Three Secrets from the Pulse Classics That Will Immediately Improve Your Patient Outcomes

By Stephen Bonzak, MS, DCCM, FICEAM, LAc

As East Asian medicine practitioners, we know that treatment should revolve around clear pulse examination, but who doesn’t feel upset with the disappointingly vague information we were taught in school regarding pulse diagnosis? Who doesn’t feel defeated when teachers tell us again and again to forget about the pulse because it will take years to learn?

The truth is everyone can learn pulse and everyone should learn the pulse. You can learn the pulse, and knowing the pulse well will make your clinical work so much more precise. Pulse gives you a definitive diagnosis and a clear way forward for treatment. This is what the ancient sages were really telling us: do not rely on what patients tell us. Listen to the pulse instead. It will reveal exactly what is happening in the body.

Historical Perspectives on Pulse Examination

Reading and interpreting the pulse does not take many years of careful study to become the centerpiece of your diagnostic skill. Since the Han Dynasty, physicians have recognized that the road to mastering the pulse can be accelerated through proper instruction. The author of the Western Han dynasty text The Methods of Pulse Differentiation and Assessment (辨脉平脉法 Biàn Mài Fǎ Píng Mài Fǎ) describes how confusing pulse diagnosis can be without proper guidance:

Question: The pulse has three parts [which reflect] the yin and yang interdependent and counterbalancing [natures]. The construction, defense, qi and blood circulate in the human body. [With] the breathing in and out, [the circulation goes] up and down and throughout the entire body. With the breathing cycle, the liquids and humors go through [the body], moving every moment, making the image [of the pulse].  In the Spring the pulse is string-like, in the Autumn the pulse is floating, in the Winter the pulse is sinking, and in the Summer the pulse is surging. Even in the same period of time, the size of the pulses can be different. The chi and cun positions can have different presentations such as short or long; therefore, the upper and lower presentations can be varied, [and the pulses in those positions] can appear or disappear. The pulses change when [human beings] are ill; [it could be a] forward, backward, low, or high. [All of these changes in the pulses] confuse people, [especially those who are] not knowledgeable about the rules [of pulse diagnosis]. [Thus,] I would like to learn [from a teacher] and get clarification.[1]

Proper instruction empowers us to uncover the hidden problems in our patients that they cannot adequately describe. I remember when I first started working with my mentor and teacher, Dr. Arnaud Versluys, MD, PhD, LAc. He could accurately describe not only the pattern and the correct herbal formula for each patient, but he could tell the patient what he or she was feeling, even if he or she had not told us so!

If the pulse does not correspond to the disease, [one] must know the cause of the change in the disease…[Therefore, one] must know whether the disease is in the interior or exterior, differentiate all three jiaos, know [where] the disease has attacked, and diagnose according to which zang-fu has been attacked. If one can master these principles, he can glimpse [reality] as if divine. The following paragraphs describe [the principles of pulse examination] so that this knowledge can be passed to those that are willing to learn.[2]

This training inspired me to learn more about the pulse. After completing a translation of the The Methods of Pulse Differentiation and Assessment with my colleague Tzu-Ying Chiang, and after studying for over 8 years with my teacher in the Tian-Zeng Lineage of Shanghan Zabing Lun pulse diagnosis, I would like to share some of the secrets to ramping up your ability to use the pulse accurately in clinic. The following reveals Three Pulse Secrets from the Classics of East Asian Medicine that can immediately improve your patient outcomes.

First: Take yin and yang seriously

We see this emphasis on yin-yang theory right from the beginning of the Huangdi Neijing:

Qi Bo responded: “The people of high antiquity, those who knew the Way, they modeled [their behavior] on yin and yang and they complied with the arts and the calculations.”[3]

Medicine without the basis of yin and yang is just a random collection of herbal recipes or needles placed in the body without regard to proper diagnosis. As a profession, we are struggling against those who wish to co-opt our techniques, but we should make it clear that while we hold those techniques as the mainstay of our clinical practice, we are more than those techniques. Chinese Medicine is first and foremost a medicine of the Way and yin and yang.

Once we can recognize yin and yang in the pulses, then the first hurdle to prescribing accurate formulas or needling the correct channels for an immediate change in our patients has been cleared:

Question: pulses have yin and yang [qualities], why is that? Answer: in general [if] the pulse is big, floating, rapid, stirred [or] slippery, it is called yang; [if] the pulse is deep, rough, weak, wiry [or] faint, it is called yin. In general, [if in] yin diseases [the physician] sees a yang pulse [the patient will] survive, [and if in] yang disease [the physician] sees a yin pulse [the patient will] die.[4]

We have all had patients who seemed to have everything wrong with them. How can we tell accurately what the body needs to have treated first rather than trying to treat all of their complaints? Pulse diagnosis makes it clear. If we find yang pulses, then treat repletion in the body. If the pulses are yin, then treat vacuity in the body. Drain the excess and supplement the deficiency. This is the basis of good Chinese medicine, but we need to be able to trust what we feel in the pulses in order to do the right thing at the right time.

Second: Trust that what you are feeling with your fingers is really what is going on in the body

So often we see patients with multiple pharmaceuticals in our clinics. What is really going on in their bodies? Could the drugs be masking some deeper East Asian medicine pattern that we need to treat? Sometimes we have patients who deny that anything is wrong with them, but the pulses clearly say something to the contrary. What should we believe? The answer is the pulses. It is always the pulse. The pulse tells us exactly what is going on inside of the body.

The teacher says: What you are asking [about] is the foundation of the [pulse examination] method. The pulse has three divisions: chi, cun, and guan. The flow of construction and defense that goes through the body is accurate like the roller that is used to measure length and the scale that is used to measure weight. Therefore, it is no slight mistake that the Kidney pulse is sinking, the Heart pulse is surging, the Lung pulse is floating, and the Liver pulse is string-like. With breathing, the flow of construction and defense circulates through the whole body according to the clepsydra cycle. [When] water drops one hundred times, they circulate around the body once returning to the cun [position], therefore you know deficiency or excess in the body. Through transmutations and transformations [of the pulse], [the physician can] understand the abundance or weakness of yin and yang.[5]

The pulse is so supremely accurate at reflecting the condition of the patient that it is likened to a scale or a clock. It is never wrong! As a matter of fact, the pulse is the only diagnostic method available to East Asian medicine practitioners that has time-tested value from over 2000 years of clinical evidence. This can be terrifying, however, since it means that you have to trust what you feel under your fingers no matter what you may think is going on. By trusting what you feel in the pulse you will immediately see improvements in your ability to manage even the most difficult cases.

Third: Trust how the classics teach us to treat whatever pattern you find

Once we trust what we feel in the pulse and begin to understand what it means in our patients, then we are compelled to treat whatever it tells us. To do otherwise would be mistreatment.

[If] the cun pulse is floating it means [the disease] is in the exterior. [If it] is deep it means [the disease] is in the interior. [If it] is rapid it means [the disease] is in the bowels. [If it] is slow it means [the disease] is in the organs. [If it] is a slow pulse, [it also means there is cold] in the organs.[6]

For example, when a patient comes to the clinic who is an athlete, they probably will have very slow pulses. Western physiology tells us that this is an indication of health, since the heart rate will decrease with improved cardiac function. Even though Western doctors may think that the person is healthy because of all the exercise, the pulse classics are telling you that he or she has cold in the organs. The herbal medicine classic the Shanghan Lun tells us that a patient with cold in the interior may require a drastic warming strategy like Aconite and Dried Ginger Decoction (Sini Tang). We should always put our medical classics ahead of what other practitioners of medicine might tell us is “right”.

A recent case from my practice is a good example. A 63-year-old woman complains of migraine headache on the right temporal region that is worse with stress. There is no prodrome nor nausea and vomiting. She reports light and sound sensitivity as well as fibromyalgia pain everywhere in her body. Her bowels are constipated. Her left cun pulse is deep and the guan is big, weak, and hollow. Her right cun is slightly wiry and the guan is wiry and bigger. Although there are mixed yin and yang in the pulses, primarily there is weakness on the left and right. The classics tell us the following:

“hollow means vacuity”[7]

“[if] the pulse is deep, rough, weak, wiry [or] faint, it is called yin.”[8]

Even though both sides are big and that can mean yang and repletion, the overall image of the pulse is one of vacuity and yin. This should guide our thinking in the case. Usually when someone comes into clinic with lateral head pain that is worse with stress, we think of liver (or gallbladder) qi stagnation or liver yang rising. In this case, however, there is not much repletion in the liver-gallbladder as evidenced by the big, soft, and hollow guan on the left. There is too much wood (wiry pulse) invading the right guan, so the earth must be weak and receiving too much wood control. The solution is to strengthen the earth and gently reduce the wood that is attacking by using the following formula: Huangqi jianzhong tang plus zhishi. On follow-up two weeks later, the patient reports that her bowel movements are much better, she is sleeping better, and the migraines have reduced in frequency and intensity. She noticed a reduction in sweating and has more stamina at work.

Hopefully this example gives you the confidence to start treating patients based on the pulse. If not, hopefully it will encourage you that it is possible for you to learn quickly how to treat difficult cases with the proper instruction in the secrets of pulse diagnosis. You can find more out about the pulse diagnostics of the Tian-Zeng Lineage through the Institute of Classics in East Asian Medicine at www.iceam.org or you can download a sample of the The Methods of Pulse Differentiation and Assessment at https://www.smashwords.com/books/view/525014.