In this article, the author discusses what he believes to be the main obstacles for Western practitioners learning and using Chinese pulse examination in their practice. According to the author, this main obstacle is a pedagogical one and a tendency not to memorise the key information to a high enough degree of certainty to make that information clinically reliable. He believes that mastery of pulse examination for making a correct TMC pattern discrimination is even more important for Western practitioners than for our Chinese counterparts. This is because, in his experience, Western practitioners are faced with patients who present, not with one textbook pattern or another, but with a combination of three, four or even five patterns. Chinese pulse diagnosis does not presuppose any exceptional, little known, paranormal endowment or ability in the person applying it. All that is required is a solid grounding in its coherent theory and a trained and well-kept hand.
Introduction Pulse examination is one of the main methods of establishing a TCM pattern discrimination. Pulse examination in modern TCM primarily means the feeling of the pulse of the radial arteries at the styloid processes of both wrists. This is commonly called the cun kou or inch opening. It is believed by practitioners of Chinese medicine that the pulses felt here can be read as a simulacrum of the flow of qi, blood, and body fluids of the entire body. The first chapter of the Nan Jing (The Classic of Difficulties) opens with the following question:
‘All the twelve channels have (sections where the) movement (in these) vessels (can be felt). Still, one selects only the cun kou in order to determine whether the five viscera and six bowels (harbour a) pattern of death or life, of good or evil auspices’. (1)
However, in my experience as a teacher of TCM, most Western students find pulse examination very confusing and difficult to master. It seems somehow very mystical and arcane. Although most Western practitioners express a strong belief and interest in pulse examination, few, I think, feel very confident of their abilities in this domain.
At the same time, I believe that mastery of pulse examination for making a correct TCM pattern discrimination is, perhaps, even more important for Western practitioners than for our Chinese counterparts. This is because it is my experience that our patients are sick in more complex ways than many Chinese patients. In China, most young practitioners do not go into private practice working in isolation from senior practitioners with lifetimes of experience. It is my experience that young practitioners in China are given relatively simple cases to treat, and, should they come across a complicated, difficult case, they can always ask a senior practitioner to help parse out the pattern discrimination. Western practitioners, on the other hand, tend to go immediately into private practice, and that after insufficient clinical education as an undergraduate. Typically, there is no one else in the clinic to ask about a difficult case. In addition, we as Western practitioners tend to see a disproportionate number of difficult cases which are either not self-limiting or have not been successfully treated by modern Western medicine and often other types of alternative medicine as well. This is because here in the West, we are so often practitioners of last resort. Further, because of the modern Western diet, the adverse effects of certain modern Western medical treatments, the ill effects of pollution, and the pervasive stress of our modern society, most of our patients suffer from complex, chronic conditions which frequently and I might even say typically do not display the nice, neat, simple patterns contained in beginners’ TCM textbooks.
In my experience, all too often, our patients present, not with one textbook pattern or another, but with a combination of three, four, or even five patterns. When the disease mechanisms at work in such complex patterns interact with each other, they produce complicated mixtures of signs and symptoms, including complicated and sometimes even seemingly contrary pulse images. Thus it is also my experience that if one wants to parse out such complicated patterns, one must be able to feel more than just the several pulse images. In addition, one must also understand how each pulse is created and the secondary and tertiary meanings of all of the pulse images. In other words, it is my experience that a simplistic approach to pulse examination is not sufficient for the practice of TCM in the West.
The obstacles to mastering the pulse The good news is that pulse examination is not that difficult to master. In my experience, there is a trick that makes pulse examination actually quite easy and straightforward. However, before revealing that secret, I would like to quote Manfred Porkert from The Essentials of Chinese Diagnosis (2) on what he calls ‘three kinds of obstacles to mastering pulse diagnosis:’
Manfred Porkert describes inadequate natural endowment under two sub-headings: 1) inadequate physical endowment (i.e., lack of sufficient sensitivity in the fingertips and the capability to concentrate) and 2) inadequate intellectual gifts (i.e., inability to distinguish, co-ordinate, and synthesise the observed data). In terms of this first obstacle to mastering Chinese pulse examination, it is up to the Deans of Admission and Academic Deans at Western schools and colleges of acupuncture and Oriental medicine to ensure that all students are endowed with these capabilities.
By ‘wrong intellectual perspective’, Porkert is referring to preconceived notions regarding Chinese pulse examination by Western health care practitioners who are often sceptical about it. If one refuses to believe that one can diagnose health and disease by feeling the pulse of the radial arteries at the wrists, then of course, one will not seriously study this art with an open mind and will not plumb its depths. This is not usually a problem at most Western schools of acupuncture and Oriental medicine. Students at such schools typically enter with a willingness to study and consider, as at least provisionally true, the basic theories and practices of Chinese medicine.
However, it is the last obstacle - an inapt pedagogical approach - which Porkert says is responsible for most failures in mastering Chinese pulse examination. In fact, it is Porkert’s opinion that: ‘Most of the failures in mastering pulse diagnosis - I should say at least 80 percent - are due to this formidable obstacle, or to approaching it too lightly.’
According to Porkert, Chinese pulse examination is a skill. However, it is an essentially intellectual skill. He goes on to say that in the acquisition of any skill, the gathering of certain intellectual information must precede physical training. This means that intellectual data must be presented before physical instruction and that it is that intellectual data which actually constitutes the indispensable basis for the effective acquisition, assimilation, and integration of physical experience. In other words and in terms of Chinese pulse examination, unless one has learned all pertinent TCM theory and the intellectual, i.e., verbal, descriptions of all the major pulse images, one cannot feel and interpret the pulses correctly.
To exemplify this point, several years ago, in going back through my case records, I noticed that I had often written down that this or that patient’s pulse was fine and floating. At the time, I had just finished reviewing the textbook definitions of the 28 pulses and these were fresh in my mind. I immediately recognised that what I had described as a fine and floating pulse is the soggy (ru) or soft (ruan) pulse. I had been feeling fine, floating, forceless pulses for years. However, until I realised that a fine, floating, forceless pulse is a soggy pulse, I was not able to make the diagnoses that go with a soggy or soft pulse. My fingers were not suddenly feeling anything physically different. My new-found ability to feel the soggy pulse was entirely an intellectual capability, a verbal epiphany, not a physical one.
Here are a few more examples of this process. A vacuous pulse is defined as a large, floating, forceless pulse. Each of these three characteristics is very simple to discriminate. Whether a pulse is floating or deep, large (meaning wide) or fine (meaning narrow), or forceful or forceless each are fundamentally basic pulse qualities. In order to determine whether a pulse is vacuous, one first must keep the three criteria of a vacuous pulse in mind. Then one checks to see if the pulse is floating. If it is not floating, then, ipso facto, it cannot be a vacuous pulse. Why? Because a vacuous pulse is one of the floating pulse images. If the pulse is floating, then the next thing to check for is whether or not the pulse is large or fine. If the pulse is fine, again, it cannot be a vacuous pulse. If it is large or wide, then one checks to see if it is forceful or forceless. Force is the strength of the beat, the amount of pressure behind the pulse. If the pulse is forceful, then yet again, the pulse cannot be a vacuous pulse. If it is forceless, voila! This combination of three qualities - fine, floating, and forceless - add up to the definition of the vacuous pulse.
A drum skin pulse is also floating and large. However, it is forceful. It is so forceful it feels hard like the head of a drum. However, it is also empty in the centre or hollow. This means that it is a very floating or superficial pulse. It can be felt with light pressure, but when one pushes down, the pulse does not just get weaker with heavier pressure but disappears altogether. This is what empty in the centre means in Chinese pulse examination. So if the pulse is large, floating, hard (or forceful), but then empty in the centre, this is a drum skin pulse.
If the pulse is floating, large, and forceless and empty in the centre, then this is a scallion stalk pulse. Above we saw that a floating, large, and forceless pulse is defined as a vacuous pulse. However, here we have added a fourth criterion -- empty in the centre. Once again, this means that the pulse is not just floating but disappears completely with increased pressure. Thus a scallion stalk pulse is a vacuous pulse which is empty in the centre.
As the reader can see, the ability to identify in clinical practice these several types of floating pulses has nothing to do with more than usual sensitivity in the fingertips. Rather, it has to do with memorising the exact, word for word definitions of each of these pulse definitions and then searching in a very step-by-step, rational, and purposeful manner to see if a given patient’s pulse does or does not have these characteristics. Once one understands how to determine whether a pulse is floating or deep, then the other key distinguishing characteristics of pulses, such as width, strength and speed are all based on simple, immediate physical sensations typically with one syllable Anglo-Saxon names, e.g., fast, slow, strong, weak, fine, wide, etc. To be sure, there are two of the 28 pulse images which must be pointed out to the student in a live patient. These are the bowstring and slippery pulses. However, all the rest are combinations of floating or deep, fine or wide, forceful or forceless, slow or fast. In addition, three pulses are skipped beat pulses. There is the bound pulse which is slow or almost slow and misses beats irregularly, there is the regularly irregular pulse which is slow or almost slow and misses beats at regular intervals, and there is the skipping pulse which is rapid and misses beats at irregular intervals. Here again, one simply needs to determine whether the pulse is fast or slow and then count the intervals between the beats - nothing mystical, nothing arcane, nothing which requires special physical sensitivity or dexterity.
The secret of Chinese pulse examination In my experience, the secret of Chinese pulse examination is exactly this: One cannot feel a pulse image unless one can consciously and accurately state the standard, textbook definition of that pulse image. If one does not know that the soggy pulse is floating and fine, one cannot write down that diagnosis even though one may be able to feel that the pulse is floating and fine. Therefore, I wholeheartedly agree with Porkert when he says:
‘Applied to the training and mastery of pulse diagnosis...the problem is not that the students cannot feel what must be felt, but that they usually are at a loss to describe, hence to assimilate, to permanently learn and keep what they have physically perceived... This, precisely, is the critical issue: there is no point in attempting practical training in pulse diagnosis unless all pertinent theory and, more important, the complete iconography of the pulse has previously been absorbed intellectually. In other words, no student of pulse diagnosis should attempt practical training unless he has not only memorised, but understood by frequent rehearsal, every single term and technical relationship instrumental to Chinese pulse diagnosis... Only on this condition will he be able to immediately describe and express with precision and stringency what he feels when actually putting his fingers on a patient’s arms. And only on this premise will he be able to recall, reflect and communicate to his colleagues what he feels.’
Porkert goes on to state:
‘If this essential condition has been met, practical mastery of pulse diagnosis in normal medical practice is - at worst - a question of several months; with proper guidance it should take only weeks to gauge, correct and refine one’s sensitivity so that the error rate drops to insignificance within one month. If, on the contrary, this warning is ignored, even with the best intentions, a student may not master quite basic notions even with years of trying... Trying to make sense of the subtle differences felt at the pulse sites without the most strict reference and conscientious attention to the intellectual tools prepared for this very purpose in the course of almost 2000 years is like attempting to interpret an ECG while spurning all knowledge of what is taught about this technique in medical colleges by physics, physiology and clinical medicine.’
I have to admit that this is exactly the case with me and my experience of Chinese pulse examination. I first read Porkert’s book in 1983 when it was first published in English. At the time I remember reading the above passages. I did not just read them, I even underlined them. However, I did not actually take the trouble to memorise the exact Chinese definitions of all the major pulse images until several years ago. Although I was able to feel the slow and fast, deep and floating, slippery, bowstring, and fine pulses, as long as I could not say either out loud or to myself the word for word definitions of the other 20 or more pulses, I could not feel them in clinical practice. Once I realised this fact and went back and memorised these definitions, I was immediately able to feel all the major pulses as long as I kept these definitions currently in mind. In addition, I have taught this approach to dozens of groups of Western students and, within two days, the vast majority of students have been immediately able to feel and consciously identify twice as many pulses as they had been previously able to.
Having studied several Oriental arts in my life, it is my experience that mastery comes from mastering the basics. Unless there is a solid foundation, one cannot build high into the sky. Beginners think that masters have some special secrets to which they are not yet privy, but that is rarely the case. Mastery always means mastery of the basics. Unfortunately, all too often it is human nature to be impatient with the basics and to try to jump to some seemingly higher, more exciting plane. In terms of Chinese pulse examination, mastery of the basics primarily means the memorisation of the definitions of the major pulse images or what Manfred Porkert calls the iconography of the pulse.
At the very least, if you want to be able to feel the basic 28 pulse images, you must memorise their definitions. As Manfred Porkert points out: ‘Chinese pulse diagnosis does not presuppose any exceptional, little known, paranormal endowment or ability in the person applying it. All that is required is a solid grounding in its coherent theory and a trained and well-kept hand.’
For many modern Western students, memorisation is a dirty word. It seems so boring and prosaic. It seems to lack mystery and imagination. But believe me, if you want to be able to do Chinese pulse examination, just do it.
Bob Flaws Bob Flaws studied acupuncture with Dr Tai Xiyu and herbal medicine and tuina at the Shanghai College of TCM. He is the director of Blue Poppy Press and has written, translated and edited over a dozen books on Oriental medicine. He lectures in the USA and internationally, and has a practice in Boulder, Colorado.
References (1) Nan Jing (The Classic of Difficulties), p. 65 (translated by Paul U. Unschuld, 1986). University of California Press, Berkeley, CA. Some words have been changed to conform to Nigel Wiseman’s terminology as it appears in English-Chinese Chinese-English Dictionary of Chinese Medicine, Hunan Science & Technology Press, Changsha, 1995.
(2) Porkert, Manfred. (1983). The Essentials of Chinese Diagnostics, Chinese Medicine Publications Ltd., Zurich, Switzerland.