Commentary on Li Shi Zhen's "Pulse Diagnosis"

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Keep informed on current news in the world of Traditional Chinese Medicine.

By James Ramholz
from Oriental Medicine Journal Volume 4, #3"

Introduction
Pulse diagnosis has always been an enigmatic as well as complex field. Not surprisingly,
acupuncture colleges offer little formal education in this area even though Li Shi Zhen's
Pulse Diagnosis (1) and various editions of the Huang Di Nei Jing have been available for
many years. Even when some of the classical literature on pulses is part of the curriculum,
many students complain they receive obscure and conflicting advice when trying to sense
the pulse movement and accurately interpret the information it can provide. Two new
books, a translation of the Li Shi Zhen from Blue Poppy Press and Dr. Leon Hammer's
work from Eastland Press, are promised shortly and should help to amend and renew
serious study in this field.

According to Li Shi Zhen there are 27 basic pulse states (2). Most basic movements can
be observed in any of nine fundamental positions (3) on each wrist. The division of each
wrist into three depths forms a grid in which "the area and nature of the disease can be
determined from the wrist pulse."(4) In this nine-sector grid, the cun position indicates
diaphragm to crown, the guan position indicates navel to diaphragm, and the chi position
navel to feet. The superficial comprises emotional, exterior, and meridian activity, the
middle shows organic or metabolic activity, and the deep level shows the bone-level or
innermost activity. Together, these sectors create a hologram of the entire body, similar in
nature to the mapping of the ear, feet, or eyes.

Mathematically, this nine-sector grid forms 486 simple combinations. Because each state
is never seen alone but combined with one or more types of energy--what Li Shi Zhen
calls a "composite pulse" (5)-- the possibilities quickly expand (6). In developing a model of
this sophistication, we can create a diagnosis system as rich and as varied as there are
conditions or patients. By adopting the criteria of Li Shi Zhen we can anticipate a method
of diagnosis and treatment that is truly as unique as the patient. Ultimately, we can have a
far richer description than 5-elements; we could calculate 5 elements of 5-elements of 5-
elements. A model this detailed gives us a much clearer picture of cancer, AIDS, and other
forms of chronic illness.

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Unfortunately, no current American text exploits this level of sophistication and complexity.
Typically contemporary texts divide the pulse levels into the yang and yin organs, then
specify a diagnosis method using Eight Confirmations in the cun, guan, or chi positions.
Many different types of problems are reduced to the same, simple rubrics- -"stagnated
liver energy," "dampness in the spleen," etc. As a result, complicated and chronic
problems can easily be misunderstood, misdiagnosed, and inappropriately treated.
Compounding this problem is the difficulty of the subject matter itself, differentiating and
interpreting subtle activity inherent in pulses especially for chronic and catastrophic
illnesses which present highly complex pulse patterns. It is unrealistic to work with models
like the Li Shi Zhen without comprehensive classroom study and extensive clinical practice
with supervision. This problem is further compounded by confusing and conflicting
information in the Li Shi Zhen itself.

Thankfully, Li Shi Zhen provides us with an important tool, asserting that all this can be
made less complicated:

The theory of the pulse is very complicated but it is based upon the four principles--
floating, sinking, slow, and rapid. Once they are understood, by elaborating on them,
the entire subject can be clarified.(7)

Li Shi Zhen asks us to divide the pulse into yang and yin vectors along vertical and
horizontal lines of symmetry, a type of fourfold analysis. For him, pulse diagnosis is an art
of deconstruction, a geometry of meaning.

The model that best includes both these dimensions is the Tai Chi diagram, a broad and
familiar abstraction that can also be used to decipher the particulars of its applications. It is
the classic emblem of complementary opposites, cyclic continuity in time, and harmonious
interrelationship--all essential parameters of health in the human body. Yang rises
vertically and accelerates horizontally; yin sinks vertically and decelerates horizontally.
Using the Tai Chi symbol as our paradigm, we can analyze how yang and yin should
ideally communicate, exchange, and balance.

The circle itself is a traditional symbol of unity. The sine wave through the diameter of the
circle is the ideal and basic pulse wave. It is the result of balance, interaction, and
harmony. Any deviation from it provides information on how yin and yang have changed
from that balance and what are the consequences for health. All 27 pathological pulse
states discussed by Li Shi Zhen can be derived from it.

Tai Chi is process-orientated, coherent, evolving, and interactive in contrast to the typical
emphasis on substance or "solid" components. In it, yang and yin are more than their sum;
they create and dynamically balance each other. As a complex system, the Tai Chi
diagram can be seen in a wide range of natural scales and applications--the double-helix
of the DNA molecule, the change of day and night, the spiral nature of galaxies. Because
this symbol is found at the heart of Taoist philosophy, the Chinese 60-year calendar, feng
shui, martial arts, and a variety of other systems, it can be used as a basis for analysis and
comparison of those systems.

We can simplify the work of Li Shi Zhen one step further by creating a list of the most
fundamental pulses. As a basic group, they illustrate a view of the essential dimensions
and types of energies found in all pulses. It is important to note that they are derived from
a balanced pulse state and fulfill Li Shi Shen's fourfold criteria:

Healthy or Balanced

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 Floating & Sinking
Rapid & Slow
Big/Small, Long/Short
Slippery & Choppy
Knotted

The Healthy or Balanced Pulse

When Li Shi Zhen speaks of the different qualities of a normal pulse in section 3.2 (8), the
descriptions he uses are not "normal" nor "healthy" in either a theoretical or clinical sense.
This data entirely contradicts the pathological indications described later in the book by the
terms scattered, choppy, blocked, wiry, tight, slippery, soft, etc. Only the description of the
middle pulse of the spleen and stomach feeling "regular, neither fast nor slow" comes
close to accurately portraying the energetic balance, coordination, and harmony expected
in a healthy person. Clearly, these descriptions are typical of critical problems associated
with those organs.

Inherent to this system is the communication and symmetry of yin and yang. The sine
wave is formed from the synergy and coordination between yin and yang. Their dynamic is
nonlinear, not simply the sum of isolated or independent elements. This relationship is as
important as the constituents and becomes their context as well as genesis. The Tai Chi
movement represents the ability of living systems to continuously regulate and renew
themselves and to regulate this process in such a way that their integrity and structure is
maintained--what is today sometimes called autopoiesis.

We would expect other systems to be derived from this one, and in fact we see it at the
heart of many illustrations in Chinese philosophical and medical literature. Whereas a
machine is geared to output a specific product, a living organism is primarily concerned
with renewing itself. We should expect to see this sine wave in all healthy relationships
and in the pulse positions of a healthy person. Therefore, any deviation from this wave
movement provides us with important information about what is happening to the energy
of the patient or the body's response to disease and the environment. It is the way
systems cycle or energetically perpetuate themselves.

Pulse Wave Energy Segments

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 AB qi Yang/yang function
BC qi Yin/yang function
CD xue Yin/yin capacity
DE xue Yang/yin capacity

The Normal pulse is often identified with the stomach energy because it is the organ which
supplies nourishment and support for all others. Together with the spleen, the earth Phase
absorbs, coordinates, and transforms; five elementally, it is at the center of the sine wave
movement. The dampness or substantial quality sometimes attributed to its pulse
character is indicative of that nurturing and supportive role. That central importance is
emphasized in the seasonal 5-Phase scheme: each Phase communicates with the spleen
before cycling to the next Phase in the shen cycle (9).

In a perfectly healthy person, all the pulses would present this smooth, balanced sine
wave movement connected at all positions and depths- -and it should be present during
the entire year, not only in late summer. While the seasonal energy will have some
influence in the pulses, emotions have a much stronger and immediate influence. The
energy movements of the four seasons add their wave shapes to the patient's energetic
movement. The interactions of those two wave forms uniquely describe the patient's
reaction to the seasonal change.

The basic wave can be further analyzed by dividing it into its yang and yin components.
The normal pulse begins with an ascending or yang movement. The convex portion
indicates the yang energy or qi of the movement [ABC], while the concave portion
describes the state of yin energy or blood of each organ [CDE]. To determine the balance
within this movement, check the size, angles, and texture of the yang portion and compare
it to the yin portion. Ideally, the yin and yang portions of each pulse should be symmetrical,
hold the same capacity, and display the same textures. A sharper angle of ascent
indicates that the pulse contains more yang energy or heat; a smoother angle indicates
that yin is more prevalent. If the ascending movement is more prominent, the pulse will
have a tendency to float; when the descending movement is more prominent it will have a
tendency to sink (10). When the rising movement is dominant it can also have a tendency
to be more superficial or express an acute syndrome. If it is a chronic condition the
syndrome expressed will be light, superficial, or immediate.

If the pulse begins with a descending motion (the sine wave is reversed), the organ energy
is reversing and, if more than one pulse position presents this reversal, the mother-son
rule of the 5-Phase theory is breaking down and the condition is more critical.

Symptoms are created by contrasts in function, energy, or movement. The capacity of a

pulse movement to create symptoms can be measured by the area of the yang [ABC] or
yin [CDE] portion of the pulse. For example, if the yin portion of the pulse is larger, then
the yin energy has the greater capacity to express a symptom. The pulse is not
necessarily obliged to express this capacity, but we can see the potential for expression.
And our diagnosis does not have to rely solely on the patient's report of their symptoms;
we can observe problems before the patient can be aware of them. This capability of pulse
reading is essential in discriminating the root of the problem from the branch; as well as in
cases where the patient has forgotten, is unaware, or is hiding aspects of the condition.

These elementary rules can be applied repeatedly as tools to analyze any pulse shape or
energy. Taking the first half or yang portion as our focus, the movement going up is yang of
yang while the second movement of the first half of the basic wave is yin of yang. In the

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yin portion of the basic wave, the movement descending is yin of yin; the movement
ascending to the horizontal axis is yang of yin. The yang of yin portion connects to the next
pulse position, feeding its yang of yang movement.

The clinical implications of this fourfold analysis are far-reaching (11). Let's consider
several examples of a Flooding (hong) pulse, which can, in general, indicate heat or
bacterial inflammation. First, we need to keep in mind that when the upbeat is yang, it
indicates the qi and when the downbeat is yin, it indicates blood. The ascending
movement of a Flooding pulse can be smaller than the descending motion, or the rising
motion can be larger than the descending motion. These two pulses offer us different
information even though both are Flooding.

Both present bacterial inflammation with a certain range of fever or temperature. Where
the downbeat is larger it indicates that the yin energy or blood is more influenced by the
heat than the qi therefore we should expect more pus formation and lymphatic blockage.
In the other example, heat affects the qi more, and we should expect a higher fever but
less pus formation.

If we want to see if the heat expressed in the Flooding pulse is affecting the upper or the
lower body, we can observe it the chi, guan, cun divisions. If the Flooding pulse is moving
towards the cun it indicates that it is affecting the upper part of the body and if it is moving
towards the chi it indicates that it is affecting the lower part of the body.

Consider the wave movement in the chi position of the right wrist, the large intestine. A
pulse that rises in a normal sine curve but becomes wiry in the yin portion before it returns
to the horizontal axis indicates that qi is not a problem but there is some problem in the yin
or blood movement related to that organ. It may indicate that some heavier materials are
stagnating and the organ itself is now being affected because that heavy material has not
been eliminated. The organ does not have enough energy so elimination is impaired,
building toward a toxic condition.

If the situation was reversed and the upbeat was wiry and the downbeat was normal, it
would indicate that the large intestine itself is affected energetically and not able to handle
routine material. The organ itself is the problem rather than the material that the organ is
managing. The difference between these two conditions can be illustrated by a person
trying to lift a box who cannot do it. There are two possible reasons: either the person is
too weak or the box is too heavy. If the downbeat is the problem, it indicates that the box is
too heavy; if the upbeat is the problem, it indicates that the person trying to lift it is too
weak.

Floating (fu) & Sinking (chen)

Floating and Sinking refer to the movement on the vertical axis of symmetry independent
of the horizontal. The Floating pulse is found at the superficial level and the sinking pulse
in the deep level. Generally, the Floating pulse indicates yang excessiveness due to wind
or heat, and the Sinking pulse indicates yin excessiveness due to cold energy. Floating
and Sinking refer primarily to the depth at which the pulse is found. Floating and Sinking
can also refer to the direction the energy is moving along the vertical axis, even when
found at different pulse depths or sectors. We may sense degrees of a Floating or Sinking
state as a stronger yang of yang movement or yin of yin movement.

Rapid (shuo) & Slow (chi)

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Rapid and Slow refer to movement alone the horizontal axis of symmetry and the speed of
the pulse movement when compared to the patient's breathing. The normal or balanced
pulse is four beats per breath. A Rapid pulse is more than 4 beats per breath. A Slow
pulse is less than 2 beats per breath. A pulse can become Rapid due to a "deficiency of
yin and an excess of yang" energy. The Slow pulse results from "a deficiency of yang and
an excess of yin"(22). In general, the Slow pulse indicates cold energy and Rapid pulse
indicates hot energy. If the pulse moves faster than 6 beats or slower than 2 it is an
extremely critical sign, usually indicative of death; yang and yin no longer communicate
with each other and are about to be cut.

When the pulse is excessively fast, the energy will be cut at the chi position, move towards
the cun, and finally disappear. When the pulse is excessively slow, the energy will cut off at
the cun position and move towards the chi and finally disappear. For these two examples
simply compare the energy of someone who just came out of a sauna and is about to faint
from the heat to someone who was exposed to freezing weather and is about to pass out.

When the pulses are slow in comparison to the rate of breathing, we can say that the
patient does not have sufficient yang energy or that his interior can be cold or damp. The
Rapid pulse indicates that there is too much heat, that the condition is affecting the upper
warmer, or that it is taking place at the surface. It could be excessiveness or it could be a
condition caused by an attack of perverse energy, etc. Heat in the interior, for example
near the bone, will be found in the deep level but will present a rapid movement. A slow
movement at the superficial level indicates cold energy invading at the surface of the body.

Big & Small, Long (chang) & Short (duan)

Big and Small refer to the vertical dimension of the wave form, its amplitude. In general
they indicate the amount of active qi available at a given moment. Long and Short refer to
the horizontal dimension of the wave, its frequency. These pulses indicate the capacity of
the related organs, and are often related to the hot and cold energy balance. Big and Long
pulses indicate that the qi flow is greater than the blood flow, while the Small and Short
pulses indicate that the blood flow is greater than the qi flow.

The horizontal dimension of the pulse wave indicates what the capacity the wave form
holds. Compare the vertical movement to voltage and the horizontal to wattage. So if it is
Big and Long it means that the output is strong, but if it is Small and Short it means that
the output is diminished but the movement can still last for an extended period of time.
When the pulse is Small it means that it will not last because it does not have enough
energy support to continue. Endurance or the capacity of a particular stress, that is how
long it will last, depends on the horizontal movement.

Slippery (hua) & Choppy (se)

These two states describe specific textures of the pulse wave and not necessarily the
shape itself. The previous pulse states show a yang/yin scale in specific dimensions, these
two pulse states are a comparison between the qi and blood and illustrate the relationship
of qi within the blood and the blood within the qi--similar to the portion of the Tai Chi
symbol which shows yang within yin, and yin within yang.

The Slippery pulse feels "round and smooth and flows evenly"(13). The sensation is like
touching oil or wet and hard beads, it curves evenly up and then back down. In general it
indicates dampness or that qi is deficient in comparison to blood. Li Shi Zhen comments
(14) that a Slippery pulse can be created when yuan qi fails "and is unable to hold liver

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and kidney fire." Typically you can expect mucus secretion or, if it is the dominant
character, a blockage to the blood flow with very low qi movement. You will commonly
verify a mucus problem by looking at the spleen's relationship to the other involved organs.
It can be found in women during pregnancy; and, if over forty, it will be evident in the
menopause pattern.

The Choppy pulse feels "thin, minute, and short and has an uneven flow, beating three
and five times with an irregular rhythm." It is often described as feeling like touching very
fine sandpaper or a "knife scraping bamboo"(15). In terms of our Tai Chi model, the
horizontal movement of the qi is not supported by the yin energy. Like the knife, the
momentum pushes forward but is carried in a jerky motion. In general, it feels very thin
and irregular, making it sometimes difficult to flow. It indicates a dry condition, where qi is
more abundant then blood. It can often be observed in anemic patients and in those
recovering from surgery because of blood loss.

Knotted (jie)
A Knotted pulse is an indication of excessive yin- -"whenever excessive perverse yin qi
coagulates"(l6). A Knotting pulse does not always occur every pulsation and can appear
irregularly. It indicates energy blockages, mucus blocks, moving clots, cysts, tumors, and
even cancer. This pulse tends to hold the peak for a prolonged period of time and then
drop, or hold the bottom and go up without a pronounced peak.

As a general rule, we know that a deficiency of yin will lead to an excess of yang. If yin
energy becomes deficient, the pulse will not be able to connect to the deep level. This will
be compensated by the further growth of Yang energy or further strengthening of the
upbeat. But since the yang movement cannot go beyond the top level, which is superficial,
it will compensate by a build up intensity at that level. As the yin energy becomes more
and more deficient, the strength of the yang upbeat will bud correspondingly, manifesting
in a Knotted pulse with a pronounced peak. If the energy is Knotting in every pulsation, it is
more serious and might indicate cancer. In this last case, it shows a severe loss of stability
of the Tai Chi equilibrium.

If this pulse shows up between two pulse waves as an independent movement, then it
could be an early sign of cancer, even though it is not clearly Knotting in the organic wave.
In some cancer movements, the pulse can be felt to rise and actually knot or vibrate in
situ: without a descending movement. This Knotted state-- as well as others which we will
look at later--is usually picked up in the top or bottom of each pulsation but they can occur
in other levels of each wave as well.

Notes
1. Translated by Hoc Ku Huynh and published by Paradigm Publications in 1981. This
text is sometimes referred to by its author's name, as the Li Shi Zhen. It is a
translation of a modern commentary of Li Shi Zhen's work, and the most complete
source currently available in English.
2. Pulse Diagnosis, p. 116
3. Pulse Diagnosis, p. 5 Each pulse position--cun, guan, and chi--is divided into three
vertical levels on both wrists. Each wrist would then form a nine-sector or tic-tac-toe
pattern.
4. Li Shi Zhen, Pulse Diagnosis, p. 6
5. Li Shi Zhen, Pulse Diagnosis, p. 11

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 6. 27 shapes times 27 shapes times 18 sectors = 23,122. This number is an arbitrary
one because there are a variety of ways to calculate possible wave shape
combinations. The complexity depends on the model chosen.
7. Pulse Diagnosis, p. 11
8. Pulse Diagnosis, p. 7
9. Maciocia, Giovanni, The Foundations of Chinese Medicine, p. 18-29
10. See later in the article for details of Floating and Sinking.
11. In clinic, the basic pulse should also be compared to different body types but we are
limited in space and cannot do so here. Briefly, when looking at the basic wave
analyze the ratio of qi and blood. You should expect the yang portion to be larger in
thin and skinny people because a skinny person has a greater ratio of qi to body
weight. If a very skinny person has the same size upbeat as downbeat, the
downbeat is either too big or his qi is insufficient. In either case, there is an disparity
in the energy balance their body should hold.
12. Pulse Diagnosis, p. 16-17
13. Pulse Diagnosis, p. 68
14. Pulse Diagnosis, p. 69. The clinical examples given in this section also mention that
a Slippery pulse results "when there is an abundance of yang qi in the body." The
other examples offered here are due to excessive yin energy, most often mucus
created from wind and heat.
15. Pulse Diagnosis, p. 70
16. Pulse Diagnosis, p. 25. Also see my article, "Cancer from the Perspective of Dong
Han Pulse Diagnosis," in Oriental Medicine Volume 3, #2.

James Ramholz, Dipl.Ac., O.M.D., is the author of Shaolin & Taoist Herbal Training
Formulas (Silk Road Books, 1992). He currently writes, teaches and maintains private
practices in Denver and Fort Collins, Colorado.E-mail: silkroad@ix.netcom.com

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