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An Introduction to Advanced Pulse Diagnosis:
Theory and Clinical Practice in Light of the Nan Jing, Li Shi-zhen and Mai Jing

by James Ramholz, O.M.D., Dipl.Ac.

Preface

My interest in pulse diagnosis goes back more than twenty years when I met and began to study with my teacher, Sung Baek, a Korean master of acupuncture and herbal medicine. He was the lineage head of the Dong Han acupuncture system that traces its roots to the Shilla Dynasty (circa 4th to 6th century) in Korea. Without question, he was the most gifted practitioner I have known, a true genius. His knowledge of acupuncture and herbal medicine was encyclopedic and his background in Western medicine was extremely extensive. Besides these intellectual gifts, he was one of the few people in the world that could sit down, examine a patient’s pulses for 30 minutes to 40 minutes, and then tell their entire physical and emotional histories in great detail–in both Western and Eastern terms–all without any discussion with the patient. I have only heard of a few practitioners in the world that are capable of that level of skill; he was the only one I ever saw actually do it. And, I watched him do it many times as part of his regular practice. I am immensely indebted to Sung Baek for the time I was able to spend listening and watching during the course of those twenty years. Because of him I am able to make a successful living at something I love to do.

The subjects discussed in this book derive from my studies with him, my own reading of the classics, as well as clinical practice. I have already presented many of the topics from this book in weekend seminars, private tutoring, and, most recently, in a 20-week post-graduate lecture series at the Colorado School of Traditional Chinese Medicine, in Denver.

An Overview of Pulse Models

It is a conceit of Romantic poetry that everything in the world pertains to Love in a particular way. Love creates purpose, organizes the world, and defines meaning in life. And, like Romantic Poetry, everything in Chinese medicine pertains to pulse diagnosis in some particular way. The pulses are signs of changes within the body, as well as between the body and its environment. Pulse diagnosis is the only real-time system of diagnosis. They report the emotional and physiological behavior of the body as it occurs, and often before symptoms manifest.

Pulse diagnosis has been an essential theme throughout Chinese medical literature. From the earliest Chinese case histories in the second century BCE, doctors prescribed remedies based on pulse taking. Although there are four ways to judge a person’s condition–visual examination (wang), listening and smelling (wen), questioning (wen), and palpation (qie)–palpating the mo (qiemo) was the most important and insightful.

In practice, however, their attentions concentrated mainly on qiemo, palpating the mo. Look at what they wrote: no monographs devoted to diagnostic listening or smelling; no essays on techniques of interrogation; over 150 works on the interpretation of hepatic signs.

If pulses did not reliably reflect the behavior of the body and disease processes, pulses would be of questionable value as a diagnostic system and would never receive the acclaim it has been given. What we read in the pulses is what is going on in patients at the moment we examine them, and the history of how their condition developed. No matter what symptoms arise, the root and branch are always clear. The principal advantage in reading pulses during an acupuncture session is that we can see the changes created by our needling strategy as we do it. We are no longer guessing or working in the dark. When you observe changes in the pulse, you know if the treatment strategy you’ve selected is effective.

Although it is advisable that no single system of diagnosis should be used alone, the richness of detail and the depth of analysis revealed by the pulses make visual examination, symptom patterns, and tongue coatings appear ambiguous by comparison. If we can read pulses in the manner I feel the classics propose by integrating all the technical details of different pulse models, our insight into the patient’s condition will be far deeper, and we should be able to see disorders before symptoms manifest. We will be also be able to incorporate details from Western medicine. Saying this, it only remains to examine how diverse classical pulse models can be integrated, yet remain consistent with classical theory when applied in contemporary clinical applications.

To show the greatest level of detail of information possible, I want to offer a brief theoretical overview of the physical and energetic dynamics of pulse models. I want to examine pulse models abstractly, that is, from the point of view of how many physical and energetic dimensions are actually used in reading pulses and, therefore, how much clinical information is available in any particular model. Although this survey is not a historical perspective, the classic Chinese texts essential to pulse diagnosis–the Nan Jing, Li Shi-zhen, and Mai Jing–set the foundation upon which this analysis is based and how pulses will be used in clinical applications.

There are many and varied methods of pulse diagnosis, each viewing the body, the meridians, and the internal organs from different theoretical perspectives of structure and energy. No single method of pulse reading represents a complete picture of what Chinese medical literature offers. Each expresses the tacit assumptions from which it is was created. Each model has its own theoretical consistency and practicality that demonstrates its clinical efficacy.

Any one method is not necessarily more true than any other; each has its own advantages and limitations. Sometimes these versions differ so startlingly that the very idea of pulse diagnosis becomes suspect. Yet, each claims to represent the same subject, the human body. They display different perspectives of the same phenomena in much the same way chemistry, physics, and biology show different perspectives of physical reality. In clinical practice, often several models must be superimposed to fully understand the patient’s condition.

In this book I primarily draw from two of the classics to develop a comprehensive framework for advanced contemporary study. Later, I plan to write more extensive commentaries on topics in the Mai Jing. The Nan Jing (circa 200 BCE) and the Li Shi-zhen (circa 1564 CE) view pulses from two distinctive perspectives. Besides examining the 5-Phase (Wu xing) and 6-Channel Theory (Liu jing) aspects of pulses, the Nan Jing describes in detail the physical and conceptual significance of the physical positions that the pulses occupy. The Li Shi-zhen, on the other hand, primarily organizes and analyzes the shapes and qualities of the pulse itself, creating an "alphabet" of 27 main types from which we can learn to read the patient’s disease patterns. When we superimpose these two systems of thought, it opens exciting new possibilities.

1-D Pulse Model

When looking at pulses using a typical TCM or 8-Principle model, each position–cun, guan, and chi–is viewed as a distinct and integral space. We don’t usually divide it into vertical levels, and no particular distinction is made in terms of correspondences depending on depth. The focus of attention is on the wave shape as a single movement and the position as background and reference. The level of detail depends on the sophistication of the practitioner who describes the waveform. The information expressed is the collective energy of that position, organ, or jiao. Like a vibrating string, it may be floating, sunken, fast, slow, choppy or slippery, etc. The Li Shi-zhen, for example, allows a possibility of 27 main types of pulses, although most practitioners do not read pulses using this level of detail. This is a one-dimensional pulse movement.

For example, a wiry movement in the left guan position can be liver depression with qi stagnation or hyperactivity of gallbladder fire. A wiry and rapid movement in the right guan spleen vacuity with stomach heat. From the pulse descriptions alone we have no way of distinguishing the different activity in the zang or fu because the pulse model does not distinguish separate levels. The model can not disclose any more details. Using 8-Principles makes deduction uncomplicated but is reductionist, sacrificing detail for expediency. It omits much of the dynamic quality of living beings, leaving a simplified system of pattern discrimination. The art, as we shall soon see, is in the details.

The amount of ambiguity in this model is quite large even when it uses the full capability of the Li Shi-zhen because it neglects the wealth of technical material found in the Nan Jing and Mai Jing. We can make this basic model more detailed by dividing each position into zang and fu levels. Or, if we extend 8-Principles and divide each position into three horizontal levels, we can begin to look at the qi, blood, and organ values of the movement in each position. Regardless, we are interpreting a single pulse movement.

2-D Pulse Models

Dividing the cun, guan, and chi pulse positions into three longitudinal levels, as described in the Nan Jing (and repeated in the Li Shi-zhen) need not be limited to merely describing a single movement spread over 3 levels. We can deconstruct this model and uncover multiple layers of meaning, including the classic’s fundamental intentions, as well as other meanings that are based on the same language, images, and ideas.

Dividing the pulse positions into 3 sectors along both the vertical dimension is important for a number of reasons. The more complex a diagnostic system can become, the more information it is capable of carrying. Therefore, the more information we have regarding a disease, its treatment, and its prognosis. Information in pulse diagnosis, just as in Western physics, is a physical quantity; it is not an abstract thing.

To read pulses differently we first need to change how we examine the pulse in two ways. The first way is to regard each of the nine sectors on both wrists as having an interpretive significance of their own. The classics say that the cun position shows everything above the diaphragm, the guan everything in the middle jiao, and the chi from the navel down. But we’re looking at three different levels and three different pulses in the each of the cun, guan, or chi positions, for a total of 9 sectors on each wrist. If we follow the physical logic of the classical model, then the superficial level is the qi, skin, and interaction with the environment, the bottom third is the organ and bone level, and the middle third is the physical space between those layers and blood level or organic function.

The second way to read pulses differently is to read the pulse wave as a sine curve rather than a bell curve. Reading the pulse as a bell curve in a single position perceptually orientates it in the vertical dimension and we tend to see an isolated wave shape in the chi, guan, and cun. While difficult for the acupuncturist who hasn’t had training or practice in this method, reading the pulse as a sine wave orientates the movement along the horizontal axis. This innovation enables us to view each of the 9 sectors (the 3 levels in the cun, guan, and chi) discretely, and we will also be able to closely observe the movements and connections between each jiao. We will also discover emergent properties of this integrated model: pulse movements between two or more organs or in space and time that are diagnostically significant.

We are now beginning to see the outline of a two-dimensional portrait. The single pulse wave has become multiple waves in a plane. It provides more than supplementary details to the diagnostic picture. When we multiply the vertical and horizontal perspectives, we multiply the information available. The information regarding the surface can be easily distinguished from information from the organ level. For example, when we view breast cancer in the right side cun, we can also check the pulse to see if it is metastasizing to the lung.

The superficial level of the pulse involves the skin, meridians, the body’s interaction with its environment, peripheral nervous system, and conscious emotions. The middle level refers to organic function and the interactions of internal components with each other. The middle level is also an interface of the surface or environment to the interior and organs. And the interior level refers to the internal organs, bone level, the adapted features of the body, and unconscious or hidden emotions.

The theoretical opposition of pulse quality and position can now be reversed or deconstructed. It is not simply a different picture of the same thing; it actually envisions a higher order of organization, a new paradigm. In the 1-D model, pulse qualities were primary and foreground; position secondary and background. In a 2-D model, the importance of position is now primary and increasingly specialized, then the quality is analyzed.

But can we do this if it’s not explicitly authorized in the classics? Unfortunately, the classics are actually poor teaching tools. They often mention things without clear details or explanations. Commentaries sometimes sound as if they’re about completely unrelated topics. Even if when we read the original text in Chinese, its meaning, translation, and interpretation are frequently in dispute. The classics are actually the starting point for study and research, not the accumulation or final arbiter of what can be known.

But, most importantly, we can consider this integrated model for the same reasons we accept the original, classic pictures: it extrapolates from and expands upon existing theory; it develops from the natural character of living systems in general; and it is of demonstrated proven clinical value. This unified system integrates two of the major pulse models found in the classics. And it allows them to be read together in a new way.

Why should we prefer to work this way if a simplified TCM method is already available? At least 3 levels of organization are required to describe living biological systems (just as 3 terms are needed describe fundamental physical forces) with the degree of detail and richness of description that begins to describe the behavior of real systems.

A minimum of three levels (the task or goal level as a special kind of boundary constraint, collective variable level, and component level) is required to provide a complete understanding of any single level of description.

Patterns at all levels are governed by the dynamics of collective variables. In this sense, no single level is any more important or fundamental than any other.

Boundary constraints, at least in complex biological systems, necessarily mean that the coordination dynamics are context or task dependent. I take this to be another major distinction between the usual conception of physical law (as purely syntactic, nonsemantic statements) and the self-organized, semantically meaningful laws of biological coordination. Order parameters and their dynamics are always functionally defined in biological systems. They therefore exist only as meaningful characteristic quantities, unique and specific to tasks.

We often find this 3-fold symmetry in Chinese medicine and Taoist philosophy. We have heaven, earth, and man; qi, jing, and shen; the trigrams of the I Ching; the three yin and three yang of the 6 Energies Theory (Liu qi); and the three jiaos of the body. When we examine 3 discrete levels in the pulse diagnosis we can find and appreciate the level of complexity and richness of description necessary for living systems. By comparison, if we use only one or two levels, we are left with only a perfunctory model. The extensive details found in the Nan Jing and Mai Jing are largely ignored.

In biological systems, one level interacts with the environment, a middle level involves the dynamics and maintenance of homeostasis, and the third level consists of the physical constitution of the organism. Some examples in humans would be gestures and words for the first level; blood sugar, electrolyte balance, and lung capacity for the second level; and the chemical composition of bone or how one molecule’s geometry fits like a key into a lock with another molecule as the third level. Global properties of the system as a whole emerge from the interaction of all 3 levels, rather than seeing the action of the parts as being imposed from a dominant central source.

Where else do we see 3-fold symmetry in Western science? Most of the fundamental physical laws require 3 written terms. The most familiar is probably Einstein’s equation, E=mc2. Here are a few other examples:

I=E/R

(Current in amperes is equal to the voltage over resistance)

P = 1/f

Period (in seconds) = 1/frequency (in hertz)

F = ma

(Force as a product of mass and acceleration)

(sin f )2 x (cos f 2) = 1

(Basic trigonometry function of right triangle)

l = hm

(Wavelength depends on the momentum of a particle times Planck’s constant)

A = p r2

(Area of a circle is equal to pi times the radius squared)

a2 + b2 = c2

(Relationship of sides in a right triangle)

N = N2+c

(The equation to generate the Mandelbrot set)

Fn = Fn-1 + Fn-2

(Formula for deriving the Fibonacci Sequence)

information = -log probability

(from Claude Shannon’s article "A Mathematical Theory of Communication" that categorized information as a negative form of entropy)

S = k log W

(Boltzmann’s definition of entropy)

eip= -1

(Euler’s mathematical argument for the existence of God)

 

3-D Pulse Model

If I understand Chinese acupuncture correctly, it is about the improvement of the self-regulation of such intermediary, autopoietic systems of the organism by means of non-linear reinforcement at suitable sites.
--Erich Jantsch
The Self-Organizing Universe (Pergamon, 1980)

From the first two ways we can create models for pulse diagnosis we can see how the diagnostic information multiplies each time a new physical dimension is added. Now we can ask, "What would a 3-dimensional model look like, and what could it tell us?" When feeling the patient’s wrist, you’re not feeling a single line or plane, even though that’s how you were originally trained to perceive it. You’re actually touching an artery that is a cylinder-shaped tube. The blood flow is in 3 dimensions.

We actually touch a 3-dimensional object. A 3-D object viewed in one or two dimensions is only a projection or shadow. There is nothing wrong with these models; they are very effective and contain so much information in them it’ll take you a quite few years to actually develop your skills in acquiring them.

In a 3-dimensional artery, we actually have a three degrees of freedom in pulse movements. The Mai Jing suggests that the cun (and other positions) can be subdivided into a bagua pattern by dividing it into superficial/deep, proximal/distal, and left/right portions. In Dong Han pulse diagnosis, each position can be subdivided into a kind of Rubik’s Cube of 27 sectors. We can see wave movements not just compounded of different qualities but compounded of different, even noncontiguous, spaces.

In some 3-dimensional pulse models, we can expect to see the merging of 5 elements with 6 Energies. Much of the Yun Chi information, such as stems and branches, may now be viewed in the pulses.

4-D Pulse Model

Returning (reversal) is the way of the Tao.
--Tao Te Ching

To go from the 1-D model to the 2-D model, we deconstructed the opposition in the priority of the pulse qualities to the physical positions (especially when in terms of levels and smaller sectors). In going from 2-D to 3-D, we reversed the priority of using 2-dimensional and 3-dimensional physical space.

In each of the 2-D and 3-D models, space is in the foreground and time is in the background. But in a 4-D pulse model this relationship is reversed. Time is brought to the foreground and space is shifted to the background.

To view a 4-D pulse model we require a long meditative, unbroken attention for an extended period. In 4-D, we primarily calculate when major changes have occurred in the patient’s life and, secondarily, examine the qualities involved with that change. Unfortunately, because of these requirements, this topic is beyond the scope of this present discussion.


Selected Bibliography

Cilliers, Paul, Complexity & Postmodernism (Routledge, 1998)

Cramer, F., Chaos and Order: The Complex Structure of Living Systems, trans. By D.I. Lewis, VCH Publishers, 1993

Kelso, J.A. Scott, Dynamic Patterns: The Self-Organization of Brain and Behavior, MIT Press, 1997

Kuriyama, Shigehisa, The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine, Zone Books, 1999.

Li Shi-zhen, Pulse Diagnosis, translated by Hoc Ku Huynh and G.M. Seifert, Paradigm Publications, 1981

Loewenstein, Werner R., The Touchstone of Life: Molecular Information, Cell Communication, and the Foundation of Life, Oxford University Press, 1999

Unschuld, Paul U., translator and annotator, Nan Ching: The Classic of Difficult Issues, University of California Press, 1986

Yang Shou-zhong, translator, The Mai Jing, Blue Poppy Press, 1997

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