Introduction: As the author states, pulse diagnosis is not merely about taking the pulse, but rather “using the hands to closely examine the patient’s body to diagnose diseases.” From this perspective, the experiences listed in the text are the author’s insights. Accordingly, we need to learn more about pulse diagnosis through books and clinical practice.Pulse Diagnosis is Not Just About Taking the Pulse When discussing pulse diagnosis, it is generally said to refer to taking the pulse; however, pulse diagnosis is not limited to this. It also includes examining the skin, the sides of the abdomen, the area below the heart, and the upper and lower abdomen. The term “切” (qiè) implies closeness, as in “切身” (qiè shēn) and “亲切” (qīn qiè), meaning to use the hands to closely examine the patient’s body to diagnose diseases. Nowadays, many doctors focus solely on taking the pulse and forget other aspects of pulse diagnosis. Zhang Zhongjing, in treating diseases, emphasized not only pulse diagnosis but also the examination of the chest, sides, and abdomen, which is extensively described in the “Shang Han Lun” (Treatise on Cold Damage). When a patient comes for diagnosis, after a brief greeting and understanding the basic situation, the first step is to take the pulse. Before taking the pulse, one can use the hands to feel the skin on the forearm, assessing the temperature of the skin. If there is fever, part of the condition can be understood beforehand; this is the first step of pulse diagnosis. Especially for diagnosing fever in children, in addition to using a thermometer and feeling the skin, I prefer to use my lips to sense the temperature, as kissing the child provides a more intimate feeling. The sensitivity of the lips is beyond that of the hands; touching the forehead with the hand is far less effective than sensing it with the lips. A person’s body temperature is not fixed and can vary; sometimes thermometers can be misleading. Asking the mother about the child’s mouth temperature while breastfeeding compared to usual can provide first-hand information about whether there is a fever, when it occurs during the day, and any patterns. The mother can provide valuable insights to the doctor. Sweating is generally one of the first questions to ask during diagnosis. This is easy to clarify in adults, but more challenging in children. One can use the palm to feel the front and back of the chest; the dryness or moisture of the skin can clearly indicate the presence of sweat. If the skin is moist, it indicates sweating, but medication should be used judiciously. These are small yet essential skills in diagnosis. For examining the chest, sides, and abdomen, the patient should first assume a proper position, lying flat on the examination table with the lower limbs flexed, relaxing the mind and avoiding resistance against the doctor. Let’s discuss the symptoms of Xiao Chai Hu (Minor Bupleurum) such as “chest and side fullness”; this is the patient’s self-perception. If there is “hardness below the ribs,” the patient may not be able to articulate it clearly. By pressing under the ribs and on the sides of the abdomen, one can feel fullness with light pressure, while heavier pressure may reveal resistance. At this point, the patient may frown or express slight pain; “urgent feeling below the heart,” “hardness below the heart,” and “pain upon pressing below the heart” indicate hardness and resistance to pressure, with varying degrees of severity. The symptoms of Chai Hu can be distinguished by their severity. The accumulation of phlegm and fluid in the chest and sides can be detected not only by the patient’s self-reported feelings of fullness or pain with breathing but also through the physician’s examination. By pressing upwards on the area below the heart and the stomach, one can elicit pain in the chest and sides, leading to a feeling of suffocation, which indicates “hardness and fullness below the heart, leading to pain below the ribs.” The symptoms below the heart, where “痞” (pǐ) indicates blockage, differ from “结胸” (jié xiōng) which is “not approachable”; however, the “hardness below the heart” in the pǐ syndrome is contrasted with the “hard fullness and pain” in the jié xiōng syndrome. By assessing the hardness and pain, one can discern the severity and nature of the disease without hidden conditions. “Abdominal fullness with pain” indicates a preference for warmth and pressure, suggesting a deficiency, while “great fullness and pain” with resistance indicates excess, suggesting a condition in the Yangming channel. The choice of medication can be adjusted based on whether to alleviate pain or purge. The temperature of the abdominal skin, as well as the tension and relaxation of the abdominal muscles, can often be felt during pulse diagnosis. The primary goal of pulse diagnosis is to understand the temperature, softness, hardness, swelling, and tenderness of the abdomen. For instance, feeling the abdominal skin’s temperature can help differentiate between cold and heat syndromes. If the skin is not warm or cold, it indicates a cold syndrome; if the patient prefers warmth, it suggests a deficiency cold syndrome. If the skin is hot and feels burning, it indicates a heat syndrome; if the patient prefers cold objects, it suggests a real heat syndrome. If pressing reveals heat, it indicates internal heat; if light pressure reveals a soft abdominal wall, while heavy pressure on the navel feels firm, it usually indicates a normal state. A thin abdominal wall that feels soft and weak often indicates a deficiency syndrome; a hard abdominal wall indicates an excess syndrome. Abdominal distension that feels full and tender, with a heavy sound upon percussion, indicates an excess syndrome; if it feels empty and non-tender, with a hollow sound upon percussion, it indicates a deficiency syndrome. Pain upon abdominal pressure, especially with resistance, indicates an excess syndrome. If pressing causes pain that is fixed and unchanging, it suggests blood stasis; if the pain is variable and occurs intermittently, it suggests qi stagnation. If a mass is found in the abdomen, attention should be paid to its size, shape, hardness, tenderness, and whether the surface is smooth. Abdominal masses that are painful indicate accumulation. If the mass is fixed and painful upon pressure, it suggests a chronic condition related to blood; if the mass is variable and painless, it suggests a condition related to qi. Percussion can also be a method of diagnosis, such as in suspected urinary stones. Small stones may not be visible on ultrasound. If there is no rupture of the urinary tract, blood cells may not be visible under a microscope, and some may not cause urinary irritation. Except for the obvious pain from kidney stones, abdominal pain from stones in the ureter can often be confused with acute appendicitis or gynecological emergencies. I often percuss the affected kidney; if the pain intensifies upon percussion, it can confirm the diagnosis. In gynecology, special attention should be paid to pulse diagnosis. Relying solely on the patient’s complaints without abdominal examination often makes it difficult to clarify the condition. The examination of the uterus and adnexa differs. By palpating the lower abdomen, one can first assess the fullness of the uterus; fullness and distension often indicate excess, while softness and shrinkage often indicate deficiency. If pressing causes pain, and the pain lessens or is preferred, it indicates deficiency; if pressing increases pain or resistance, it indicates excess. The examination of the adnexa is located in the lower abdomen, where any masses or pain can be assessed. Zhang Zhongjing’s discussions on women’s diseases often focus on cold syndromes and excess conditions, as “women’s diseases are due to deficiency, accumulation of cold, and qi stagnation, leading to obstruction of the meridians and blood, resulting in years of cold accumulation, blood stasis, and cold injury to the meridians…” This summarizes the essence of his teachings. By examining the skin, one can discern between exterior and interior conditions, as well as cold and heat; by examining the chest and abdomen, one can explore yin and yang and deficiency and excess. The knowledge gained through the physician’s own examination is intuitive, while the knowledge gained through cold machines is mechanical and can only serve as an auxiliary tool. Relying entirely on medical auxiliary examinations has become a bad habit, leading to a decline in diagnostic skills among physicians, and it is dangerous to say that diagnostic skills are nonexistent.
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This article is adapted from: WeChat Official AccountTianyi Hall. The original text is excerpted from “Medical Insights”, published by the People’s Military Medical Press, author: Fan Zhengyang, edited by medical student Xiao Rongrong.
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