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Pulse diagnosis includes two components: pulse palpation and pressure diagnosis. Pulse palpation involves feeling the pulse; pressure diagnosis involves touching, feeling, and pressing specific areas on the patient’s body to understand the internal changes of diseases or surface reactions, thus obtaining diagnostic information.
1. Pulse Diagnosis
Pulse diagnosis is a method where the practitioner uses their fingertips to palpate specific areas of the pulse to observe the pulse quality. By examining the pulse, the practitioner can perceive different pulse qualities of the patient to understand the condition and diagnose diseases. It is a unique diagnostic method in Traditional Chinese Medicine (TCM).
(1) Principles of Pulse Formation
The pulse quality reflects the state of the pulse. The heart governs the blood vessels, encompassing both blood and pulse; the pulse is the vessel of blood. The heart and pulse are interconnected; the rhythmic beating of the heart propels blood through the vessels, which in turn generates rhythmic pulsations (thus forming the pulse). The movement of blood within the vessels is driven by the vital energy (Zong Qi). Blood circulates throughout the body, continuously flowing, and besides the heart’s leading role, there must be coordination among various organs. The lungs govern all blood vessels, and all blood flows converge in the lungs, which govern Qi. Through the distribution of lung Qi, blood can circulate throughout the body; the spleen and stomach are the sources of Qi and blood transformation, with the spleen governing blood; the liver stores blood, regulates circulation, and adjusts blood volume; the kidneys store essence, which transforms into Qi, serving as the fundamental source of Yang Qi in the body and the driving force for the functional activities of all organs. Moreover, essence can transform into blood, making it one of the material foundations for blood production. Therefore, the formation of pulse quality is closely related to the Qi and blood of the organs.
(2) Clinical Significance of Pulse Diagnosis
Since the formation of pulse quality is closely related to the Qi and blood of the organs, when there are pathological changes in Qi and blood, the circulation of blood and pulse is affected, leading to changes in pulse quality. Thus, by observing changes in pulse quality, one can determine the location, nature, and the balance of pathogenic and righteous Qi, as well as infer the progression and prognosis of the disease.
1. Determining the location, nature, and balance of pathogenic and righteous Qi
Although the manifestations of diseases are extremely complex, from the perspective of disease location, it is either superficial or deep. The floating or sinking quality of the pulse often reflects the depth of the disease location. A floating pulse indicates a superficial disease; a sinking pulse indicates a deep disease. The nature of the disease can be classified into cold and heat patterns, and the rate of the pulse can reflect the nature of the disease; for example, a slow pulse often indicates a cold pattern, while a rapid pulse often indicates a heat pattern. The struggle between pathogenic and righteous Qi leads to pathological changes of deficiency and excess, and the strength or weakness of the pulse can reflect the deficiency or excess of the disease. A weak pulse indicates a deficiency of righteous Qi, while a strong pulse indicates an excess of pathogenic Qi.
2. Inferring the progression and prognosis of the disease
Pulse diagnosis has certain clinical significance in inferring the progression and prognosis of diseases. For instance, if a long-standing illness shows a gradual softening of the pulse, it indicates a recovery of stomach Qi and a sign of improvement; conversely, if a long-standing illness shows signs of Qi deficiency, such as weakness, blood loss, or prolonged diarrhea, resulting in a flooding pulse, it often indicates a critical condition with excess pathogenic Qi and deficiency of righteous Qi.
In cases of externally contracted febrile diseases, if the heat gradually subsides and the pulse shows a softening quality, it is a sign of recovery; however, if the pulse is rapid and the patient is agitated, it indicates a worsening condition. (For example, if there is profuse sweating, a quiet pulse, and the body feels cool, it indicates improvement; if the pulse is rapid and the patient is agitated, it indicates a critical condition.)
(3) Locations for Pulse Diagnosis
There are various methods for pulse diagnosis, including the comprehensive method, the three positions method, and the cun-kou method. The comprehensive method is mentioned in the “Su Wen: San Bu Jiu Hou Lun,” where the pulse palpation locations include the head, hands, and feet. The three positions method is found in the “Shang Han Za Bing Lun” by Zhang Zhongjing from the Han Dynasty. The three positions refer to the Renying (carotid artery), cun (cuneiform), and chi (dorsalis pedis artery). The latter two methods have been less commonly used in later generations; since the Jin Dynasty, the commonly adopted pulse palpation location has been the cun-kou. The cun-kou method first appeared in the “Nei Jing,” advocating the exclusive use of the cun-kou, as noted in the “Nan Jing,” but this view was not widely adopted until the “Mai Jing” by Wang Shuhe in the Jin Dynasty, which promoted the exclusive use of the cun-kou for pulse diagnosis.
The cun-kou, also known as the pulse mouth or Qi mouth, is located at the radial artery pulse point on the wrist. The theoretical basis for exclusively using the cun-kou is that it is the artery of the Taiyin Lung Meridian, where Qi and blood converge. The movement of Qi and blood in the five organs, six bowels, and twelve meridians all begins and ends in the lungs; therefore, any changes in the Qi and blood of the organs can be reflected in the cun-kou. Additionally, the Taiyin Lung Meridian originates from the middle jiao and shares the same Taiyin nature with the spleen meridian, connecting with the Qi of the spleen and stomach, which are the foundation of postnatal life and the source of Qi and blood transformation. Thus, changes in the Qi and blood of the organs can also be reflected in the cun-kou, making it possible to diagnose changes throughout the body.
The cun-kou is divided into three sections: cun, guan, and chi, marked by the styloid process of the radius. The area slightly inward from this point is the guan, the area before the wrist is the cun, and the area behind the elbow is the chi. Each hand has three sections, totaling six pulse points. The cun, guan, and chi can be further divided into floating, middle, and sinking qualities, which is the three positions and nine qualities of the cun-kou method.
The divisions of cun, guan, and chi correspond to different organs, and interpretations have varied among physicians throughout history. Currently, the following is commonly accepted:
Left cun corresponds to: Heart and Zhongji (pericardium) Right cun corresponds to: Lung and chest
Left guan corresponds to: Liver and gallbladder, and diaphragm Right guan corresponds to: Spleen and stomach
Left chi corresponds to: Kidney and lower abdomen Right chi corresponds to: Kidney and lower abdomen
(4) Methods and Considerations for Pulse Diagnosis
1. Timing
The best time for pulse diagnosis is in the morning, as patients are less affected by food, activity, and other factors, and the internal and external environment is relatively calm. The Qi and blood in the meridians are less disturbed, making it easier to discern the disease pulse. However, this does not mean that pulse diagnosis cannot be performed at other times.
In general, a quiet internal and external environment is required for pulse diagnosis. Before diagnosis, the patient should rest for a moment to calm their Qi and blood, and the practitioner should also maintain a calm demeanor before beginning the pulse diagnosis. The examination room should be kept quiet. In special circumstances, pulse diagnosis can be performed anytime and anywhere without strict adherence to these conditions.
2. Positioning
The patient should be seated or lying flat, with the arms resting at heart level, the wrists straight and palms facing up, and a cushion under the wrist joint. This allows for unobstructed Qi and blood flow, reflecting the true pulse quality of the body.
3. Finger Technique
The practitioner and patient should sit side by side, with the left hand palpating the patient’s right hand and the right hand palpating the patient’s left hand. When palpating the pulse, the middle finger should first be placed on the inner side of the high bone (styloid process) at the guan pulse position, followed by the index finger at the cun pulse position, and the ring finger at the chi pulse position. Once the positions are correctly placed, the three fingers should form a bow shape, with the fingertips aligned, and the pads of the fingers should contact the pulse body. The spacing of the fingers should be adjusted according to the patient’s height; taller individuals should have a wider spacing, while shorter individuals should have a closer spacing, with moderation being key. The three fingers should apply simultaneous pressure on the pulse, known as total pressure; to focus on a specific pulse quality, one finger can be lifted slightly while palpating the other two. For instance, to focus on the cun pulse, slightly lift the middle and ring fingers; to examine the guan pulse, slightly lift the index and ring fingers; and to examine the chi pulse, slightly lift the index and middle fingers. In clinical practice, total pressure and single pressure are often used in combination, making this comparative method of pulse diagnosis quite practical. Single pressure can be used to assess the three sections of the cun-kou to determine which meridian and organ are affected, while total pressure is used to examine the changes in the five organs and six bowels.
For pediatric pulse diagnosis, the “one-finger (thumb) method” can be used, without subdividing into three sections, as the cun-kou area in children is short and does not allow for three fingers to be placed.
4. Lifting and Searching
This refers to the technique of varying the pressure and movement of the fingers during pulse diagnosis to explore the pulse quality. The key to pulse diagnosis lies in three actions: lifting, pressing, and searching. Light pressure on the skin is called lifting, also known as floating or light taking; heavy pressure on the muscles and bones is called pressing, also known as sinking or heavy taking; and moderate pressure that is neither light nor heavy, used to explore the pulse quality, is called searching. Therefore, it is essential to pay attention to the changes in pulse quality between lifting, pressing, and searching. Additionally, when the three sections of the pulse show discrepancies, the finger positions should be gradually adjusted to explore both internal and external aspects. Searching implies seeking, not merely taking.
5. Calmness
One inhalation and one exhalation is considered one breath. During pulse diagnosis, the practitioner’s breathing should be natural and even, using the time of one breath to count the patient’s pulse rate, including normal and pathological pulse qualities such as slow, rapid, soft, and hard. Today, a stopwatch can assist in pulse diagnosis. However, the significance of calmness extends beyond this. Calmness also means maintaining a focused and attentive mindset during pulse diagnosis. Therefore, in addition to counting the pulse with “breath,” one should also maintain an open mind and be fully concentrated.
6. Fifty Pulses
Each pulse diagnosis must include at least fifty beats. This means that the time spent on each side of the pulse should not be less than fifty beats. The significance of this is twofold:
First, to ensure that there are no missed diagnoses of rapid, knotted, or intermittent pulses. Second, it emphasizes that pulse diagnosis should not be rushed; it must aim to clarify the pulse quality. If the first fifty beats do not yield a clear understanding, one can extend to the second or third set of fifty beats. In summary, each pulse diagnosis session should last 2-3 minutes.
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