JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984

1
AN INTRODUCTION TO PULSE DIAGNOSIS
By Julian Scott
Pulse diagnosis comes under the heading of the fourth method of diagnosis "to feel";
and as such, it is generally regarded as the least important method of diagnosis; "To see,
to hear, to ask" being considered superior. This is not to say that, as a method, it is
unimportant. Far from it; a practitioner would be neglecting his duty if he did not take
the pulse; but it suffers from some shortcomings which will be discussed. There is much
confusion concerning pulse diagnosis, and it is hoped that this article will clear away
some misunderstandings and go some way towards reconciling points of view which
may appear to be opposed, but which are in fact complementary.
HISTORICAL INTRODUCTION
The legendary doctor Bian Que who lived during the Warring States period is accorded
the distinction of being the first to use pulse diagnosis in the "Records of the Historian"
by Su-Ma-Qian. The earliest extant descriptions of pulse taking are in the Nei Jing,
which was also compiled in the Warring States period, but it almost certainly includes
material from traditions that go back much further, possibly even prior to Bian Que. The
other early text is the Nan Jing "The Classic of Difficult Questions" which has some
chapters concerning pulse diagnosis. Both the Nei Jing and the Nan Jing emphasise the
overall quality of the pulse, although in the Nei Jing there is a brief reference to the three
different positions on the radial artery, relating them to the internal organs, much as
they are used today. The Nei Jing also mentioned a different system of pulse taking,
according to nine different positions on the body, relating them to "Heaven, Earth and
Man". This may be a survival of a system of analysis by subdivision into three parts,
which was superseded in the Warring States period by the subdivision into two parts
characteristic of Yin-Yang. This subdivision into three parts actually survives in Chinese
medicine today in the San Jiao or "Three burning spaces", but nowhere else.
The positions where the pulse should be taken to find out the relative strengths of
Heaven, Earth and Man are as follows:
HEAVEN Heaven Both sides of forehead, near Taiyang (Extra) point
Earth Both sides of cheek at Daying ST-5
Man In front of ears near Xiaguan ST-7
EARTH Heaven On the radial artery at Jingqu LU-8
Earth On the hand at Hegu L.I.-4
Man On the ulnar artery at Shenrnen HE-7
MAN Heaven On the leg at Wuli LIV-10
Earth On the leg at Taixi KID-3
Man On the leg at Jimen SP- 11
There is no further reference to this system in the Nan Jing, so it might be thought that
as a system it had died out, having been superseded by the system of taking the pulse at
2
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
2
the radial artery (known also as Cun Kou). However, the famous doctor Zhang Zhong-
Jing writing in the 2nd Century AD referred to a system where the pulse was taken at
the radial artery, the carotid artery (at Renying, ST-9 point) and the leg artery (at Fuyang
BL-59 point) and criticised those who took little notice of the pulse at these last two
regions. He felt that misunderstandings would occur if these positions were not used.
This view is still held today, in that if no pulse at all can be felt at all three positions, in a
patient who suddenly falls unconscious, then the prognosis is poor.
Pulse qualities through the ages
Some modern texts refer to "the 27 pulse qualities" while other texts refer to 28. If we
look back through the ages, we find that different texts have widely different numbers
of pulse qualities. The reason for this is not that there is any real disagreement as to the
meaning of different pulse qualities but that certain combinations of pulse qualities were
sufficiently important to be given a separate name. The number of pulse qualities
mentioned in different texts is given in the table below.
TEXT PERIOD NUMBER OF PULSE
QUALITIES MENTIONED
Nei Jing Warring States,
Before 300 BC
21
Shang Han Lun Later Han,
About 150 AD 23
Mai Jing About 250 AD 24
Hua Sou Yuan, 12
th
Century 30
Li Shi Zhen Ming 1576 27
Zhang Lu Qing 32
Pulse position through the ages
Of greatest interest is how to take the pulse at Cun Kou, the radial artery. Over the
centuries different writers have ascribed different meanings to the three different
positions on each wrist. In the first table we give a selection of interpretations of pulse
positions, starting with the Nei Jing, and ending with Dr. J.F. Shen who is currently
practising in New York. Two versions appear in bolder type than the others, because
these two are commonly used throughout China and the Chinese speaking world. A
superficial glance shows that there are many different interpretations, and it may at first
be thought that there is genuine disagreement. As we proceed through this article, we
shall find that the areas of disagreement are small and are much less than the areas of
agreement. It is a tribute to the accuracy of pulse diagnosis that, over the length and
breadth of China, and stretching back over 2' thousand years, there is so much
agreement. Viewed in this perspective, we can admit that it would be surprising if some
of the hundreds of thousands of doctors who have used this method did not have some
contribution to make or have some different emphasis.
In the table below there is a feature which is somewhat glossed over, and this is the question
of where one should look if there is more than one organ at a position. The Nei Jing states that
organs are to be found in the "Lateral or Outer" (Wad) position while the parts of the body are
3
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
3
to be found at the "Medial or Inner" (Nei) position. There is of course discussion as to whether
this really means medial and lateral or whether it means deep and superficial. This example is
followed by later texts; but by the Ming dynasty this interpretation was rejected, and in the
Bin Hu Mai Xue by Li Shi-Zhen it is expressly stated that the two organs are to be found at the
same place. So for example it is stated that the Guan position on the left relates to the LIV and
incorporates the GB. There is no reference to superficial or deep levels, and both organs can be
found both at the superficial level and deep level. As we proceed through the text, we find
that this is the natural outcome of combining the theory of pulse positions with the theory of
pulse qualities - theories which had previously been separate.
LEFT RIGHT BOOK
Lateral/Outer Medial/Inner Medial/Inner Lateral/Outer
Cun HE Shanzhong Chest LU
Gua
n
LIV Diaphragm ST SP
Nei Jing
Chi KID Abdomen Abdomen KID
Cun S.I. HE LU L.I.
Gua
n
GB LIV SP ST
Nan Jing
Chi BL KID KID Mingmen
Cun S.I. HE LU L.I.
Gua
n
GB LIV SP ST
Mai Jing The Pulse
Classic by Wang Shuo he
210-285 A.D.
Chi BL KID Yin KID Yang SJ/BL
Cun Pericardium HE LU Chest
Gua
n
GB LIV SP ST
Bin hu Mai (1576) by Li
Shi Zhen
Chi SI/BL KID KID L.I.
Cun Pericardium HE LU Shangzhong
Gua
n
GB LIV SP ST
Jing Yue by Zhang Jing
Yao (1561-1639)
Chi BL/L.I. KID KID SJ/S.I./Mingmen
Cun Shanzhong HE LU Chest
Gua
n
GB/Diaphragm LIV SP ST
1792 Yi Zhong
Chi BL/L.I. KID KID L.I.
Cun HE LU
Gua
n
LIV SP
The Essentials of Chinese
Acupuncture 1964
Chi KID KID
Cun HE
Diaphragm
Left-LU-Right Diaphragm
Gua
n
LIV/GB Oesophagus
SP/ST
Duodenum
Dr Shen 1981
Chi L.I./KID/Uterus S.I./BL
4
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
4
INTRODUCTION TO THE PRACTICE OF PULSE TAKING
A) SOME GENERALITIES
1. The purpose of taking the pulse
The purpose of taking the pulse is to find the condition of the interior of the body, with
special reference to the internal organs. This is very important, but often it is not clearly
understood. Thus if there is some problem in the channels (meridians) this will not
show on the pulse unless the related organ is also affected. So an injury to a limb or even
arthritis from Bi syndrome will not show on the pulse, unless a related organ is also
affected.
As mentioned above, diagnosis by feeling is the fourth, and last, method of diagnosis.
Having carried out the three other methods of diagnosis, there should be a clear idea of
the condition of the patient, and so there should be a very clear idea of what pulse to
expect. In fact it can be put even more strongly - do not take the pulse unless you know
what to expect. It is said that if there is a discrepancy between the pulse and the
symptoms in acute disease, then the prognosis is very poor. Only if it is known what
pulse to expect can it be said with certainty whether the pulse and symptoms agree or
not.
2. Strengths of pulse diagnosis
The main strength of pulse diagnosis is that it can be used on all types of patient. In
looking diagnosis, there is much variation in pigmentation between different races; in
asking diagnosis, there is some subjectivity on the part of the patient as to the relative
strength of pain etc. By contrast, pulse diagnosis is carried out by the practitioner, who
brings his own frame of reference with him.
Another strength of pulse diagnosis is an extension of this first: pulse diganosis can
predict disease before it occurs. When disease is still so slight that the patient is unaware
of it, the pulse may already be affected. The third strength of pulse diagnosis is also a
weakness; the pulse is affected by a patient's emotions. If a patient arrives in a state of
high emotion from some recent event, the pulse will show this, and give a false
indication of the state of disease; on the other hand emotion is often closely related to
disease and quick changes in emotion can often be detected on the pulse.
3. Weakness of pulse diagnosis
The weakness of pulse diagnosis is that there are many factors which can influence the
pulse and the practitioner has the task of making allowance for these factors. To this
extent taking the pulse is subjective. The main influencing factors are:
a) State of heart and blood vessels
The pulse is due to blood circulating in the blood vessels and pumped by the heart. If
these are affected in any way, there will be an overall alteration to the pulse. As an
5
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
5
example we may take the slow heart beat characteristic of an athlete. If an athlete suffers
from a fever, his pulse will be more rapid than his normal rate, but may nevertheless be
slower than 76 beats per minute.
As another example, there are two ways in which the arteries are commonly affected -
hardening of the arteries, and enlargement of the arteries due to too much exercise when
young. The former will give a hard and wiry pulse throughout, while the latter will give
a large and hollow pulse throughout. While these pulses certainly reflect something
about the body's condition, they do not necessarily reflect the current condition of the
internal organs, but rather tell something about the history of the patient.
b) Qi of lung and stomach; exercise and diet
The general level of the pulse is related to the general level of Qi in the body, but more
especially to that of the LU and ST. So if a patient has recently taken vigorous exercise
the pulse will be more rapid. Manual workers have large and forceful pulses, and often
the pulse on the right side is larger with right handed workers, whether they are male or
female. By contrast, the pulse of mental workers is relatively weak and slow.
As for diet, alcohol will increase the speed of pulse; after a meal the pulse will be large
and forceful, while prolonged hunger leads to a weak pulse.
c) Qi of the 5 Zang
It is said that if the pulse beats 50 times without any dropped beats, the Qi of the 5 Zang
is flourishing. If one beat is dropped after only 40 beats, then one Zang is affected; if one
beat is dropped after thirty beats two Zang are affected. Thus it is said that no pulse is
properly examined unless at least 50 consecutive beats are taken.
d) Emotions
Emotions affect the pulse immediately. Thus overjoy or excessive anger can affect the
pulse. The pulse may be a valuable indicator of emotions, but sometimes recent
emotions are not related to longer term disease.
e) Weather and seasonal variations
In cold weather the pulse will normally be deep and slow, while in hot weather (or
central heating) the pulse will normally be superficial and rapid.
According to Li Shi Zhen the following seasonal variations of pulse are normal:
In Spring the pulse should be wiry
In Summer the pulse should be overflowing
In Autumn the pulse should be fine like a hair
6
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
6
In Winter the pulse should be deep and strong like a stone.
(The descriptions of seasonal changes in the Nei Jing are slightly different. In the UK
with its relatively mild seasons, these variations are not as pronounced as in China,
which has a more extreme climate.)
______________________________________________________________________________
B) HOW TO TAKE THE PULSE
1. Preparation
Some preparation is needed before taking the pulse, both to prepare the practitioner and
to prepare the patient, so that a reliable recording can be obtained. The practitioner must
first of all be calm, but more important, should already have a clear idea of what the
pulse should be before he takes it. He should have already carried out the three other
forms of diagnosis, to look, to hear and to ask. In some cases the diagnosis will be so
clear from these steps that pulse taking is unnecessary, and in fact may even be
misleading.
The other preparation that the practitioner should make is to try and determine how
much allowance should be made for external factors such as hurry, emotional condition,
weather etc.
The preparation for the patient is to give the patient time to settle down and relax so
that the pulse truly reflects the state of the internal organs, and does not relate to the
conditions of the past few hours. It is this factor which leads to the recommendation in
the Nei Jing that the pulse should be taken at dawn. Clearly it is not practical to carry
out pulse diagnosis only in the first hours of the day. On the other hand a valid reading
will not be obtained at the end of a gruelling day's work.
2. Position
Li Shi-Zhen says "At the beginning of a diagnosis, let the patient extend his arm placing
his palm upwards and relaxing it". In principle, the wrist should be at the level of the
heart when taking the pulse. There are two common ways in which this is obtained -
firstly with the patient sitting up, with the hand on the table on a pillow; secondly with
the patient laying down. The former position is the most convenient, and is generally
thought to give a truer reading. It is the position adopted in China whenever possible. If
the patient is not well enought to sit up, then the pulse is taken with the patient laying
down. With the patient's hands outstretched on the table, the index, middle and ring
fingers are placed on the Cun, Guan and Chi positions respectively. The fingers should
be at right angles to the direction of the artery, and all three fingers should lightly rest
on the pulse at the same time. Some doctors advise taking the patient's right pulse with
the doctor's right hand. However all the Chinese doctors I have spoken to stress that this
is not essential. The most important thing is to be comfortable while taking the pulse.
Thus if the patient is sitting to one side of the doctor, then the doctor will only use one
hand for diagnosis. This gives reliable readings.
7
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
7
3. Where to take the pulse
There is little point in changing the words of Li Shi-Zhen "Behind the wrist there is a
high bone (the styloid process of the radius). It marks the Guan position. In front of the
Guan position is the Cun position, which belongs to Yang and behind the Guan position
is the Chi position which belongs to Yin". In practice the styloid process lies in between
the Guan and Cun positions. As a measure of scale, the distance between the Cun and
Chi positions is about one Cun of the patient.
WHAT THE PULSE POSITIONS MEAN
Referring back to the pulse positions through the ages, the reader may justifiably feel
confused and wonder whether there is any purpose at all in taking the pulse; and if so,
should Ll ShiZhen's method be used or that of the Nei Jing, or a mixture of
the two. In the next section we will give a reconciliation of the different points of view,
but now we give important rules to bear in mind when taking the pulse.
1. The pulse relates to the Zang rather than the Fu.
2. The pulse relates to the three jiao i.e. the upper part, the middle part and the
lower part of the body.
3. The superficial, middle and deep levels relate to Qi, Blood and Jing respectively.
If these factors are borne in mind, then a clear understanding of the pulse can be
reached.
1. Zang rather than Fu
Why does the pulse represent the Zang rather than Fu e.g. why does the middle pulse
on the left hand side relate more to the LIV than the GB? The reason is that as far as
internal medicine is concerned, most of the functions of the body are related to the Zang
rather than the Fu. So for example the functions of the LIV are to store blood, ensure free
flowing of Qi, dominate the tendons and open into the eye, while the function of the GB
is merely to store bile and to assist in the function of digestion. The functions of the LIV
are more important and far-reaching than those of the GB, and are more likely to go
wrong. However, even when there is real dysfunction of the GB, there will also be
dysfunction of the LIV.
At this stage it must again be emphasised that the pulse does not relate to the channels
(meridians). So although in many ways the GB channel is more important than that of
the LIV, having more points and being longer, as far as the internal workings of the
body are concerned, it is to the LIV that the important functions of the body are
ascribed. Some of these attributions may seen arbitrary and at variance with other
systems of medicine, but it has to be accepted that this is the way Chinese medicine has
been written. Chinese medicine is a coherent and logical system, provided that the
meaning of the terminology is clearly understood. The transplanting of Western ideas of
the working of the organs into Chinese medicine is about as successful and fruitful as
transplanting the organs themselves.
8
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
8
2. The three jiao
The distal pulse (Cun) relates to the upper part of the body, the intermediate pulse
(Guan) relates to the middle part of the body and the proximal pulse (Chi) relates to the
lower part of the body. The upper part of the body refers to the chest and the area above
the diaphragm. The middle part of the body refers to the area between the diaphragm
and the navel, and the lower part of the body refers to the area below the navel. The left
hand pulse relates to the left hand side of the body and the right hand pulse to the right
side. So if there is an injury to left side in the chest area resulting in stagnation of Qi, the
left hand distal pulse may be a little tight. More commonly, the energy in one Jiao is full
or empty, and this will reflect in the pulse in the corresponding position on both sides
being full or empty. So if the upper Jiao is empty, it is common for both the distal pulses
to be empty. If the middle Jiao is full (a common occurrence) then both the middle
pulses will be full. These descriptions appear to be in conflict with the earlier definition
that the pulse positions relate to the Zang. Indeed there really is conflict here, because
the pulse at the different positions can relate either to the Zang or to the three Jiao.
How can one tell whether the pulse relates to the Zang or to the Jiao? The answer is that
often it is not possible to tell merely by taking the pulse, and other factors will have to
be taken into account. Thus if the distal pulses are both empty, it may mean that both
the HE and LU are injured and weak; or it may mean that there is relatively little energy
in the upper part of the body, but that there is nothing wrong with the organs. A
definite distinction cannot be made on the basis of the pulse alone, and reference would
have to be made to other forms of diagnosis.
3. Superficial Intermediate and Deep levels
To a certain extent this rule anticipates a later section where we discuss the qualities of
pulses. Strictly speaking, a superficial pulse is a clearly defined pulse quality, as is the
deep pulse. However, it is well to introduce the idea at an early stage as it helps to
clarify many points. The Qi, Blood and Jing are the three main forms of energy in the
body. Qi is relatively yang and flows externally and performs work functions. Jing
(often translated as "essence") is relatively Yin and is the embodiment of the Yin
functions of the organs. (See J.C.M. No.7 "The Origin of Qi and Blood.) Blood is
intermediate between Qi and Jing, having both a cooling function and an active
function.
Qi being Yang relates to the superficial level; Jing being Yin relates to the deep level.
Blood being intermediate relates to the intermediate level. It is anticipating the later
sections, but some examples will illustrate these principles. When there is attack of
pathogenic energy such as wind-cold (as commonly seen in influenza), the body's
energy goes up to the superficial level in order to fight the pathogenic energy.
Correspondingly the pulse is superficial. As another example we can take the pulse
which appears when there has been excessive bleeding in the body. This pulse is hollow,
which means that there is some strength at the superficial level and some strength at the
deep level but that the intermediate level is weak. Immediately after bleeding there is
less blood in the body, but the Qi and Jing have not had time to be affected. So we see
9
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
9
that the intermediate pulse which relates to blood is relatively empty, while the
superficial and deep pulses, relating to Qi and Jing are unaffected.
Reconciliation of different interpretations
We can proceed now to the difficult task of reconciling the apparently differing
pronouncements of famous doctors. First of all we discuss the question of superficial
and deep. In nearly all cases it will be seen that if there is a difference of opinion, it
either reflects a difference of emphasis, or else it relates to a real ambiguity in the
information that the pulse supplies.
Pulse position - the organs
First of all we would draw the reader's attention to the pulse positions that have
remained the same through the ages i.e. the pulse positions that are common to all
writers. It will be seen at a glance that the position of the Zang, and that of the ST are
nearly the same in all writers. So we see that the HE, the LIV and the KID appear at the
Cun, Guan and Chi positions on the left hand side, and that the LIV and SP appear on
the Cun and Guan on the right hand side, with the ST also at the Guan position, We
mentioned earlier that the Zang were more important than the Fu in that they had many
more functions; so we see that there is really an enormous measure of agreement
between writers over the ages, and that any differences are relatively small.
Pulse positions - Intestines and San Jiao
The two systems which we compare in most detail are those shown in large boxes in the
diagram, namely those of Wang Shuo-He as given in the Mai Jing (pulse classic) and
those of Li Shi Zhen as given in Bin Hu Mai Xue. We chose these two systems to
compare because both are in common use at the present time. There are other systems in
use but they are usually variations or combinations of these two.
It will be seen on comparing these pulse systems that the most important discrepancy
concerns the placing of the pulse relating to the intestines. In my view this reflects a real
problem in the body, which causes confusion among generation after generation of
students, namely that the intestine organs, the Fu, are in the lower part of the body,
while the related channels are in the upper part of the body. This can give rise to all
sorts of confusing situations, such as when the upper part of the body is empty, but the
lower part is full. In this case we can have the intestine organs being full, as they are in
the lower part, while the channels are empty as they are in the upper part. (An example
illustrating this will be given later on.) So the two systems give different positions,
because there is a real problem where to look for the intestine pulses. Should one expect
the Cun pulse to relate to the intestines because the corresponding channels are in the
upper Jiao; or should one expect the Chi positions to relate to the intestines because the
intestine organs are in the lower Jiao? The solution adopted usually depends on the
practitioner. Acupuncturists, whose stock-in-trade is manipulating the channels, usually
prefer the system of Wang and look for afflictions in the intestine channel in the Cun
position. Herbalists, whose potions go directly to the internal organs, usually adopt the
10
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
10
system of Li, and maintain that disorder of the intestines appear in the Chi position.
However, to insist that one system is correct, while the other is wrong, is bigotry.
This raises again the question of how to tell whether a full pulse in the Cun position
relates to the LU or HE organs, or to the L.l. or S.l. channels. Again there is no direct way
that this can be told from the pulse, and other systems of diagnosis have to be used.
Usually there is no confusion, for problems in the LU organ can be distinguished at a
glance from problems in the L.l. channel.
Superficial and deep
The Mai Jing seems to indicate that the pulses of the Fu are to be found at the superficial
level, while the Zang are at the deep level. Li Shi-Zhen on the other hand, insists that the
pulses of the organs to be found at one position are at the same depth. Thus he says that
the middle pulse on the right hand side relates to the SP and incorporates the ST. Both
these points of view are current in Chinese Medicine to this day. There is a third view
which is held by the Vietnamese school (as represented by N. Van Nghi) that the
superficial pulse relates to the Zang, while the deep pulse relates to the Fu i.e. exactly
the opposite of the system in the Mai Jing. This point of view has the support of the Nei
Jing, which uses the character Wai, (usual translation "outer") for the position of the
Zang. However the mainstream of Chinese Medicine seems quietly to ignore this
uncomfortable statement in the oldest of books, and we should do so also. The question
that remains is whether it is right to regard the superficial part of the pulse as relating to
the Fu and the deep as relating to the Zang. In my view it is unwise to grant uncritical
acceptance of a model which is just a little too elegant. If we return to the rules stated
earlier we see that the superficial relates to Qi and the deep relates to Jing. Now most of
the functions of the Fu require Qi. Their main task is to transport the food in various
stages of decomposition and to expel the dregs, while performing some separation. By
contrast, the function of the Zang is to store Jing. So we see already that the superficial
part of the pulse, since it relates to Qi, will tend to relate to the Fu, while the deep part of
the pulse, since it relates to Jing, will tend to relate to the Zang. As an example, we can
take affections of the lower part - if external cold attacks the BL, giving symptoms of
cystitis etc. The pulse in the lower left Chi position will be superficial. On the other
hand, if the patient is also very weak and lacking in KlD-Jing, the deep pulse will be
empty. One can find many examples of pathological conditions where a problem of Qi
soon shows as a problem in the Fu, while a problem of Jing soon shows as a problem in
the Zang. However, this is by no means always the case. One can take as example the
syndrome of Wind-Heat attacks the LU. This is a superficial syndrome and affects the
Qi, and so the pulse is superficial, especially in the Cun position on the right hand. The
symptoms are clearly LU symptoms with severe cough, sore throat etc. In this case,
there is no possibility of ascribing the superficial pulse to the L.l.
Left and Right
The main problems which occur here are where to place the intestines, the BL and Ming
Men. Some writers put them on one side, and some on the other. Here the discrepancy
represents a genuine ambiguity in the body. Thus if there is long term constipation
giving a fullness in the L.l., this fullness may show on either side. Similarly an attack of
11
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
11
damp-heat in the BL may show in a full tight pulse on either side. Again, to make a
definite distinction only by examining the pulse is not possible, and recourse should be
had to other methods of diagnosis.
As for the position of Ming Men, this is so clearly related to the function of the KID that
it would be splitting hairs to look for a difference in the pulse position. Ming Men is
related to KID Yang which is traditionally placed on the right side. In practice, if one
KID pulse is deficient, so is the other.
PULSE QUALITIES
In some schools in The West, more attention is paid to the different pulse positions. In
China more attention is paid to the overall quality. In fact the first thing that is learnt is a
simple differentiation of the basic qualities, and differentiation according to position
only comes later. In my experience this approach is valid, for there are usually more
similarities in the pulse at different positions than there are differences. For example it
will be immediately obvious whether the overall pulse quality is strong or weak, even
though there are some differences in each position. This view is supported by all the
texts through the ages, starting of course with the Nei Jing, which rarely mentions pulse
positions, but frequently mentions overall pulse qualities. In practice, the most refined
diagnosis comes from combination of qualities and positions.
Basic principles of pulse qualities
"The theory of the pulse is very complicated, but is based upon the four principle pulses
- floating, deep, slow and rapid. Once they are understood, by elaborating them the
entire subject can be clarified."
So speaks Li Shi-Zhen in his pulse book. There can be no better way of starting pulse
diagnosis than with these qualities, and some other basic qualities. We have seen that
the superficial level relates to Qi and the deep to Jing. If the pulse at the superficial level
is stronger than that at the deep level, it is called Floating pulse. This can arise either due
to excess at the Qi level, or due to deficiency at the Jing level. How can this situation
occur? Excess at the Qi level can come when there is excess of a Yang pathogenic factor,
especially some exterior disease. In this case the pulse will be Floating and Strong. By
contrast, if the Floating pulse is due to deficiency of Jing, this will be a Weak and
Floating pulse. Normally Jing will be associated with the Yin levels of the body.
The same principle may be applied to the Deep pulse, which may be Deep and Strong,
due to excess of some Yin pathogenic factor (such as penetration of cold-damp) or Deep
and Weak due to absence of Yang Qi.
Fast and Slow
Turning to the main qualities of Fast and Slow, the Fast pulse relates to hot conditions
while the slow pulse relates to cold conditions. Hot conditions are usually classified into
full heat and empty heat (Yin Xu). The full heat will have a full and rapid pulse while
the empty heat will have an empty and rapid pulse.
12
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
12
It is appropriate at this point to mention pulses with some irregularity in rhythm. This
pulse is related to blockage of Qi in some part of the body. Frequently the irregularity is
seen as a faster pulse on the patient's in-breath, and slower pulse on the patient's out-
breath. This usually relates to obstruction of Qi in the upper part of the body.
CLASSIFICATIONS OF MAIN PULSE QUALITIES
Fast Related to hot conditions. Full heat is fast and forceful - Yang
Excess Empty heat is Fast and weak - Yin deficiency (xu)
Speed
Slow Relates to cold conditions
Full cold is slow and forecful - Yin Excess
Empty cold is slow and weak - Yang deficiency (xu)
Floating Excess at Qi level or deficiency at Yin level.
To be seen in superficial disease (Yang excess disease) when the
Wei Qi is fighting the pathogenic factor at the superficial level.
Floating and strong.
To be seen in interior disease due to Yin deficiency or Jing
deficiency. Floating and weak.
Hollow In the hollow pulse, the intermediate level (which relates to
blood) is weaker than the pulse at the superficial and deep levels.
Usually some internal bleeding problem.
Depth
Deep Excess at the Yin level or deficiency at Qi level. To be seen in deep
disease (disease has penetrated deeply to the internal organs) -
deep and strong.
To be seen in diseases due to deficiency of Yang energy - deep
and weak.
Strong Relates to Shi (full conditions, when the body is basically strong
but has been attacked by external pathogenic factor.
Strength
Weak Relates to Xu (empty) conditions when the body is weakened by
long term disease etc.
Tight Relates to cold and stagnation
Wiry Relates to LIV. The stagnation is more severe and amounts to
obstruction.
Slippery Relates to phlegm
Quality
Rough Relates to deficiency of Qi and Blood
Strong and Weak
While we are discussing the basic qualities, one so basic that Li does not even mention it
is the differentiation between the strong and weak pulse. We have already implied that
strong relates to a Shi or full condition while weak relates to a Xu or empty condition. It
is not difficult to recognise full and empty pulses, the only exceptions are the Drumskin
pulse which is superficial and weak. It can sometimes feel like a strong pulse because at
13
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
13
the most superficial layer there appears to be strength; but only the slightest pressure is
enough to reach a layer where the pulse is very weak. The Hidden pulse is opposite,
with a strong pulse at a very deep layer. It can be confused with a Weak pulse, for it is
only felt on quite strong pressure; until this pressure is applied, there is little to be felt.
Qualities of Tight, Slippery, Wiry and Rough
These basic qualities refer to the feel that the pulse has under the finger, and are
correspondingly hard to describe. The Tight and the Wiry pulse are similar in nature,
with the tight pulse only slightly Wiry. I will not attempt any further description of
these pulses than is given in the table of pulse qualities - the best way is to find a patient
who has very clear signs of LIV Yang rising, and feel their pulse. It will be a Wiry pulse.
It is quite similar to the pulse felt in patients with hardened arteries - though this pulse
is Wiry, Hard and Long.
The Slippery pulse again is hard to describe, and the best way to observe this is to find a
patient who suffers from catarrh. Their pulse will either be rather Soft, or else it will be
Slippery.
The Rough pulse is a pulse that is irregular in amplitude and rhythm.
CLASSIFICATION OF MAIN PULSE QUALITIES
Introduction to 27 qualities
Once these basic qualities are firmly fixed in the mind, it is time to proceed to an
examination of the 27 pulse qualities given in the table. It seems a large number of pulse
qualities, but it will be seen that the new qualities are either combinations of qualities
given so far, or extreme cases of the qualities given so far. Brief notes are given in the
table by way of explanation. We also give a few little "boxes" showing some symptoms
that might be expected if that pulse quality is found at a particular position. These
symptoms need not be memorised, for they can be deduced - we take as an example the
first box, the Slippery pulse. The Slippery pulse relates to phlegm or heat. If it is found
in the Cun position on the left hand, it means that the phlegm and heat is affecting the
HE or giving rise to the symptoms given. An explanation for the other symptoms in the
boxes is left as an exercise to the reader.
Pulse qualities and their meanings
English
name
Pinyin Other translations and description Meaning
Floating Fu Superficial
See text for description
Pathogenic Wind
Yin Xu
Qi disease
Deep Chen See text for description Pathogenic Qi within Qi
obstructed
Yang Xu
Organ disease Oedema
(1)
14
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
14
Slow Chi 60-70 Cold within Yang Xu HE injured
by exercise (2)
Fast Shuo 82 = fast
96 = very fast
120 = serious (or nervous)
Heat
Yang abundant
Yin Xu
Qi or Blood Xu
Shock, weak nerves (3)
Slippery Hua "Like a pearl rolling in a basin" Phlegm
Heat
Pregnancy
Choppy Ce "Rough". "Like bamboo scraped with a
knife". Irregular amplitude and/or rhythm.
(4)
Pathogenic Qi
Blood and Jing weak
Qi obstructed
Cold and Damp
Tight Jiu Like a rope with one end fastened and the
other going round. (5)
Pain
Pathogenic Cold
"Infection"
Long Chang Like a pencil (6) Shi
Qi rebellious and fire
Wind-stroke (very long)
Short Duan Only appears in middle of doctor's finger Xu, especially of Yuan Qi
Full Shi(7) Full, long and hard Shi condition
Empty Xu (8) a) Empty-Soft. Floating and big. Slow and
soft movement
b) Really empty
Blood Xu
Summer Heat
Jing Xu and cold pathogenic Qi:
dangerous
Overflowing Fills whole area beneath fingers (9) Pathogenic Wind, especially
Wind-Heat
Blood Xu (if weak)
Deficiency of fluids
If after long disease, the prognosis
is poor
Hollow Kou "Scallion", "Onion stalk". Strong at top,
empty in middle, strong at bottom
Hollow + Weak = loss of blood
Hollow + Strong = about to bleed
Hollow + Soft = Qi stagnant
Hollow and Strong in whole pulse
= a) high blood pressure, ( 10) b)
diabetes
Small Wei "Minute" (11) Hardly discernible Lost Yang with Qi and Blood
injured
Very serious
Wiry Xian "Taut". "Bow-string". (see text) LlV-Wind
Phlegm
Pain
Drumskin Ge "Leather". Superficially taut, soft on
pressure. See text
Shi Cold
Extreme Qi and Blood Xu (12)
Hard Lao Long, wiry, hard Qi accumulation
Soft Ruan
(13)
"Weak Floating". Cotton floating on water Yin Xu
KID empty
Jing exhausted
Marrow exhausted
Weak Ruo Thin or fine and soft Yang decayed
Often seen in protracted disease,
not dangerous
Scattered San If middle depth is selected, pulse becomes
hollow; if deep is selected, undiscernible
KlD-Qi destroyed: always a sign
of danger
15
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
15
Thin Xi "Fine" "Thready" Decayed Qi
Yin Xu - often with Yang
symptoms
Damp
Debility
Hidden Fu Hidden or sunken beneath muscle; near
bone. Deeper than Deep pulse
Disease has penetrated to zang
Wind-Cold on exterior;
pathogenic cold on interior
Big Da "Broad", Twice as broad as overflowing
pulse but not so full and large
Internal pathogenic heat
Yang Ming fever developing
Unsteady Dong Rapid, slippery, shaking. Fluctuates
between light and heavy.
Pain
Fright, deep fear
Qi and Blood wild
Sweating in Yang Ming fever (15)
In healthy person, overwork
before puberty
Hasty Cu Halting at times
Fast and interrupted
Fire
Obstruction of Qi
Knotted Jie Slow and interrupted Obstruction, accumulation
Congealed cold
Irregular Dai Stops after set number Zang injured
HE nerve troubled
If stops after 2 or 4 - dangerous
(1) Deep
"Oedema" is my addition. It is normally related4. Choppy
to Qi obstructed or Yang Xu.
(2) Slow
In Western medicine a normally slow heart beat is often regarded as beneficial to health.
In Chinese medicine it may be regarded as a sign that the heart has been enlarged by too
much exercise when young. This may lead to tiredness and lethargy in later life.
(3) Fast
The patient's pulse is often faster the first time they come for treatment, as they do not
know what to expect.
(4) Choppy
Also described as small, minute and short with irregular rhythm. It is a Xu pulse and is
associated both with deficiency of Qi and blood and also with obstruction. In this case
the obstruction occurs because there is not enough energy to move the obstruction - in
contrast to the LIV sort where the obstruction is withstanding enormous pressure.
(5) Tight
The tight pulse is slightly wiry. The wiry pulse relates to LlV-type obstruction. In the
tight pulse we see obstruction manifested in pain, or due to cold. According to Dr. Shen,
the tight pulse is associated with "infections" in the Western sense of the word. When
the pulse is tight at the middle depth only, it may mean heat in the blood.
(6) Long
The long pulse refers to the length under the finger in the direction of the artery. In a
very long pulse, it seems rather that there is a pencil being moved up and down in the
16
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
16
artery. It contrasts with the short pulse, where the length in the direction of the artery is
small i.e. the pulse can only be felt in the middle of the finger. In a healthy person, the
long pulse indicates a strong constitution. In a healthy person, the short pulse indicates
a delicate constitution.
(7) Full
The character Shi is the same as Shi for excess or full condition.
(8) Empty
The character Xu is the same as Xu for deficient or empty condition.
(9) Overflowing
The overflowing pulse spreads out sideways from the artery like a river that is bursting
its banks. The prognosis is poor if this pulse appears after a prolonged disease, for this
pulse relates to a full condition after a long disease. This is an example of the pulse and
the symptoms going the opposite way.
(10) Hollow
"True high blood pressure" relates to high blood pressure that is continuous, as opposed
to blood pressure that raises at times of high emotion, but then falls again.
(11) Small
This pulse is extremely small.
(12) Drumskin
This pulse sometimes appears in patients who are extremely weak inside, but screw
themselves up to carry out their daily work - living on their nerves. They are very likely
to suffer from needle shock, as they suddenly relax.
(13) The character also means soggy. This pulse can also appear when there is internal
damp. In this case it is soft but not weak.
(14) Scattered
A dangerous pulse when it appears from natural causes. Often related to some internal
poisoning, often a sign of cancer. Not such a serious pulse when the poisoning can be
directly related to taking Western medicines. The scattered quality will go when the
patient stops taking the medicines for a while.
(15) Unsteady
"Yang Ming fever" relates to differentiation of syndromes according to the 6 Jiao. Article
to appear.
Quality Position Left side Right side
Slippery Cun
Guan
Chi
Heat in HE
Vomiting
LIV-Heat
Dizziness
Frequent bloody cloudy
Catarrh
Vomiting
Middle Jiao Stuck: Heat
Gurgling intestines
17
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
17
urine KID fire rises tinnitus
Choppy Cun
Guan
Chi
Palpitations
Pain in HE
LlV-Blood Xu
Knee and back pains
Weak cough
LU-Qi weak
SP weak
No appitite
KID Fire weak or injured
Tight Cun
Guan
Chi
Head hot
Heart pain
Epigastrium full and painful
Back and sides painful
Pain under umbilicus
Cold
Asthma
Hypogastrium painful
Hernia
Cold accumulation
Overflowing Cun
Guan
Chi
Overfull HE
Hardened arteries
True high blood pressure
LIV swollen by anger
+ Hollow: diabetes
Prostate trouble
Full LU
Water in LU
ST swollen by working after
meals
Wiry Cun
Guan
Chi (12)
Heart pains
Lumps
LIV dispersing power gone
Back and leg pains
Hernia
Empty KID
Headaches
Chest and rib pains
Cold and Full
Pains in abdomen
Abdominal pains
Dysentery
Soft Cun
Guan
Chi
Easily forgets
Cramps
Jing/Blood wasted
Qi weak
sweating
SP weak
Scattered Cun
Guan
Chi
Palpitations
Swellings
Yin exhaustion
Sweats
Yang exhaustion
Summary of the qualities
After studying the qualities in the table, we find that we can analyse them according to
the main qualities of depth and quality and strength, and arrange them in the following
way:
18
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
18
SUPERFICIAL DEEP
Strong Weak Strong Weak
TAUT Tight
Wiry
leather
Full
Firm thin
SOFT Flooding Scattered
Soft
minute
hidden weak
The pulse and pregnancy
The pulse may change in pregnancy. Sometimes it is a pathological sign; sometimes it is
not. It is said that if the pulse becomes slippery in pregnancy, this is not a pathological
sign.
According to Li Shi-Zhen, if the left pulse at the Chi position is more slippery and rapid
then the child will be a boy; if the right pulse at the Chi position is more slippery and
rapid then the child will be a girl. However he qualifies it saying "This idea is ancient. It
is not always correct but is often a helpful indication".
______________________________________________________________________________
Concluding remarks
1. When first taking the pulse, it is not possible to remember the 27 qualities and have
them available for instant access. In order to develop this facility, ask the following
questions, firstly about the overall pulse, and then about the individual positions.
1. Fast or slow?
2. Superficial or deep?
3. Strong or weak?
4. Wiry, slippery, rough? In answering the questions, you have made the basic
diagnosis.
2. As far as pulse positions are concerned, remember that the positions relate primarily
to Zang or solid organs and the three Jiao, and that some of the Fu or hollow organs can
appear at different places. Do not be too rigid in sticking to one system of diagnosis.
Some case histories
1. Master B. 6 years old, was brought to me by his mother, who said that he had been
listless, pale and eating very little. The G.P. had said not to worry, but she was
nevertheless concerned. In this case the patient was very shy and refused to put out his
tongue for inspection. In the absence of a clear symptom picture, and tongue diagnosis,
the pulse gave the most reliable information. The pulse was slightly Slippery and Small
in all positions except the right Guan position which was Full and Slippery. His stools
were more or less normal, and he complained of an ache in the region of the stomach.
19
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
19
From this I deduced that the patient's condition was retention of phlegm in the ST. This
diagnosis was confirmed in a dramatic way a few moments later, when, as a result of
treatment, he vomited phlegm over my trousers. After this performance the pulses were
less Slippery and much better balanced i.e. the right Guan pulse was nearly normal. This
illustrates that the pulse can change extremely rapidly if the condition of the organs
change.
2. Mr. R. 28 years old suffered from epilepsy. He had much evidence of sputum, on his
tongue and from his nose. His abdomen was swollen and his body covered with hair.
His pulse was slightly Rapid, and Soft (soggy), characteristic of heat and dampness. As a
result of an extended course of treatment, his nose cleared, his abdomen became so
much Jess distended that he had to buy new trousers, and the excess body hair
disappeared. The pulse however was almost unchanged. This showed that although his
symptoms were much improved the basic condition of the organs was still the same,
and that he could easily revert to the condition he was in before.
3. Miss S. 26 years old complained of lethargy. On examining the pulse, it was found to
be slightly Rapid, Full and Wiry in the left Guan, and Tight on both sides, between the
Guan and Cun. The Tight quality appearing on both sides suggested obstruction of Qi
somewhere in the chest region. (Not in an organ, which would have had a Tight quality
on one side only). The Wiry and Rapid left Guan pulse indicates LlV-Yang rising. I
asked her if she had a tight feeling in the chest. She answered that she had had this tight
feeling since losing her temper a week previously.
4. Mrs. B. 48 years old had a recurring condition of cystitis. For many years she had
contracted cystitis every two or three months that had necessitated the use of antibiotics.
Both Chi pulses were very Small and Soft and Deep, indicating that she had very weak
KID energy. During the time that she had cystitis, the left Chi pulse was still very Small
but Tight and superficial. Thus in her case the left Chi pulse related to the bladder, and
the superficial and tight quality related to the attack of cold.
5. Mr. N. 23 years old complained of a painful shoulder. He enjoyed playing all sorts of
sports, but found he could not do so because his shoulder became so painful the day
after using it. The pain occurred along the L.l. channel. He had tried physiotherapy and
other manipulative techniques but with no lasting results. On taking his pulse I found
that both the Cun positions were Empty, and the right Chi position Full and a little
Tight. Once glance at his physique showed that his condition was good, so that any
disorder in the Chi pulse would not relate to the KID, but must relate to the Fu. Since
the main symptom he complained of was along the L.I. channel, it pointed to some
obstruction of Qi in the L.I. organ. After some questioning it appeared that he had been
kicked in the abdomen in a football match some years previously, but had thought
nothing of it. His abdominal muscles were completely tense and knotted, but as
treatment progressed these muscles relaxed and it was possible to feel the knot deep
down, from the obstruction of Qi in the L.I. This case is specially interesting, for the
Right Cun pulse relates to the L.I. channel and the right Chi pulse relates to the L.I.
organ. The obstruction of Qi in the L.I. organ is a full condition in the Lower Jiao.
Consequently the right Chi pulse is too Full; the symptoms of the arm are all empty
conditions and result from the channel not being nourished by the organ. The Qi is
20
JOURNAL OF CHINESE MEDICINE NUMBER 14 JANUARY 1984
20
obstructed in the organ and is unable to reach the channel. As a result, the Cun pulse is
weak.
Further reading
This article is merely an introduction to pulse diagnosis. The principles have been
elaborated and worked out in the 27 qualities. The basis is very simple, but to diagnose
accurately from the pulse requires much experience. There is no particular magic or
mysterious process in building up this experience, beyond careful observation and
thought. There are a number of texts available in English which will help in further
study. The text of Li Shi Zhen's Bin Hu Mai Xue is now available in a translation by Hoc
Ku Huynh of P.O. Box 202-K, Haymarket, NSW Australia. (Also available from Felicity
Moir, 17a Kensington Park Gardens, London W.ll. Cost 19.00) For a description of
pulse qualities, and their meaning when they appear in different positions see "The Web
that has no Weaver" by Ted J. Kaptchuk. This book also contains useful diagrams
illustrating the pulse qualities. For an unusual approach based on years of clinical
experience see "Chinese Medicine" by Dr. J.H.F. Shen published by Educational
Solutions Inc., 80 Fifth Avenue, New York, N.Y. 10011.
21