Chinese Medicine Book Club Issue 953
One issue daily, accompanying the growth of TCM practitioners
Author/Zou Mengcheng
IIntroduction: Pulse diagnosis is a practical technique for physicians. How to examine the unclear forms of pulse? What is the Xian pulse? What diseases does it indicate? What about the Kiao pulse, is it only related to bleeding? What does the term “San” in the San pulse signify? Perhaps this article will provide the answers.
Three Questions on Pulse Diagnosis
1. Self-Examination of the Double Xian Pulse
The Xian pulse is primarily associated with the Liver meridian, which belongs to Wood and has a horizontal Qi, making it prone to invade other organs and cause diseases. Therefore, Wei Zhi Xiu once said, “The liver is the thief of all diseases.” In clinical practice, the Xian pulse or pulses with Xian characteristics are often observed. Mastering the diagnostic methods and significance of the Xian pulse is both necessary and important. The Xian pulse can be classified into single Xian and double Xian. The common understanding of the Xian pulse typically refers to the single Xian pulse, which is characterized by a single line appearing in one hand, regardless of whether it is the left or right hand. There is also a double Xian pulse, which, although less frequently seen, often indicates severe, chronic, or complex conditions. If one cannot grasp the disease mechanism and make timely decisions, even a slight error can lead to significant consequences, thus warranting further study. In the 1960s, I experienced a serious illness where the pulse was observed as double Xian, and despite consulting many renowned practitioners, none could recognize the pulse or discuss the condition accurately. The prescribed herbs and formulas not only failed to help but worsened the illness. Reflecting on this experience still gives me chills. Here, I will share my insights on the double Xian pulse for the benefit of readers.
The characteristics of the double Xian pulse have been interpreted in two ways by previous scholars:
One interpretation states that if one hand shows a single Xian pulse and both hands show Xian pulses, it is considered a double Xian pulse. As stated in “Four Diagnostic Methods” citing “Pulse Examination”: “If both hands have Xian pulses, it is double; if one hand has a Xian pulse, it is single.” Dai Tongfu further states, “If both positions are Xian, it is called double Xian.” Although there are slight differences, they essentially belong to the same category.
The other interpretation suggests that a double Xian pulse appears as two Xian pulses in one hand’s cun position, or may be seen in either hand. If both hands show Xian pulses, it is considered four Xian pulses, with two in each hand. As noted by the Japanese scholar Tanba Genkan in “Essentials of Pulse Diagnosis”: “Double Xian means the pulse comes like two lines… whereas single Xian is just one line.” Xu Zhongke in “Golden Chamber Essentials” also states: “If one hand has two pulses, it is also called double Xian.”
Among the two interpretations, I lean towards the latter. The former describes the ordinary Xian pulse, which may appear in one hand or both hands, and is typically referred to as the “single Xian pulse.” My own experience during illness showed that both hands had two distinct, strong Xian pulses, parallel and slightly fluctuating, with a firm pressure that did not diminish. Some have observed that the two Xian pulses in one hand are not parallel but exhibit a high-low pattern, which is also reasonable, though I have not encountered it myself and will await further clarification.
Secondly, the diseases associated with the double Xian pulse do not fall outside the range of diseases indicated by the Xian pulse. Previous discussions can be summarized into three points: First, according to the “Pulse Classic”, “Double Xian indicates tightness and pain under the ribs.” This view is supported by both Shua Bo Ren and Wu Shan Fu. Second, “Double Xian indicates cold stagnation.” This is echoed by Zhang Luyu in “Three Essentials of Diagnosis”, Xu Huixi in “Pulse Techniques Explained”, and Li Yangang in “Pulse Techniques Compendium”. Third, double Xian indicates deficiency. As Xu Zhongke states in “Golden Chamber Essentials”: “This pulse is often seen in individuals with weak original Qi, indicating deficiency, and should be treated with warming and tonifying methods, along with phlegm transformation for recovery.”
Regarding my condition at that time (refer to the first half of the article “Calming the Liver and Transforming Phlegm for Treating Epilepsy”), it was characterized by internal disturbance of phlegm-heat in the heart and liver, along with Yin deficiency and Qi stagnation. Mr. Chen Nianzu treated it with methods to clear the liver, transform phlegm, nourish Yin, and calm the spirit, which proved effective. The most prominent symptom observed was abdominal distension and pain, with discomfort radiating to both sides, corresponding to the first point mentioned above. There was indeed a deficiency, and warming tonification was not appropriate. The key difference was the opposing cold and heat; the former indicates cold stagnation, while I had liver heat. This is not a mistake in the previous discussions; it must be understood that the pulse is the final diagnostic method and should be combined with observation, inquiry, and examination for accurate diagnosis. If one only relies on the pulse, it may present mixed signs, and one should also consider the deeper, true nature of the pulse, which is often hidden. If it were cold stagnation, the double Xian pulse would also show signs of deep, slow, tight, or rough characteristics. My own condition, characterized by phlegm-heat, presented as a strong, fine double Xian pulse with a slippery quality that did not diminish upon pressure. Careful observation in these areas will yield unexpected insights. With time and practice, one can achieve remarkable results.
2. Understanding the Kiao Pulse
The Kiao pulse has been likened to a scallion by previous scholars, leading to various interpretations due to this analogy. Ancient texts present two views: One view describes the Kiao pulse as having both floating and sinking characteristics, with the middle being empty. For example, “Pulse Techniques Compendium” states: “The Kiao pulse resembles a scallion; if you press on the scallion, the floating part touches the outer skin, the middle is empty, and the sinking part touches the lower skin.” The second view states that both sides are present, while the center is empty. As stated in the “Pulse Classic”: “The Kiao pulse is floating, large, and soft, with the center being empty when pressed.” Additionally, “Four Diagnostic Methods” states: “The Kiao pulse is large and soft like a scallion, with the center being empty when pressed.”
The two views are similar yet different: both use the scallion as a metaphor, one focusing on the sides and the other on the top and bottom, resulting in only slight differences in the pulse’s shape without any essential distinction. Modern scholars, such as Xiao Tongwu in “Pulse Diagnosis Decisions and Cases”, have combined these two views: “The main characteristic of the Kiao pulse is that it is large and floating around the edges, with a void in the center, not due to floating and sinking, but solely due to the absence in the middle.”
Regarding the characteristics of the Kiao pulse, I agree with the view of Shuhe in the “Pulse Classic”. The Kiao pulse is rarely seen in clinical practice and is difficult to verify. I have encountered a description comparing it to a small, soft, and elastic rubber tube, similar to human blood vessels. The Kiao pulse is observed after significant bleeding, when the arterial vessels experience a rapid decrease in blood volume, yet the vessels have not yet contracted, or due to excessive blood loss, they are temporarily unable to contract, resulting in a state where the vessel tension remains, with more Qi and less blood in the pulse vessel, thus feeling soft upon pressure, akin to pressing a rubber tube filled with air.
When pressing on the rubber tube, the floating aspect feels soft and large, the middle feels softer than the floating aspect, while the sides feel slightly more solid than the middle. If it is a weak pulse, both sides and the middle will feel equally weak, and the soft pulse will appear relatively large. If one presses down on the rubber tube, it becomes extremely difficult to distinguish the feeling of the bottom of the rubber tube, as the Kiao pulse typically presents with uniform tension around the blood vessels. Thus, when pressing on the Kiao pulse, one only feels the tension on the top of the blood vessel; when pressing in the middle, the sides of the pulse vessel are compressed, increasing the tension, hence the sensation of “both sides being solid”. When pressing down, the tension on the upper part of the pulse vessel, combined with the force of blood flow within the blood vessel, greatly exceeds the tension at the bottom of the pulse vessel, making it impossible to feel the “bottom of the scallion”. This description may seem largely imaginative, but it aligns with clinical reality.
As for the diseases associated with the Kiao pulse, it is universally agreed that it indicates significant bleeding, while the “Pulse Techniques” also associates it with blood stasis and abscesses, which many practitioners do not accept. The “Pulse Studies of Binhai” cites the “Pulse Techniques” and has often been criticized by others. In fact, both conditions are indeed associated with the Kiao pulse. Although significant bleeding originates locally, once bleeding occurs, it rapidly affects the entire body and should be viewed as a systemic disease. Therefore, the appearance of the Kiao pulse must be observed in all three pulse positions. Moreover, the time observed is very short; after bleeding, the pulse vessels become unfilled, and the tension of the blood vessels decreases, leading to pulse contraction, which manifests as a fine pulse or a thin, rough pulse, and the Kiao pulse will no longer be observed. Hence, in clinical practice, the Kiao pulse is not commonly seen.
The Kiao pulse indicating blood stasis and abscesses tends to persist longer than the transient nature of the Kiao pulse seen in significant bleeding. I speculate that its formation is due to the obstruction of Qi and blood flow. “The pulse is the blood’s channel, the precursor of Qi and blood.” This means that the pulse’s beating reflects the information of Qi and blood flow in the body. When a certain organ or tissue is healthy, its Qi and blood flow smoothly, and the corresponding pulse diagnostic position will also present a normal pulse. When there is local blood stasis or stagnation, or abscess formation, on one side of the organ or tissue, the other side may still allow Qi and blood to flow, but the affected area will have reduced flow, and due to the obstruction, only a thin, rough pulse will be felt at the diagnostic position. If blood stasis and abscesses obstruct the flow of Qi and blood, the Qi and blood must flow around the sides or edges, and the pulse information will reflect this as two thin, rough pulses, which seems reasonable. If there is also a fire element, then the presence of abscesses must indicate heat stagnation. Regarding blood stasis with heat, previous scholars have noted that areas of hardness must have hidden Yang, and prolonged stasis transforms into heat, which is also inevitable. The Kiao pulse indicating blood stasis is sometimes seen in medical texts, such as in Sun Dongxu’s “Medical Cases of Shengshengzi”, Volume 1, treating the “Guanglu Gong” case of rib pain, where Sun argued based on the pulse that it was phlegm-heat, stating, “If it is blood stasis, the pulse must be deep, or Kiao, or rough.” This suggests that the Kiao pulse is comparable to the rough pulse and deep pulse, both indicating blood stasis. Additionally, in “Chen Xunzai’s Medical Notes”, it is recorded: “Although a weak person may have blood stasis, their pulse will also be Kiao, and there must be one part that is Xian, and it should be supplemented to remove the blood, using Taohe Chengqi Decoction with five qian of ginseng, divided into three doses for gentle attack, which can save two or three out of ten.” This illustrates that the Kiao pulse has a dual nature: it indicates both blood loss and blood stasis. The blood loss it indicates is only in the early stages of significant bleeding; once the bleeding has persisted, the pulse will change. When indicating blood stasis, the Kiao pulse should be strong, or may also present with Xian, rough, or deep characteristics.
3. Observing Rain to Understand the San Pulse
Regarding the shape of the San pulse, the “Pulse Classic” states: “The San pulse is large and scattered.” Later practitioners mostly follow Shuhe’s view, though the descriptions are more detailed, yet they do not exceed its scope. Some describe it as floating large and scattered without gathering, while others describe it as aimlessly rootless, and some liken it to willow catkins drifting, scattered and chaotic. However, what exactly is the shape of the San pulse? How can it be recognized under the fingers? What does it mean to be “scattered and not gathered”? What does it mean to be “aimlessly rootless”? What does it mean to be like “willow catkins drifting and scattered”? Pulse diagnosis is a practical technique for physicians. How to examine the unclear forms of pulse?
In my clinical practice, I have repeatedly pondered and sought to understand, yet I find it difficult to clarify under my fingers. The key to the shape of the San pulse lies in the term “scattered”; however, the meaning of “scattered” is not easily grasped. One summer day, while sitting by the window, I suddenly heard the rumble of thunder. A heavy rain followed. The ground in the garden accumulated water, and as raindrops fell into the water, bubbles formed, and the raindrops fell like tangled threads, creating a chaotic and scattered appearance. I suddenly realized that the shape of the San pulse closely resembles this. Among the twenty-seven pulse types, except for the San pulse, the other twenty-six pulses, although each has its own shape, do not deviate from the linear form of the pulse body. Even if an artery protrudes in one area, its shape may resemble a bean, sliding and jumping, yet upon careful examination in other areas, there will always be a linear pulse body to be found. The San pulse, however, does not present a linear pulse body; instead, it appears as numerous scattered pulsating points on the skin over the cun position, rising and falling chaotically, with no fixed location or discernible pattern. Previous scholars have likened it to the erratic drifting of willow catkins, which is precisely the case, akin to my observation of the rising and falling bubbles in the rain. This is what the “Pulse Classic” refers to as “scattered”; there is no fixed point, and the rise and fall are not constant, which is “chaotic”. It was only at this point that I began to understand the shape of the San pulse, and since then, I have never failed to diagnose it in clinical practice. However, the San pulse is not commonly seen; most of the cases I have encountered are patients with atrial fibrillation, especially those with atrial fibrillation and dyspnea. 【Chinese Medicine Book Club (WeChat ID: zhongyishuyou) Edited and Published】
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