How pulse assessment and diagnosis works:
Chinese Medicine as a general rule contains an extensive history of scholarship and dialogue regarding the etiology of disease, assessment of pathology and treatment protocol. As you may imagine, generations of individuals discussing the finer points of health issues surveyed over large expanses of China lends itself to a lot of conflicting information and a myriad of theoretical models. Even today, with a wealth of access to information, people tend to piece together wellness insight from doctors, doctor Phils, WebMD, their mother’s echoes of their grandmother, as well as their own day-to-day experience. In some way, this is how it has always been, and how it will always be. We make sense of our world through a collection of perspectives, rather than relying on a singular all-encompassing truth. We are complex beings, with ever-evolving needs as well as perspectives.
From the context of Classical Chinese medicine, we are always attempting to ask better questions in regards to our inquiry of knowing. When it comes to wellbeing, we are trying to refine and simplify questions that reflect more efficient ways of getting to the root of an issue. Thus as Josephine Spilka, one of my teachers has articulated in the past, it is essential, when the patient is experiencing confusion in their lives—namely signs and symptoms that are contradictory, to be clear as practitioners. The more clarity we can cultivate, the simpler our reckoning with the patient’s illness.
One of the ways Chinese Medical clinicians have approached this refined clarity has been through pulse diagnosis. In Western Medicine, this is called SOAP notes, which stands for Subjective, Objective, Assessment, Plan. Essentially, what a patient tells you in the treatment room is not always completely reliable, not because their perception of their experience is incorrect—instead, it relates to being in the center of an issue, and being separated from perspectives that could bring clarity to the issue at hand. When a patient comes into the treatment room and we go through an oral intake, and I ask further questions regarding why they’ve assessed their home life at 4/5, and their life-purpose at 1/5, this is great information—but these language exchanges can still remain incomplete. Chinese Medicine often addresses the empty spaces, the words that are not spoken, the aspects of a patient’s health that they would not necessarily consider relevant to their disease. Thus, the oral intake is one element, but pulse-taking takes us even deeper.
When we feel the pulse, we are assessing what lies underneath the patient’s experience as filtered through the narrative of their words, their signs and symptoms. This type of inquiry proved dynamic and complex over centuries of observation. Around the 3rd century BCE, an imperial physician named Wang Shu He observed that despite the complexity of what can possibly be felt in an individual’s pulse, he deduced that there were only 6 pulses that are needed for the sake of diagnosis. He assessed that when palpating the clinician should look for these qualities:
- Speed: is it slow or rapid?
- Height: Is it floating and closer to the surface, or submerged and deeper?
- Width: is the pulse wide and rolling or does it come to a point?
Each of these parameters gives us information on the state of the body’s resources. If the pulse is rapid, it indicates there is heat somewhere in the body. If the pulse is floating/on the surface, it indicates that the body is allocating resources to the exterior of the body to potentially fend of an invading pathogen. This might correlate to a patient contracting a cold, where their neck gets tight, they might break into a sweat, they might get a fever. This rapid pulse would therefore be felt above the normal amount of pressure the fingers apply to the radial artery.
If the pulse is has more width, such as in the case of the quality being slippery, this often will indicate the presence of stagnation of a particular substance, such as blood or fluid moving through a particular region of the body. Stagnation can lead to food stagnation, digestive issues, heart issues, circulation issues and more. Our diagnosis and treatment protocol would then have to include the breaking up of stagnation, focused to the particular regions indicated by the pulse.
How do you know what region of the body has heat or stagnation?
Depending on the side/radial artery being palpated, we are accessing the state of separate sets of organ systems.
The right side corresponds to the state of the body’s Yang, or functionality/energy. If, for instance, the pulse feels lackluster in the kidney position on the right side, we look to see how this reflects in the individual’s overall energy: if it is difficult for them to get out of bed in the morning, if they have urination issues, if they have back pain.
The left side corresponds to the state of the body’s Yin, or structure/stability. This side governs the state of our blood, body fluids, and generally the thicker, more slow moving substances of the body that contribute to maintaining the health of the internal organs, the skeleton, the blood vessels etc. If the Liver position on this side is thin, we look for other signs and symptoms that might corroborate the picture of liver blood deficiency, such as dry eyes, thin/fragile nails and hair, poor night vision, scanty menstruation.
The pulse is a dynamic snapshot of the state of the internal landscape of the body, and it takes cultivation to recognize the root of an individual’s pathology. Generally, as practitioners, we are looking for major discrepancies within an individual’s signs and symptoms, their demeanor, the color of their tongue with the information felt in the pulse. For instance, if a 6’5” male with broad shoulders, a red complexion, and booming voice comes in for treatment of back pain, and upon feeling his pulse we notice that his liver pulse is very deficient, we might find that despite the what appears to be an excess condition is rooted in deficiency. We would then treat accordingly.
Thus, pulses that have more width, more height, correspond to conditions of excess. Those that are thinner and easily give way when palpated more deeply, as well as those that are more submerged correspond to conditions of deficiency.
These differentiations allow us to further hone our observation of the potential source of a condition, as well as to rule out other possibilities. For instance, sleep issues, such as insomnia, are often correlated to the state of the heart blood. If the blood deficient, the heart becomes agitated, heat or vexation occurs, and that heat rises and agitates the mind. This can lead to anxiety, mental restlessness, palpitations etc. However, if the individual is having difficulty falling or staying asleep, the spleen and liver pulse are wiry, and the patient is having vivid nightmares, we might be able to assess that dampness is a strong factor in the manifestation of insomnia.
The pulse is therefore such a powerful diagnostic tool as it helps us witness the patient moment-to-moment, but from a vantage that is much deeper and whole.
The Pulse and the reception of Qi:
Though we have covered a lot regarding pulse examination, it is a factor of health and diagnostics that continues to confound, inspire and challenge clinicians in their assessment of disease. As human beings are complex with complex needs, there are no two pulses that are identical, and there are no two perspectives that will agree wholly on what a “tight” quality feels like. One of my teachers, Master Jeffrey Yuen describes the necessity of always including the description “slightly” in the context of each quality, as the reality is that the assessment of pulse is really the clinician’s reading of an individual’s capacity to transform from state to state.
As discussed in other sections in this website, Qi really describes a state of transformation, specifically the capacity of the body to readily and smoothly make those transitions. When the transition is poor, we have heat. When the transition is difficult, we have blood stasis.
There are several reasons that the radial pulse was observed to be a reliable indication of a patient’s bioecological landscape. However, from a Chinese Medicine perspective, we are always assessing the way in which we can become clear about the nature of our reality, especially in the context of illness, where our expectations of what should be are challenged by mounting circumstances.
A larger discussion reserved for another day as to how Chinese medical practitioners came to form of pulse diagnosis that we presently use, leads us to a classical text called the Nanjing, or the Classic of Difficulties. Essentially, clinicians found that much of the academic and intellectual information that they received from scholastic predecessors did not match up to their everyday experience with patients, the changing of cultural and economic needs, etc. The Nanjing represents one of the first ongoing attempts to make sense of the paraxodical nature of the way in which we assess an individual’s disease, our own expectations, and the system of tools that are consequently developed to adapt to changes in wellbeing.
While this is a larger discussion that warrants time, study and cultivation, it is not completely helpful for the patient, especially when time in a fast-paced world is an increasingly precious commodity. Master Jeffrey Yuen truncated this Nanjing approach to more approachable terms, and the approach surrounds the concept of the “Reception of Qi”.
There are three organ systems that govern the Reception of Qi: the Lung, the Spleen, and the Kidney. The Lung corresponds to the upper region of the body, the Spleen the middle of the body, and the Kidney the lower part of the body. The Nanjing as a text begins with the question: where is the mouth of Qi, namely, where does life begin? The palpation or inquiry into an individual’s pulse is a way of literally and metaphorically asking the patient where they believe life begins. In another way, it is an invitation for the patient to ask themselves that same question, invoking a space or opportunity for them to find those answers themselves.
Why is this important in the context of the pulse examination?
The pulse is an extremely dynamic portrait of the state of your internal body. There are few methods that we, as human beings, are able to access objectively what motivates us as individuals. Often, illnesses, such as a skin rash, emerge to bring attention to a process unfolding, an expression unfolding that we are either not allowing ourselves to see, or unable to access. An inquiry into the “mouth of Qi” helps us develop language through which we can dialogue with the body on a moment-to-moment basis. One of the reasons why some clinicians historically reject the reliability of the pulse is due to its changeability. But this is also the boon of assessing the pulse, as we are able to recognize the discrepancies –the failure of the pulse to change when we’re angry, or the quickness with which the pulse rises to an unexpected event.
The regions corresponding to the reception of Qi are then, the radial pulse, the carotid pulse and the posterior tibial pulse. There is a rich history of clinicians attempting to answer the question of the origin of Qi, and though these three regions, namely the acupuncture points Lung-9, Stomach-9 and Kidney-3—the radial pulse became a general favorite among clinicians over the centuries. The Lung, from a Chinese Medicine perspective represents our first encounter with the external, the landscape over which our own expectations and sensitivities meet the changing expectations of the world—it is thus constantly and exquisitely astute in its assessment of what is in a state of transformation.
Another reason that Lung-9 as an acupuncture point was considered an auspicious region for palpation, within the context of the Primary meridians, is due to its belonging to a category of points called “shu-stream” and “yuan-source”, which correspond to the region of the body where Qi starts moving from the external to the internal—thus, if change begins to affect this region, it will begin to have access to or influence over the body’s Qi dynamic, and eventually access to the internal organs.
Yet another consideration for the palpation of this particular pulse is its relationship to the way in which Qi flows. As China is historically an agrarian society, the language developed to describe the nature of reality often reflected the relationship of human beings to their landscape—especially how the landscape orients and shapes its inhabitants. One of the major ways this occurs is via the waterways. Depending on the depth, width and height of the container, say of a mountain or ravine, the water tends to behave in variable ways. The Primary Meridians are often describes in this same way. Water was thought to give birth to life, the chaos from which all life emerges. So, too, Qi tends to behave in an analogous way as water, as Qi represents our capacity to meet life as it changes and to transform accordingly. Depending on the region of the body, the Qi is said to flow at different rates and potencies, according to the landscape of the body. The regions closer to the extremities, the fingers and the toes, the Qi is more volatile, like a well—a lot of action, a lot of movement, but more erratic.
As you move closer to the elbow, the acupuncture points represent states and movement of Qi that become more ordered, more specific in their directionality, more lasting their effect. Thus if a patient comes in for an acute case of wind-cold, or the flu, lasting only 24 hours, we would expect to not only feel a floating pulse, but we would expect to feel it in the Lung position on the right arm, and we would develop a treatment strategy that would utilize points that are on the fingertips, or those more distal to the body.
Lung-9 becomes the preferred region for palpation as our experience as human beings is not solely governed by our subjective knowing, Kidney-3. Nor is it completely governed by our community, represented by Stomach-9. Instead, the shu-stream, the wrist region, the Lung’s source point represents the Cun or measurement of our experience. The cun measurement in Chinese medicine is simply a measure of distance from one region to another. But when we, as clinicians, are assessing an individual and their well-being, we are absolutely required to take into account the way in which they are oriented within their life, how they are shaped by their environment, and the way in which their life represents a unit of measurement for how being unfolds for them. This is why the question of origin was so significant to the individual’s contributing to the Nanjing discussion; as clinicians must recognize the difficulties and contradictions that life presents.
Thus, when we examine your pulse in the treatment room, what we are really doing is asking you how you measure your life. If your pulse is really low, vacant, listless, we might ask you what excites you in your life, where you might have disappointments. If your pulse is rapid and you complain of a history of poor sleep, we might ask you what are your expectations for your life, and if they match the resources that you have. Are you in debt, but live like you’re a queen? Do you eat out at restaurants all of the time? Why can’t you eat at home? “Well, eating at home has never been something that was enjoyable.” When we get to this place within the inquiry, this is where we begin to actually do the work, as once you start asking yourself, defining for yourself the origin of Qi—only then are you able to recognize the way in which you are able to measure up to your life, your dimensions, and the expectations or demands that your body give you.
This region of pulse examination is the way in which we ask you to listen to what your body is saying, to trust those aches and pains, to sit with the rapids of your anxiety or uncertainty.
Pulse examination is an essential part of your health assessment and an incorporated component of your acupuncture treatment, both initial and follow-up. Chinese Medicine is based in observation and inquiry, so any questions regarding the treatment process are welcome and encouraged. Your body is your greatest teacher. I am here to here to help you hone that skill!