the two sides to be compared (that is, the relative difference in pulse strength between the sides). In this way, irrespective of whether both left and right side pulses are overall weak or overall strong, one side is compared to the other side to determine which of the two is relatively stronger or weaker. For example, both the left and right pulses may equally be assessed as ‘weak’ – lacking in strength -, yet of the two sides, the left pulse may be weaker than the right. Thus the right pulse is assessed as been relatively stronger, but need not be a definitively ‘strong’ pulse. It is only relatively stronger because the left pulse is weaker.
During the assessment the practitioner should try and maintain a similar amount of finger strength when palpating the left and right sides. To confirm that this is the case, always ask for feedback from the patient about whether the strength being applied is perceived by them as being similar.
Step 3 Assess whether any relative strength differences are due to vacuity (deficiency) or repletion (excess)
This step involves the subsequent evaluation of any perceived relative strength differences found in Step 2. This includes evaluating the pulse strength in both relative and absolute terms, to determine the presence of vacuity or replete patterns.
Relative strength differences
For health of the circulatory system Qi and Blood must be relatively balanced. Relative differences in pulse strength between the two sides indicate that the Qi and Blood are unbalanced. (This is in spite of whether both pulses are overall/absolute weak (that is forceless), of normal strength or have an increase in strength (forceful).)
Differences in relative strength imply that while the individual may be ‘healthy’ the identified imbalance represents a potentially impending imbalance/illness if not addressed. Accordingly, treatment attempts to address the rebalancing of the body’s Qi and Blood.
Absolute strength differences
If there is a significantly noticeable difference in pulse strength between the two sides a judgement needs to be made by the practitioner about whether:
• One side is weaker and the other is of ‘normal’ strength, or
• One side is stronger and the other is of ‘normal’ strength.
Thus the practitioner is also required to determine the ‘absolute’ strength within each side’s pulse: that is, is the pulse forceful or is it forceless? This is required to determine whether the ‘weaker’ pulse is reflecting a ‘vacuity/deficiency’ or whether it is of ‘normal’ strength but feels weaker because the other side’s pulse is stronger than usual. Thus:
• An increase in pulse strength above ‘normal’ in the left or right pulse indicates replete disturbance of the Qi or Blood, depending on which side the pulse was stronger
• A decrease in pulse strength below ‘normal’ in the left or right pulse indicates vacuity of the Qi or Blood, depending on which side the pulse was weaker.
In either situation, the Qi/Blood balance is viewed as imbalanced and pathology already manifested. (Interpretation of the pulse via another pulse assumption system is preferred in this situation, as more appropriate and clinically useful information for informing about the nature of the pathology can be gained. For example, examining the pulse using pulse parameters and overall pulse qualities.)
If the left and right pulses are similar in strength then the Qi and Blood are balanced, irrespective of both being stronger or weaker in strength than is normal for that patient. As such, other pulse assumption systems such as overall pulse qualities or the Five Phase approach may be of more value in interpreting the pulse wave for diagnostic purposes and informing treatment.
Other pulse parameters in the determination of Qi/Blood balance
Additionally, the pulse parameters of arterial wall tension and ease of pulse occlusion can be utilised to provide further information about the quality of Qi and Blood:
• An increase in arterial tension in the left pulse indicates Blood vacuity.
• A decrease in arterial tension in the right pulse indicates Qi vacuity.
• A pulse which is easy to occlude indicates Qi and Blood vacuity irrespective of which side it is located on.
Step 4 Select appropriate acupuncture points, herbs or other therapeutic interventions to address the findings
Once it has been determined whether there are any differences in strength between the left and right pulses, relative or absolute, and if the differences are due to vacuity or repletion of the Qi or Blood, the practitioner needs to select appropriate acupuncture points, herbs or other therapeutic interventions to address the disharmony. Acupuncture and herbs would either supplement or drain, depending on the nature of the identified disharmony. Additionally, the patient’s diet may need to be addressed.
9.1.4. Extraneous variables affecting the assessment of Qi/Blood balance
9.1.4.1. Practitioner handedness
The problem with comparing assessments of inter-arm differences, from the practitioner’s perspective, is the consistent application of finger pressure. A difference in finger strength being applied by the practitioner between left and right sides would cause the pulse sensations to be perceived differently and the results interpreted incorrectly. For example, if a practitioner is right-hand dominant, they would have better discrimination in adjusting their fingers on the right hand when feeling for the different levels of depth as compared to their left hand. This may cause a bias in the assessment of inter-arm differences in pulse strength.
Solution to the problem
Palpating both pulses simultaneously helps to limit and control any bias in finger strength discrimination introduced by being left- or right-hand dominant. Either as a beginner to the technique, or as a seasoned practitioner, receiving feedback from the patient concerning finger strength will provide valuable feedback for:
• Learning to discriminate strength/finger pressure between the two hands
• Continuing to ensure that strength/pressure discrimination is similar
• Limiting extraneous variables and subsequent interpretation within a diagnostic framework.
As such, simultaneous palpation ensures that:
• Finger palpation is being applied accurately
• The technique is being applied reliably
• Any findings are valid within the conceptual framework being used.
9.1.4.2. Subject handedness
Further concerns with the system relate to the dominant hand of the subject or patient being assessed. For example, the individual’s dominant hand usually has a greater muscle bulk, requiring a greater blood supply. Accordingly, the arteries will have remodelled to deliver the blood and nutrients required for healthy function. This may be felt as a wider artery. Thus assessment of the Qi/Blood balance maybe skewed in someone with a noticeable difference in arm use and muscle bulk. This may also apply to individuals with injuries such as sprains or broken bones in which the arm has been in a period of immobilisation. Thus pulse difference may be reflecting localised changes in blood flow requirements rather than being a systemic indicator of Qi or Blood balance.
Solution to the problem
Also look at other pulse parameters such as arterial tension. Often if Blood is deficient then arterial tension will be increased. When Qi is deficient then the arterial tension may be decreased.
9.2. The San Jiao: Three Heaters
The view that the individual’s physiology is a microcosmic reflection of the macrocosm, the world in which the individual resides, is a recurring theme in CM. The best-known application of this theme in pulse diagnosis is the Five Phases (Wu Xing), but another is the San Jiao pulse system. In particular, the San Jiaos is an application of the Heaven-Earth-Humanity theme. It relates specifically to the thoracic, abdominal and pelvic cavities of the torso; these are known as the Three Jiaos (See Box 9.2). Each cavity has an association with certain organs and their association with the distribution and metabolism of Qi and fluids.
Box 9.2
Translations of the term ‘Jiao’
The term ‘Jiao’ can be translated in two ways:
• The first translation relates to its common conceptualization as ‘burners’ or ‘heating’ action. In this context Jiao literally means charcoal. In many English CM texts, Jiao has been taken to mean that the three torso cavities are distinctly related to a warming or heating action.
• The second translation relates to the concept of water channels. This refers to the CM San Jiao concept of relating the Jiaos to fluid metabolism: as conduits for both the movement and transformation of fluids. Traditional descriptions of the form of the San Jiao often describe the organ as being composed of a network of channels for fluid distribution (Qu & Garvey 2001).
In this context, the Chinese cosmological perspective on the function and nature of Heaven, Earth and Human is reflected respectively within these three regions of the torso (Table 9.3):
• The Heart and Lungs are located in the thoracic cavity and are ascribed to Heaven and production of Qi (movement and function)
• The Spleen and Stomach are located in the abdominal cavity and are ascribed to the Earth and are responsible for the separation of the pure from the impure – (transportation and transformation – digestion) and Gu Qi, nutrients and fluids. The Liver also has a relationship with digestion.
• The pelvic cavity contains the Kidneys and Intestines. These are ascribed to Humanity, and besides excretion (liquid and solid waste), are considered to be the foundation of Yin and Yang in the body.
| Left Position | Right Position | ||
|---|---|---|---|
| Cun | Heart | Upper Jiao | Lung |
| Guan | Liver | Middle Jiao | Spleen |
| Chi | Kidney Yin | Lower Jiao | Kidney Yang |
9.2.1. San Jiao organ
The San Jiao or Triple Heater (Triple Energiser) organ is a concept unique to CM. Rather than being a distinct organ, it is a synergy of the three distinct regions, the three cavities which are often described as defining the San Jiao. Physiologically it is attributed to fluid metabolism, hence its definition as a curious Fu. In addition to the interaction with the fluid the San Jiao can be also classified as a curious Fu for the ‘storage’ of the organs Zang and Fu which are enclosed within the respective torso cavities. In this way, the San Jiao is described as both a Fu or hollow organ as well as a curious Fu; for both the cavity-like structure that it is and the interaction that it has in the metabolism and distribution of fluid, one of the three treasures (San Bao) and storage of the organs. Even in CM the conceptual ‘organ’ that is the San Jiao is unique (Box 9.3).
Box 9.3
The application of the San Jiao in CM
This system has a number of different variations and names within the literature, but is primarily assessing the functional integrity of the San Jiao (Triple Heater) via the organs located within each of the respective cavities or Jiaos of the torso.
9.2.2. Association of the pulse to the San Jiao
The logic of this pulse system lies with the location of the organs within the three cavities or Jiao in the torso. In this way, if a Jiao becomes dysfunctional then everything that it encloses or stores would additionally be affected, including the organs: and this is reflected in the related organ’s pulse at the radial arterial.
In using this San Jiao pulse system, the corresponding pulse positions on each wrist are paired and associated with a Jiao (Table 9.3). These are:
• Upper Jiao: Paired Cun pulse positions
• Middle Jiao: Paired Guan pulse positions
• Lower Jiao: Paired Chi pulse positions.
Therefore, in this context, the zangfu organ pulses reflect the functional capacity of the related Jiao in which the organs reside. However, Jiao related dysfunction presents with simultaneous changes in two of the pulse positions; the two pulse positions relate to the two organs which the Jiao encloses (Table 9.4).
| Combined pulse positions/sites | Related cavity | Organs within cavity | Division | Organ function |
|---|---|---|---|---|
| Cun | Thoracic cavity | Heart and Lungs | Heaven: Yang/intangible/function | Ruler of Blood-Visible movement of blood and Master of Qi-breathing |
| Guan | Abdominal cavity | Spleen and Stomach, Liver | Earth: Yin/solid | Transformation and transportation-(ripen and rot). Smooth flow of Qi |
| Chi | Pelvic cavity | Kidneys and intestines | Humanity: interaction of Yin and Yang-water/liquid | Excretion-Yin and Yang |
For example, if the heart is dysfunctional then resultant changes in pulse rhythm or strength may occur, or alternatively, the Heart pulse at the left Cun position may present with a decrease in strength. Similarly, if the patient presents with shortness of breath then the Lung would be indicated and the pulse at the right Cun position would reflect this. In both these situations, the individual organ is dysfunctional, not the Jiao because only a single pulse position was affected; the pulse that related to that specific organ. However, in the situation where the individual presents with both Lung and Heart symptoms described, this could be described as an Upper Jiao dysfunction or illness. In this sense, it is the poor functioning of the Upper Jiao distribution of fluids and nutrients that has caused the associated organs, (the heart and lungs), in this cavity to become dysfunctional. In terms of pulse diagnosis, this should be reflected bilaterally in the wrist pulses relating to the Upper Jiao. In the case just described, then there should be a similar pulse quality or change in pulse parameter manifesting simultaneously at the left and right side Cun positions: the organ dysfunction inferred from the pulse is secondary to the related Jiao dysfunction. In a clinical context, rather than directing treatment at the Lung or Heart separately, treatment is directed towards the Upper Jiao instead: the cavity in which the Lungs and Heart are housed (Box 9.4). Conversely, if a pathological pulse quality is presenting in only one of the paired pulse positions, then that respective organ is considered to be dysfunctional rather than the Upper Jiao and, as such, treatment focuses on that particular organ (Box 9.5).
Box 9.4
Three Jiaos and the Cou Li
In their discourse on the classical medical location, shape and structure of the San Jiao, Qu & Garvey (2001) proposed that rather than the distinct organ entities, it is the lining or distribution network of actual cavities/spaces between tissue linings that constitutes the San Jiao. These are termed the Cou Li. Cou refers to cavities. The largest of these are the thoracic (chest), abdominal and pelvic cavities. Additionally, the San Jiao Cou concept also encompasses smaller spaces in the extremities and muscles. All these spaces are connected via a distributing network of tubes. These are termed the Li. Based on classical descriptions of the San Jiao in the Ling Shu (Chapter 18), they propose that the San Jiao is constituted from the cavities rather than actual organs. The San Jiao is described by Kaptchuk (2000: p. 96) as having ‘a name but no shape’, attributed to its ‘formless’ nature.
Some interesting recent published research papers indirectly supports the Qu & Garvey discourse. Lee et al (2004), Shin et al (2005) and Lee et al (2005) report on the histological identification of threadlike structures on the surfaces of internal organs, in the blood and lymphatic vessels, and under the skin. These are termed the Bonghan ducts after Bonghan Kim who reported first observing them in 1963. Lee et al (2004) describes the Bonghan ducts as a ‘circulatory system that was completely different from the blood vascular, nervous and lymphatic systems’ (p. 27). As a circulatory system, it is reported a distinct and observable liquid flow within these vessels with a hypothesized large mitochondrial count and nerve-like properties (p. 6, Lee et al, 2005).
Just as the San Jiao is a radical concept to a physiologist, Shin et al (2005) describe the Bonghan ducts similarly as a radical challenge to modern anatomy. Lee et al (2005) state:
Whatever the eventual outcome of deeper investigations of these claims, the finding of the novel structure inside lymphatic vessels is not mere curiosity but rather a herald of a breakthrough in establishing the third circulatory system that consists of the Bonghan ducts inside blood vessels, on the organ surfaces and under the skin. Further studies of its histological aspects and physiological functions suggest the possibility of new insights in both biology and medicine as well as acupuncture theory (p. 6).
While speculative (as is much of the discussion on the San Jiao), if these structures are as reported, it is not inconceivable that they occur throughout the lining of the cavities and interstitial spaces of the muscles, as explained in the concept of the Cou Li or San Jiao. Further investigations are required to establish certain claims about the ducts reported by Kim (1965) ‘the lymphatic intravascular threadlike structures … related to immunological and hematopoietic function’ (Kim 1965, as reported in Lee et al, 2005).
It is the immunologic claim that is of most interest to the concept of the San Jiao as the distributions of Cou via the Li within the muscle and skin also have an immunologic function against external pathogens (Qu & Garvey, 2001).
Box 9.5
Relation of the San Jiao to anatomical and physiological structures
The literature relates the San Jiao to a range of anatomical and physiological structures, including:
• Cou Li
– Organs
– Cavities
– Water channels
• Burners
– Heat and metabolism.
9.2.3. Application and assessment
This system of pulse diagnosis uses the Zang organ arrangement in the Nan Jing to imply the functional integrity of the related cavity, or Jiao in which the organs reside (see Box 9.4 for a discussion of Cou Li).
San Jiao pulse diagnosis makes use of the paired pulse positions of each arm. For example, left Cun is matched with right Cun (upper Jiao), right Guan with left Guan (middle Jiao) and right Chi with left Chi (lower Jiao). Both positions are palpated simultaneously; the practitioner’s right index finger is placed on the left Cun and the left index finger on the right Cun. The paired pulse positions are palpated simultaneously to identify possible common changes in pulse parameters (excluding pulse rate, which should be consistent across all positions) or the CM pulse quality that is manifesting within each arm’s pulse (Box 9.5).
Although pulse assessment in the San Jiao pulse system focuses primarily on the parameter of pulse force, other changes in additional pulse parameters – for example, pulse occlusion or depth – may also be utilised, as long as they occur in both corresponding pulse positions in the Jiao in question. But for purposes of demonstrating the system we focus here on the parameter of force and the related assessment of relative strength.
There are five stages to the assessment process for interpreting pulse findings in the San Jiao pulse assumption system:
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Related posts:
Historical pulse records and practice
Issues of reliability and validity
Getting started: pulse techniques, procedures and the development of a methodical approach to pulse assessment
Genesis of pulse qualities
The pulse: its place in contemporary biomedical and CM practice
Simple CM pulse qualities and associated pulse parameters
