Other systems of pulse diagnosis

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.

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:

The process for evaluating the pulse in this system entails four stages:

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).

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:

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).

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).

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:

There are two presentations of the paired pulse positions when dysfunction is present:

The Eight Principles is a relatively simple approach to pulse diagnosis that can be of assistance in the overall diagnostic process, especially if you have difficulty identifying the pulse quality as it relates to the 27 specific CM pulse qualities.

As the experienced clinician realises, rarely does a pulse quality occur alone: it is usually in combination with at least one other quality or a combination of many parameters and this can make identification of overall pulse qualities difficult. In fact, often, there is no overall ‘traditional pulse quality’ to be felt, as described in the CM literature.

By using the Eight Principles pulse diagnosis you may be able to recognise a pattern emerging, with a combination of basic pulse parameters that defines one of the CM specific pulse qualities. As such, the Eight Principles may help with the pulse parameter system, identifying specific CM pulse qualities by simplifying recognition of the pulse changes.

The Eight Principles approach uses three general pulse parameters. These are:

In the context of pulse diagnosis, the basic pulse parameters used in this system are the level of depth, pulse rate and strength. Each parameter as a standalone ‘diagnostic’ imparts only limited information about the condition. For example, an increase in pulse rate (perhaps the Rapid pulse) can be categorised as representing heat. However, whether the heat is due to an external pathogen or internal causes cannot be determined from this parameter alone (see Box 9.6). For this reason two other pulse parameters, pulse force and depth, are used in addition to rate (Table 9.6). It is the use of all three sets of parameters together that allows the practitioner to correctly identify the condition and inform treatment intervention within an Eight Principles context (Box 9.7). If a Rapid pulse also presents with a lack of force, it can therefore be categorised as vacuity heat (or empty heat, deficiency heat). If the Rapid pulse presented with excessive force then it can be categorised as Excess heat.

To determine the nature or source of Excess (replete/full) heat, further differentiation of the pulse would be required. Where is the pulsation felt most forcefully, at the superficial or deep level of depth? If superficial, this would then appear to indicate an EPA of Heat. If the pulse is strongest at the deep level then the heat could be seen as either arising internally, or an EPA has now progressed to the internal level. The acuteness or chronicity of the condition can help provide further clues as to which case it may be.

Thus the basic pulse parameters can inform about the location, nature and duration of the condition. Treatment then aims to support ailing organs or correct Qi and Blood for vacuities; excess or repletion are drained, while EPAs are expelled (Box 9.7).

The Eight Principles system also encompasses a fourth category, Yin/Yang, which is used to describe the general nature of a condition. Whether a condition is described as Yin and Yang depends on the determination of the preceding three categories:

This categorisation approach using Eight Principles can also apply to chronic conditions such as rheumatoid arthritis that has a sudden acute flare-up, and hence Yang (heat) signs within a chronic Yin (Damp) condition. Similarly a Yin condition can have Yang signs. For example, vacuity of Yin may give rise to vacuity (empty/deficient) heat signs over time. Another common example is damp accumulation causing stagnation in the interior and eventually transforming to heat. This would be viewed as Yang signs within a Yin condition (in this case, accumulation of Yin fluids).

Thus the Eight Principles also can be used to identify:

Some literature sources use basic descriptive pulse qualities that relate to depth (Floating and Sinking), strength (Replete and Vacuous), and rate (Rapid and Slow) parameters, which can be used within the Eight Principles as demonstrated above. However, as distinct CM pulse qualities, there are other pulse parameters that define these CM pulse qualities beyond the Eight Principles system. (Refer to Chapter 6 and Chapter 7). For example the Floating pulse, while often described as strongest at the superficial level, is also defined by an incremental decrease in strength when finger pressure is applied. That is, the pulse can be felt at the superficial level but also at the middle level, to a lesser degree. As such, generic pulse parameter descriptors, as illustrated in Table 9.5, rather than specific CM pulse quality names, are best used in the Eight Principles system to prevent confusion with the overall CM pulse qualities.

The diagnostic use of pulse assessment in this pulse assumption system is predicated on the notion that disharmonies within the organ systems, whether emotionally, psychologically, physiologically or spiritually based, can be identified by certain changes occurring in the pulse. In this sense, disharmonies are caused by a disturbance affecting normal Qi function and consequently organ function.

Depending on the nature of the identified disharmony, acupuncture treatment aims to correct the identified disturbance through the movement, drainage or harmonisation of Qi between and within the organ groupings using the Sheng and Ke cycles (Box 9.8). A specific group of points termed Five Phase or elemental points located at the channel segments that transgress the distal portions of the limbs is needled for this purpose. There are additional point groupings that are also needled, including the Lou, Yuan, Mu and Back Shu points. This process of regulating Qi is termed the movement of energy and finds a use within Five Phase or elemental acupuncture.

In the Five Phase system, the pulse is used in two ways:

This pulse assumption system is used specifically to identify imbalances reflected by relative and absolute differences in strength between and within the Zang and Fu organs via the wrist pulses. The system uses the three pulse sites Cun, Guan and Chi on each wrist at two levels of depth: superficial and deep (Box 9.11). Thus there are 12 positions, six located superficially and 6 located at the deep level of depth, with each position associated with a Zang or Fu organ.

The assignment of organs and associated phase or element characteristic to each of the 12 pulse positions is based on the arrangement presented in the Nan Jing (Table 9.7, Fig. 9.1, Box 9.13). Thus the six Zang or Yin organs are assigned to the deep level positions and their related Fu or Yang organs to the superficial level of the same corresponding position. For example, the left Cun position has the Heart assigned to the deep level of depth and its related Yang organ, the Small Intestine, is assigned to the superficial level of depth. The Heart and Small Intestine are assigned to the Fire element.

Thus the system assesses the relative and absolute strength of balance between the two levels of depth within a pulse site, the superficial and deep, comparing the balance of the Yin and Yang organ partners, as well as assessing the strength between other pulse sites and related organs.

Assessment of pulse using this system primarily focuses on comparative differences in strength. This occurs discretely within each of the pulse positions when assessing relative differences in strength between the superficial and deep levels of depth. Comparative differences in strength are also required in comparing the strength of one phase to another by comparing the strength difference between the pulse positions. This generates a lot of data, so it is it is useful to use a paper-based recording method to note your assessment results. This assists in making diagnostic judgements on your findings and subsequent selection of acupuncture points.

The ‘normal’ pulse is used as a gauge to determine whether pulse strength, of the pulse generally, is appropriate or not. Physique, age, gender and level of activity are important variables in this process, assisting in determining what is normal or abnormal for the individual having their pulses assessed. With this in mind, these variables provide a range of normal pulse presentations and are always considered against the ‘normal’ pulse as described in Chapter 5 and Chapter 6. (Never subjectively assume what the ‘normal’ pulse for a patient should be.)

The five stages of the Five Phase pulse assessment method are as follows:

Five Phase pulse diagnosis has a few idiosyncratic variations not normally considered in other systems of pulse diagnosis. For example, the movement of the Qi ebbs through the channels with respective times of the day – the Chinese Clock or the Law of Midday-Midnight. This in effect produces a two-hourly ‘high tide’ zone of Qi, termed the horary flow, reflected in a relatively stronger pulse at the wrist for which the position correlates to the organ. Concurrently, there is also a ‘low tide’ ebb and the pulse position of the corresponding organ would be expected to have a relatively weaker pulse at that two-hourly time of the day. As such, the Zang and Fu organ positions show whether the energy flow to its particular functional area is normal, excessive or deficient. For example, at midday the Heart is said to be at its ‘strongest’ with the Qi ebb at its maximum. Concurrently, the gallbladder is at its weakest. The GB is strongest at midnight, at which time the Heart is at its lowest Qi ebb point.

The normal strength variations with the ebb and flow of Qi as described by the Chinese Clock may also be useful in identifying deficient and excess conditions during the horary flow time for the related organ. For example:

This approach to pulse diagnosis has relevance to the system which uses ‘open hourly points’ (na zi fa) (Fig. 9.3).

There are variations in the available literature on the Five Phase approach which incorporate pulse qualities in addition to simply assessing differences in strength. Such approaches are derived from the traditional descriptions of overall pulse qualities found in the Mai Jing and grafted on to assessment of channels using Five Phase pulse diagnosis. For example, such an approach proposes that a Stringlike (wiry) pulse can simultaneously occur at one position while at another position the pulse is a Short pulse, complicated by a Replete pulse in yet a third position and a Slippery pulse in the deep level at a fourth position. There are assumptive and practical problems with this approach, the most obvious of which is the manifestation of pulse ‘qualities’ forming simultaneously within the same individual’s pulse but which in fact are mutually exclusive, both by definition and by each pulse’s respective underlying formation mechanisms (see Box 9.12).

In using contemporary theory and extant systems of practice as a reference to interpret the description of the Nine Continent pulses in a clinical context, it would be easy to make the mistake of associating the pulses with specific acupuncture points or anatomical sites reflecting blood flow. Before the Han era the artery and pulse were synonymous with the channel, and as such it was the pulsating length of the palpable artery that correspondingly inferred the strength of the channel Qi and the region for which it transgressed. The arteries were simply extensions of the channels.

This is confirmed in the writings of the Jia Yi Jing (The Systematic Classic of Acupuncture and Moxibustion). It is written that ‘three vessels pulse around the large toe and their state of repletion or vacuity should be examined’ in determining the nature of an illness affecting the associated channels to which the pulses related (Mi 1994: p. 306). The three vessels are allocated by the translators as arterial segments:

Depending on the state of the blood vessels, the indication for using acupuncture to supplement or drain depends on whether the pulse is replete and racing or vacuous and slow.

Interestingly, Veith’s (1972: p. 189) translation of the Nei Jing relates the Nine Continent pulse to the five spiritual resources (controlled by the five Zang: Lungs (Po), Liver (Hun), Heart (Shen), Spleen (Ji), Kidneys (Jeh); Qi relating to the temples, ears and eyes, mouth and teeth; and the space within the breast (the expression of the organ’s spiritual aspect and the body’s upright Zheng Qi).

However, identifying the nature of a disease may not have been the primary use of the Nine Continent pulse system. Rather, it was identifying the location of the disease (Unschuld 2003: pp. 254-255). It is the ‘physical appearance and the treatment of the vessel to ‘regulate depletion and repletion and to eliminate evil and disease’ that is important. For example, a pulse that was different in strength from other pulses indicated the presence of a pathogen. The nature of the pathogen didn’t particularly matter, as treatment often involved bleeding points to release pathogens from the channels.

The Nei Jing also provides extensive coverage on the prognostic use of the Nine Continent pulses and includes extensive discourses on determining the appropriateness of the body’s response in the presence of illness from these as well. This is based on changes in the pulse parameters within each of the nine positions and also by comparing the pulses between positions. For example, the following points regarding the determination of health or illness by the Nine Continent pulse are derived from the Nei Jing.

Health is indicated when:

Illness is indicated when:

It is strange and somewhat ironic that to understand the potential uniqueness of the regional pulse system for diagnostic purposes, it is best to look at the biomedicinal system for guidance. For biomedicine, regional pulse palpation forms a small but important aspect of assessing the circulatory integrity of blood perfusion into the skin, muscle and limbs – conditions quite distinct from organ function as posited in the Nan Jing. In this way, simultaneous comparison of the strength in the dorsalis pedis and femoral arteries can determine whether blockages are impeding the arterial blood flow, while simultaneous pulsation in the femoral and radial pulses indicate potency of systemic blood flow.