Pulse diagnosis is primarily used for disease diagnosis. It is one of the four diagnostic methods and serves as an important basis for diagnosing diseases, assessing disease progression, and prognosis, which has always been valued by practitioners.
Some may ask, since ancient times, the four diagnostic methods have been arranged according to their diagnostic value in the order of observation, listening, inquiry, and palpation. However, I believe that pulse diagnosis plays a decisive role, which seems to contradict ancient teachings. It cannot be denied that there is a difference from traditional views.
I believe that observation, listening, inquiry, and palpation are the sequence of application in the diagnostic process, rather than a ranking of importance.
When a physician examines a patient, they always first observe the patient’s complexion and form, assess their breath and voice, inquire about their suffering, and then diagnose their pulse to clarify the diagnosis. If we discuss the importance of the four diagnostic methods, palpation should come first. This is because palpation plays a crucial role in judging the four elements of a complete diagnosis.
A complete diagnosis in Traditional Chinese Medicine (TCM) must include four elements: first, the nature of the disease; second, the location of the disease; third, the severity; and fourth, the trend of the disease.
These four elements can be summarized as the “Four Determinations”: determination of nature, determination of location, determination of quantity, and determination of trend.
For example, if a patient is wheezing, the nature is heat, the location is in the lungs, and the heat is severe, the diagnosis would be “Lung Heat Accumulation”.
How is the trend of the disease reflected?
Excess heat can injure fluids and consume qi, it can transmit to the pericardium, descend to the Yangming, or transform fluids into phlegm, etc. The pulse must clarify the trend of the disease, interrupt and reverse it, first stabilizing the area not affected by the pathogen to prevent its transmission.
Only with these four elements can we consider it a complete diagnosis, but it may not necessarily be a correct diagnosis. The correctness of the diagnosis must also be verified by clinical practice; if the subjective and objective findings match and the expected therapeutic effect is achieved, then we can say this diagnosis is correct or basically correct.
If treatment worsens the condition, and the subjective and objective findings do not match, although the diagnosis is complete, it may not be correct. Among the four elements of a clear diagnosis, pulse diagnosis generally plays an important, even decisive role.
01
Determination of Nature
The judgment of the nature of the disease is mainly based on the pulse, which is well documented in ancient Chinese medical texts.
For example, in the Shang Han Lun (Treatise on Cold Damage) 140: “If a patient with Taiyang disease has a rapid pulse and does not have chest tightness, this indicates a desire for resolution. A floating pulse indicates chest tightness. A tight pulse indicates a sore throat. A wiry pulse indicates tightness in both sides of the ribs. A thin and rapid pulse indicates that the headache has not stopped. A deep and tight pulse indicates a desire to vomit. A deep and slippery pulse indicates harmonizing heat and benefit. A floating and slippery pulse indicates blood loss.”
This emphasizes the reliance on the pulse.
In the Jin Kui (Golden Chamber) section on lung atrophy: “A rapid and weak pulse indicates lung atrophy, while a rapid and strong pulse indicates lung abscess.”
In the Jin Kui section on malaria: “The pulse of malaria is wiry; a wiry and rapid pulse indicates more heat, while a wiry and slow pulse indicates more cold.”
In the Jin Kui Yao Lue (Essentials of the Golden Chamber), it states: “If the patient’s pulse is floating, the disease is on the surface; if floating is at the back, the disease is internal.”
Similar records abound in classical medical texts and literature throughout the ages.
From my over 50 years of clinical practice, I have a deep understanding of this and increasingly rely on pulse diagnosis.
The nature of the disease can only be cold, heat, deficiency, or excess, all of which can be reflected in the pulse. Conversely, one can judge the cold, heat, deficiency, or excess of the disease based on the pulse.
Generally, it is confirmed that a strong pulse indicates excess, a weak pulse indicates deficiency, a rapid pulse indicates heat, and a slow pulse indicates cold. This is the judgment of the nature of the disease.
Especially for critically ill or complex patients, or those with very few symptoms lacking sufficient differentiation basis, or those with many symptoms making it difficult to start, pulse diagnosis must be relied upon for judgment.
02
Determination of Location
The judgment of the location of the disease is also mainly based on the pulse and combined with the symptoms of the meridians and organs.
For example, if there are changes in the pulse at the cun position and symptoms of the heart meridian appear, then the location can be judged to be in the heart; if symptoms of the lung meridian appear, then the location can be judged to be in the lungs. The same reasoning applies to others.
However, some patients may have symptoms above while the disease is located below, or symptoms below while the disease is located above, which requires even more reliance on pulse diagnosis for judgment.
For instance, if a person has had a headache for four days with no other symptoms, a student in training may think it is an external pathogen and prescribe a warming and cooling exterior-releasing formula. However, upon examining the pulse at the chi position, it is floating, indicating that the fire is strong and invading the bladder meridian, causing the headache. Using Zhi Bai Di Huang Wan (Anemarrhena and Rehmannia Pill) resulted in recovery.
Regarding the distribution of the pulse in relation to the organs, I would like to discuss the following:
One theory suggests that the floating pulse indicates the heart and lungs, the middle pulse indicates the spleen and stomach, and the deep pulse indicates the liver and kidneys. This theory is not clinically applicable.
Is it true that all heart and lung diseases are only found in the floating pulse and not in the middle or deep pulses? Are all liver and kidney diseases only found in the deep pulse and not in the floating or middle pulses?
For example, if a patient is wheezing and the cun pulse is deep and rapid, it indicates that heat is accumulating in the lungs, forcing the lung qi to rebel and cause wheezing. This condition cannot be detected by the floating pulse but is diagnosed through the deep pulse. How can we say that heart and lung diseases are only diagnosed through the floating pulse?
Another theory divides the cun and chi pulses into internal and external organ assessments. The cun position is a very small area, as thin as a wheat straw, and further dividing it into internal and external, upper and lower, is difficult to grasp and tends to be abstract, which is not how it is used clinically.
A more consistent opinion is to assess the left and right pulses according to the cun, guan, chi distribution. The left pulse at cun, guan, and chi corresponds to the heart, liver, and kidneys; the right pulse at cun, guan, and chi corresponds to the lungs, spleen, and life gate; the pericardium is at the left cun; and both chi positions are considered to belong to the kidneys by some.
Regarding the distribution of the organs, the gallbladder is at the left guan, the stomach is at the right guan, and the bladder is at the chi, with a relatively consistent opinion among various schools. However, there is considerable divergence regarding the distribution of the large and small intestines, with about three different opinions, each holding their own views, leaving scholars in disagreement.
The distribution of the organs should not be overly mechanical and rigid, as it is not only abstract but also impractical.
I judge the location of organ diseases based on the cun pulse indicating upper jiao changes, including the heart, lungs, pericardium, and chest, neck, and head; the guan pulse indicating middle jiao changes, including the spleen, stomach, liver, gallbladder, and upper abdomen; and the chi pulse indicating lower jiao changes, including the kidneys, bladder, large and small intestines, uterus, lower abdomen, waist, knees, and feet.
As for determining which organ or meridian is affected, it is necessary to combine the symptoms expressed by that organ and its meridian for comprehensive analysis and judgment.
For instance, if the cun pulse is rapid and the symptom is coughing, it indicates that there is heat in the upper jiao. However, whether this heat is in the heart, lungs, chest, or head cannot be determined solely by the pulse; by observing that the patient is coughing, which is a symptom of the lungs, and combining it with the cun pulse, it can be concluded that it is lung heat.
If the same cun pulse is rapid and there are symptoms of irritability and insomnia, it can be concluded that there is heat in the heart.
According to the Mai Jing (Pulse Classic), the cun, guan, and chi are used to assess the three jiao, without mechanically pairing them with the organs.
The Mai Jing states that the three positions correspond to: “Cun corresponds to the upper jiao, affecting the head and skin; guan corresponds to the middle jiao, affecting the abdomen and stomach; chi corresponds to the lower jiao, affecting the lower abdomen to the feet.”
This method of localization is simple, practical, and accurate, without the pitfalls of being overly abstract or rigid and complicated.
03
Determination of Quantity
The assessment of the severity of the disease is a concept that is both vague and precise. It is vague because it is difficult to quantify; it is precise because the physician must clearly understand the severity of the condition to facilitate prescription and medication.
For example, for lung heat, should gypsum be used at 50g or 10g? Without clarifying the severity of the condition, it is impossible to determine the appropriate medication and dosage.
Using insufficient medication for a severe condition is ineffective, while using excessive medication for a mild condition is also inappropriate. The severity of the disease can also be judged from the pulse. For instance, a rapid pulse indicates heat; the stronger the pulse, the more severe the heat, while a lighter pulse indicates milder heat.
04
Determination of Trend
The judgment of the trend of the disease is primarily based on pulse diagnosis.
The so-called trend of the disease refers to the tendency of the disease to develop and change, which can be categorized into three situations: first, gradual improvement; second, a stalemate between the pathogen and the righteous qi; and third, deterioration, with the condition worsening, transforming, and potentially leading to death.
Disease is not static; it undergoes continuous changes in nature, location, and severity, and these changes determine the outcome and prognosis of the disease.
Firstly, during the course of the disease, the causative factors are constantly changing.
For example, in an externally contracted disease, it may start with a cold pathogen, which can linger and transform into heat; the heat can then injure the yin and transform into dryness. The changes from cold to heat to dryness are due to the changes in the causative factors, and the nature of the disease also changes accordingly.
These changes are primarily judged based on the variations in the pulse. A tight pulse indicates cold; as the cold pathogen transforms into heat, the pulse changes to floating, surging, and rapid; as the yin is injured and transforms into dryness, the pulse changes again to thin and rapid.
This article is excerpted from:“Selected Insights from Classical TCM Masters”, Lü Zhijie.