(1) Characteristics of the String Pulse The string pulse is one of the most common pulse patterns in clinical practice. When the pulse beats, it feels like pressing a taut string. The string pulse is one of the pulse patterns that we can easily grasp and experience; it was the first pulse I learned to feel. Having played the violin and erhu since childhood, the sensation of the string pulse is very similar to that of a string on a musical instrument. Later, to practice pulse diagnosis, I gave up playing, allowing my left hand to develop distinct fingerprints. The sensation of the string pulse is characterized by a tightness that feels like a taut string when the pulse beats. This sensation can be experienced on the strings of the erhu, yangqin, and pipa, especially on the strings of the erhu. One can also feel this sensation on the string used for cotton candy, which is even more typical, as it moves straight up and down, tightly stretched. Clinically, the tightness of the string pulse varies with the condition, and we categorize it into four types: Standard String Pulse: This is the typical string pulse. Moderately String Pulse: This is not as tight as the standard string pulse, indicating a lower degree of tension. Slightly String Pulse: This is not very tight, with a lower degree of tension than the moderately string pulse. Faint String Pulse: This has a slight feeling of tightness. (2) Mechanisms and Diagnostic Significance of the String Pulse 1. Liver and Gallbladder Qi Stagnation The first mechanism for the formation of the string pulse is liver and gallbladder qi stagnation. When qi is stagnant, how does this manifest? Those who practice qigong know that one should relax the body, gradually loosening the neck, shoulder, and limb muscles, even the muscles of the scalp and around the ears. If one becomes tense, the muscles will tighten. In Western medicine, it is said that when a person is tense, adrenaline and norepinephrine are secreted, causing muscle tension and constriction of blood vessel smooth muscles. The liver and gallbladder are responsible for the smooth flow of qi; if qi does not flow smoothly, it becomes stagnant, leading to a string pulse. Clinically, the most common occurrence of the string pulse is associated with liver and gallbladder qi stagnation, which we assess based on the probability of disease occurrence. 2. Intense Wind Force (mainly referring to Liver Wind) The second mechanism for the string pulse is intense wind force. Here, wind primarily refers to internal wind, particularly the intense wind of the liver. If a person has abundant yang qi, it becomes agitated, like wind filling a sail, causing the sail’s ropes to become taut. The sensation of the string pulse under the fingers is similar to that of a rope or string. Intense liver wind can also produce a string pulse. I once treated a hyperthyroid patient in Shenzhen who had been on Western medication for two years without improvement; their pulse was stringy and somewhat hard. I warned their family that this patient was at a higher risk of thyroid crisis, which could lead to high fever, vomiting, fainting, and convulsions, as well as elevated blood pressure, due to the stringy and tense pulse, which was caused by excessive yang qi. After advising them to stop the Western medication and using Bai Tou Weng Tang (Bai Tou Weng Decoction) with Ejiao (Donkey-hide Gelatin) for treatment, the pulse gradually softened, and the liver wind subsided. Additionally, yin deficiency is also a significant cause of intense liver wind and string pulse, which is commonly seen in clinical practice. I will illustrate this with four typical cases I have treated, all elderly patients. Three were female and one male, all suffering from diabetes complicated by hypertension. These patients had been hospitalized, received insulin injections, and taken large amounts of antihypertensive medications. Some were even treated with a combination of hydrochlorothiazide and propranolol, along with angiotensin-converting enzyme inhibitors and calcium channel blockers. However, their blood pressure remained high, and their blood sugar levels did not decrease, consistently ranging from 13 to 17 units. Two of the elderly women experienced severe insomnia, unable to sleep for two months, and were extremely agitated. Some were bedridden, unable to move, feeling completely exhausted. The pulses of these patients were all fine and stringy, with three showing this on the left wrist and one on both wrists, indicating the need to differentiate pulse locations. This is similar to Wu Jutong’s description of fine and tense pulses, which can cause concern for the physician, as such pulses may indicate a rapid deterioration of the condition, with kidney yin depletion progressing quickly. Yin deficiency leads to virtual wind and intense agitation, resulting in dizziness, headaches, irritability, and insomnia, with signs of excessive yang and insufficient yin. Blood pressure may drop, but blood sugar remains high. If the yin is depleted, the body loses strength, becoming immobile, as the muscles lack nourishment from blood and yin fluids, leading to a state of collapse. If the condition progresses to a stage of both yin and yang deficiency, where yang is severely depleted and yin is nearly exhausted, insulin injections can only worsen the patient’s condition. We must view diseases from a TCM perspective; a fine and tense pulse is a precursor to kidney failure, as well as gastric failure. Depleted yin leads to a lack of resources, and weakened yang results in a loss of energy. Therefore, I insist on treating patients with TCM while discontinuing Western medications. After a prolonged period of TCM treatment, these four patients showed significant improvement. The urgency I feel stems from the depletion of yin, which leads to an uncontrolled rise in yang, resulting in excessive wind. Secondly, I am concerned that the patients are still taking medications like Metformin and insulin, which exacerbates the situation. It is crucial to stop insulin and other blood sugar-lowering medications, which is a challenging task. Fortunately, I have established credibility with them, but it took several stern discussions to convince them to stop. Stopping Western medications is no joke; it places the entire responsibility on us for TCM treatment, and there is no one to blame if something goes wrong. One elderly patient, after stopping insulin, saw her blood sugar rise to 27, a level she had never reached before. However, after continuing TCM treatment, her blood sugar dropped to the teens, which was a relief! Although these patients had become insulin-dependent, stopping insulin led to a decrease in blood sugar, and they no longer relied on it, which made them very happy; one even regained the ability to move after being bedridden. Diseases are a process of change. In the later stages, when the body is on the verge of collapse, any medication requires a functioning body to be effective. Insulin and Metformin depend on the body’s condition to work; how can we recklessly deplete the body? Diabetes can lead to kidney deficiency, yang deficiency, yin depletion, and essence deficiency, necessitating the cessation of Western medications to avoid fatal consequences. Therefore, I have documented all of this in this manuscript; I am not afraid of backlash, as saving lives is paramount. This effort has saved many lives over the years, not just one or two more years of life. We cannot assume that current scientific advancements are at their peak, allowing for unreserved use of Western medications. We must firmly uphold the principles of TCM, which views disease in stages. Yin deficiency and yin depletion are different stages; careful clinical observation will provide clarity. The intense and urgent string pulse indicates the onset of kidney failure and gastric failure. If Western medications continue, it will lead to becoming a victim of outdated science. There are many such victims, and we can only correct as many as we can. 3. Fluid Stagnation Blocking Qi Mechanism It is necessary to first introduce the concept of the San Jiao (Triple Burner): it is one of the six fu organs. There has been much debate about its tangible and intangible aspects, and a unified understanding has yet to be reached, resulting in few clear indications of its specific pathological changes. This remains a significant topic for further research in TCM, and I cannot discuss it in detail here. Based on limited understanding, it is initially believed that the San Jiao should be a tangible organ, serving as a large membrane throughout the thoracic and abdominal cavities (including pleura, peritoneum, diaphragm, etc.); all organs reside within its upper, middle, and lower regions, protected and supported by it. The main function of the San Jiao is to regulate water. However, during its different processes, it can produce various physiological phenomena, such as “the upper jiao like mist (like water vapor), the middle jiao like foam (like water bubbles), and the lower jiao like a ditch (like water channels).” It also serves as the fire organ of the kidneys, governing the circulation of qi, blood, and fluids. Therefore, its pathological changes are mostly due to fluid accumulation, leading to swelling, with fewer cases of qi stagnation or blood stasis. However, qi stagnation can impede the flow of fluids, and blood stasis can also lead to fluid retention, which is closely related to “water metabolism.” Although the onset may emphasize the upper, middle, or lower jiao, they are all interrelated, and the pathological origins often stem from various organs, yet they still exhibit characteristics of San Jiao pathology. Fluid stagnation in the San Jiao blocks the pathways of liver and gallbladder qi, leading to qi stagnation, which can result in a tense and string pulse. 4. Cold or Dampness Obstructing Qi Mechanism Cold or dampness causing a string pulse is relatively rare. The ancients said, “A tight string is hard to distinguish,” which is indeed true. Clinically, cold can also lead to a string pulse, but it may not be tight. Zhang Zhongjing stated: “A double string pulse indicates cold… a moderately string pulse indicates fluid.” This is mainly due to cold remaining in the meridians, causing qi and blood to contract, leading to a string pulse. Many practitioners believe that the string pulse indicates pain, but in reality, this string pulse is caused by obstructed qi mechanisms. Clinically, patients with abdominal pain, tightness under the ribs, and cold hernia pain often present with a string pulse. Qi obstruction leads to pain; for example, in the “Jin Kui Yao Lue” regarding abdominal fullness and cold hernia, “A string pulse at the cun indicates tightness and pain under the ribs, and the patient feels cold.” Dampness (phlegm) can also lead to a string pulse due to its tendency to accumulate and stagnate qi. If the dampness (phlegm) is particularly stubborn, it can also cause a string pulse. (3) Differentiation of Diagnostic Significance of the String Pulse How can we differentiate the four different mechanisms that lead to a string pulse? It is challenging! Just like differentiating a slippery pulse, whether it is due to food stagnation, heat, pregnancy, or phlegm is quite difficult! It is nearly impossible to differentiate based solely on the pulse itself. Therefore, the differentiation of the slippery pulse does not discuss the basic pulse; it must be based on the four examinations. The differentiation of the string pulse is also difficult and requires the four examinations. However, it can sometimes provide some basis for differentiation. 1. Liver and Gallbladder Qi Stagnation Often Presents as a Left String Pulse, Sometimes with a Dominant Left Guan Pulse Liver and gallbladder qi stagnation often presents as a left string pulse, and it is rare to find a right string pulse. The vast majority are left-sided string pulses, with bilateral string pulses being less common. Some patients may only have a dominant left Guan pulse, resembling a bean inside. Therefore, it is essential to differentiate the cun, guan, and chi positions, as previously mentioned, with the left chi pulse being stringy and hard, which has significant prognostic implications. 2. Wind-Induced String Pulses Often Present as All Six Pulses Being Stringy String pulses caused by wind often present as all six pulses being stringy, frequently observed as floating string pulses in both hands. This indicates a disruption of qi and blood. Qi and blood are congested above. String pulses caused by external wind are rare in clinical practice; however, when liver wind invades, dizziness and headaches are the primary symptoms, which are significant for diagnostic purposes. If the string pulse is pronounced, the headache is characterized by distension and throbbing, with pain at the vertex and temples, indicating a significant condition. 3. Fluid and Dampness-Induced Pulses Are Often Stringy and Rough If the string pulse is caused by fluid and dampness obstructing qi mechanisms, it is often stringy and rough, as fluid can also present as a rough pulse. Dampness can also lead to a pulse that is not smooth, hence it often presents as stringy and rough. 4. Cold-Induced Pulses May Be Stringy and Tight.
