脉法: What's Up with Pulse Anyway

The following is an excerpt from 彭子益’s 圆运动古中医学, The Ancient Chinese Medicine of Circular Movement by Qing Dynasty physician and scholar of ancient Chinese medical theory PengZiYi. This book is currently being recommended by some of the great doctors of the modern PRC as an introduction to the true practice of Chinese medicine based on the understanding of cyclical energy flow within the body.

I have come back to the chapter on pulse diagnosis following the recent AWB training session in Shanghai in an attempt to flesh out and further understand the principles of Jacques’ pulse diagnosis. It is interesting that in comparing the two, I have found them almost identical in their theoretical reasoning and very similar in technique, thus indicating a common source somewhat removed from the common understanding/explanation of pulse diagnosis in modern TCM circles.

These readings are the initial steps toward a personal goal of beefing-up my own rudimentary understanding of pulse diagnosis, which as Peng indicates requires a highly integrated study approach that permeates all aspects of the medicine. Stay tuned for more commentaries, translations and with any luck, major epiphanies, as the journey continues…

学脉之法，一曰脉位，一曰指法，一曰脉象，一曰脉理。明白脉位与指法，然后能捐除自己的成见，看清脉来的真象。脉象脉理，必须于普通学法之中，有系统以贯之。

Trans: The study of pulse diagnosis consists of pulse position, finger technique, pulse patterns and pulse theory. After understanding pulse position and finger technique, you should abandon all preconceptions in order to clearly grasp the true pattern of the pulse. It is important to have a system for the study of pulse patterns and pulse theory within the course of your ordinary studies in order to form a more integrated understanding.

指法与脉位

自来诊脉两手分诊。圆运动学的诊脉，必须两手合诊，因整个圆运动的消息，须两手合诊…又须三指斜下，次指按在寸脉的浮部，中指按在关脉的中部，名指按在尺脉的沉部。沉部在骨，中部在肉，浮部在皮。斜下者，中指比次指重，名指比中指重…是为三部诊法。若三指不分轻重，便不合寸关尺三部脉的本位。三部之法之中，又有九侯之法。三部九侯者，一部三侯，三部九侯。下指诊脉，不可将指头死按脉上，就如用眼睛看物，却把眼睛珠放在物上，如何能将所看之物看得明白。三部九侯指法无差。

诊脉动称为看脉，不如将看字改为听字，能将听字的意义体会有得，则诊脉必有聪明过人之处。听字比看字静得多，看是我去看他，听是听他来告我，必能听而后得整个认识也…先将指头审查九个字地位，以侯脉来，指头与脉见面之后，仍不听脉，仍只审查九个字地位，有意无意之中，听出脉的病点来，然后继续搜求，由合听而分听，由分听而合听，整个脉体即是整个人体的河图。由合以求分，便知病之所在，由分以求合，便得处方的结果。总而言之，不可由我去找脉，须侯脉来告我。我去找脉，我便有成见了，就得不着脉的真象了。

On FingerTechnique and Pulse Position

From times long past, pulse diagnosis has been performed on each of the two arms separately. According to circular movement theory, pulse diagnosis must be performed on both arms simultaneously in order to fully observe information regarding the circular movement of the body as a whole…It is also necessary to use downward diagonal placement of the three fingers. The index finger is pressed to the superficial level of the cun position, the middle finger is pressed to the mid-level of the guan position, and the fourth finger is pressed to the deep level of the chi position. The deep level corresponds to the bones, the mid-level to the muscles, and the superficial level to the skin. Downward diagonal reading means the pressure applied by the middle finger is greater than that of the index finger and the pressure applied by the fourth finger is stronger than the middle finger. This is the three position method of diagnosis. If the three fingers are not differentiated according to varying degrees of pressure, they will not correspond to the fundamental positioning of the cun, guan, and chi pulses. In addition to the three positions, there are also the nine indications, each position containing three indications, making nine in total.

When performing pulse diagnosis, the fingers cannot rest stiffly on the pulse. The process is similar to placing one’s line of sight on a distant object, adjusting one’s focus or angle until the object is comprehended. Three position nine indication pulse diagnosis is much the same.

Although the verb “to look” is often used in referring to pulse diagnosis, however, the verb “to listen” may be much more appropriate. If you are able to experientially grasp the meaning of this character “to listen”, you will certainly become more skilled than the average person in pulse diagnosis. The process of listening is much quieter than that of looking. Looking involves movement away from oneself in order to see something, while listening involves the movement of some information toward oneself. We must be able to listen in order to gain a complete understanding. First, use the fingers to investigate the status of the nine indications, waiting for the pulse to come to you. The pulse and fingers meet, and yet we still do not listen to the pulse; simply remain examining the status of the nine indications in a relaxed state between consciousness and unconsciousness, listening for the point of disease within the pulse. As you continue seeking, listen to all indications in symphony and then split individually; listen to each indication individually and then again in symphony. The pulse pattern as a whole is like the individual’s unique River Picture. Seeking individuation among the symphony will allow you to locate the point of illness, while listening to the symphony of the pulse as the sum of its individual parts will allow you to determine the appropriate prescription. In summary, you cannot go searching for the pulse. Instead you must wait for the pulse to come to you. Going searching for the pulse implies that you have preconceptions that will prevent you from obtaining the true pattern of the pulse.

The Science of One

If you stop for a moment to consider the sheer volume and scope of information you are expected to master as a student and practitioner of Chinese medicine, it can be dizzying to say the least. From herbal properties and combinations, to acupuncture points and treatment protocols, to anatomical knowledge and diagnostic tools, your bookshelf quickly fills with a collection of intimidatingly thick volumes that ramble on for hundreds of pages with several thousand years of differing opinions on nearly every aspect of the practice.

In a modern world where specialization and differentiation are considered the hallmark of a well-developed 'science', it is easy to get caught up in this habit of acquiring information in the same way we have been trained to do since first launching into our academic careers with the baby-steps of our ABC's. This undertaking that spans decades is akin to a mental journey far out and away from the mind center and is characteristic of the fundamental stage of learning. There comes a point, however, where our orientation should begin to shift, and having familiarized ourselves with the material reality of the concepts of Chinese medicine, we begin to return to the root of true wisdom. In Ch. 16 of the LaoZi, "归根: Returning to the Root" we learn:

夫物芸芸,各复归其根.
归根曰静,静曰复命.
复命曰常,知常曰明.
不知常,妄作凶.
知常容,容乃公.

(refer to http://www.yellowbridge.com/onlinelit/daodejing.php for a nice comparison of English translations)

The theme of this passage rings through in Ch. 6 of the NeiJing where the ever-patient QiBo responds to a question by HuangDi regarding the nature of Yin and Yang, with:

阴阳者，数之可十，推之可百，数之可千，推之可万，万之大不可胜数，然其要一也.

《素问・阴阳离合论》

This concept of grasping the singular, essential nature that runs through all of the seemingly disparate elements of TCM is something that we must always be conscious of in our study and practice. Unfortunately, as I come upon the half-way point of my fourth year of formal TCM education, I am yet to have a single professor tell us what this mysterious, all pervasive concept is. It took an unassuming, older gentleman from Switzerland and 2 weeks of reminding to come to the concrete, unshakable realization that the answer is so simple as to be overlooked and can be summed up in a single word: ENERGY.

To quote briefly from Jacques Pialoux's Guide to Acupuncture and Moxibustion we can outline this concept of energy according to its modern scientific attributes as "the product of various interactions (nuclear, electromagnetic, and gravitational) in the form of motion, or vibration. It is characterized by: frequency (its quality), amplitude or power (its quantity), and its direction (including both where it originates from and the destination it is moving toward)."

YuanQi! Of course we talk about qi with incredible frequency as we study TCM; we throw the term around so flexibly that it becomes an ethereal, abstract concept somehow removed from the reality of the human body. I hear professors and doctors mold the term to fit any situation; to explain any problem, and have come to the opinion that if traditional medicine is to continue to gain strength as a viable means of healthcare in the modern world, we as practitioners must hold ourselves to the same strict standards as other scientists. Our treatment protocols should be centered around the simple questions contained within the definition for energy: what is it?, where is it coming from?, where is it moving to?, does this represent a physiological or pathological function of energy?

As LaoZi states, we must become clear in our understanding of the fundamental principles of the matter at hand, lest we act carelessly. As for how we do this, I think the conversation takes a clear turn away from the academic toward the esoteric in passages such as Ch. 48 "忘知: Forgetting Knowledge":

为学日益，为道日损．
损之又损，以至于无为．
无为而无不为．

I find this passage particularly relevant as I get into my final semester of book learning here at the university, where knowledge reigns and understanding often gets left by the wayside. The work that lies ahead for me is to deconstruct the system that has been downloaded to me over the past 4 years, to understand the why. Why is this particular acupuncture protocol the accepted standard for a particular illness?; Why does this combination of herbs produce this effect? It's this deconstructionist approach to learning that I think separates learning from scholarship and imitation from mastery.

The Horary Cycle and our Body’s Natural Rhythms

The following article has been translated and adapted from a posting on 中国中医网.

In Ancient times, the Chinese separated the day into 12 periods of time based on the motion of the sun through the Heavens, each two hours in length. Each individual period became intimately associated with one of the 5 zang/6 fu organs, its corresponding meridian and its physiological functions. Below are further details of this system as it relates to human physiology and basic suggestions for promoting health through proper daily rhythm.

The Zi Period, 子时: Maintaining Yang Qi through Sleep
11pm to 1am is the period when Yin energy is at its height. Yin energy directly correlates to the physiological process of sleep. Therefore, we should be soundly asleep during this period. Just getting into bed during these hours, reading, watching television, or struggling to fall asleep is not an efficient use of this time.

The Gallbladder meridian is most active during the Zi period. According to the law of transformation of Yin and Yang (extreme Yin produces Yang; extreme Yang produces Yin), the gallbladder is responsible for giving birth to the first Yang energy of the 24 hour cycle. This Yang energy in its infantile state is highly vulnerable. Therefore, we must protect and allow it to grow through proper sleep.

The Niu Period, 丑时: Production of Blood by the Liver
1am to 3am is the period when the liver is most active. The liver, and its corresponding meridian, are responsible for stimulating new growth, further strengthening the Yang qi released by the gallbladder. The liver carries out its physiological functions of filtering toxins and producing blood during this time. Extensive clinical observation has shown that many patients who suffer from liver disease are fond of staying up late into the night. This deprives their liver of adequate opportunity to complete its tasks, and over time, leads to illness.

The Yin Period, 寅时: The Ideal Time for Measuring the Pulse
The morning from 3am to 5am is known as the “peaceful dawn”. During this time, the energy of the Heavens is approaching a state of equality; the relative state of Yin and Yang begin to come into balance. The lungs are most active during this period. As the day begins to break, the pulses most accurately reflect the state of the individual. One can note whether the pulse is stiff or tight. For those over 40 with a stiff pulse, there is a high correlation with high blood pressure; for those in their twenties or thirties with a tight pulse, it is likely that they are under a great deal of stress at work or suffering from a heightened level of general anxiety. A pulse that is both stiff and tight is known as a “wiry” pulse, often characteristic of high cholesterol and arteriosclerosis.

The Mao Period, 卯时: Drink a Glass of Water, Clear the Body of Toxins
The large intestine is most active during this period from 5am to 7am. It is important to begin the day at this time with a glass of warm water on an empty stomach. This is particularly effective for individuals who suffer from chronic constipation. As the energy of the large intestine begins to grow stronger, the water helps act as a catalyst to stimulate peristalsis, thus eliminating toxins from the body. The toxins contained within our stool compose about 50% of the total toxins of our entire body. The Mao period represents “the opening of the heavenly gate”, corresponds to the second month of the lunar calendar, when life, fueled by the growing force of Yang energy, emerges from the Earth, thus making it the ideal time for vacating the bowels.

The Chen Period, 辰时: Balancing the Nutrition of the Morning Meal
The stomach is most active during the Chen period, from 7am to 9am. We should take out morning meal at this time, thus making use of the abundant energy of the stomach. Breakfast should include some form of animal-based protein, including eggs or other breakfast meats.

The Si Period, 巳时: The First Optimal Period for Work or Study
9am to 11am is the time dominated by the spleen. The spleen is responsible for assimilation and transport of nutrients. This is the period of the day when brain activity is at its peak, making it the first ‘golden’ period of the day, ideal for study or work. However, this productivity and effectiveness is dependent upon having eaten a healthy breakfast. The spleen processes and assimilates food digested by the stomach, converting it to the energy that drives our various physical and mental activities. It is also the best time of the day for seniors to exercise.

The Wu Period, 午时: A Quick Nap to Fortify Yang Qi
The Heart channel is most active during this period from 11am to 1pm. During this time, we should follow lunch with a brief period of rest. According to the principles of transformation of Yin and Yang, Yang energy has reached its apex. The NeiJing tells us that Yin is associated with the interior and sleep, while Yang governs the exterior and waking hours. Therefore, by following the midday meal with a brief period of rest, we can further this transition of Yang to Yin. This is especially important for Yang deficient people to fortify their Yang energy with a longer period of sleep. For the rest of us, a half hour of rest should be sufficient to protect the Heart energy and Yang qi.

The Wei Period, 未时: Protect Blood Vessels by Drinking Water
1pm to 3pm is the time of the Small Intestine. At this time, the small intestine completes the absorption and assimilation of nutrients from digested food matter. The blood stream is now laden with the nutritional building blocks of life, a state somewhat analogous to the crowded streets of rush hour traffic. At this time, we should drink a glass of warm water or tea in order to help dilute the blood and promote circulation. This can help protect vessel walls from the excessive strain of nutrient-rich blood.

The Shen Period, 申时: The Second Optimal Period for Work or Study
The period from 3pm to 5pm is the second golden period for concentration of the day, when the urinary bladder is most active. The small intestine has completed its assimilation of nutrients and made them available for consumption by the brain, making it easier to carry out high-concentration oriented tasks.

The You Period, 酉时: The Best Time for Preventing Kidney Trouble
The kidneys are most active during the You period, from 5pm to 7pm. Drinking another glass of warm, clear fluids at this time assists the kidneys in filtering toxins from the body, helping prevent afflictions such as kidney stones and bladder infections.

The Xu Period, 戌时: The Third Optimal Period for Work or Study
The period from 7pm to 9pm is governed by the pericardium. At this time in the day, the heart energy relaxes into an eased flow, ushering in the third golden period for work or study of the day. It is also an ideal time to go for an after-dinner walk or get in some other form of exercise. As the pericardium hour draws to a close, finish it off with another glass of water or non-caffeinated tea to maintain proper circulation.

The Hai Period, 亥时: Preparing to Rest
The SanJiao, or triple burner, is most active during the hours of 9pm to 11pm. At this time, our day should slowly begin to draw to a close. Computers, TV’s and cell phones should slowly be retired for the day to allow the mind time to settle into a restive state. It is an ideal time for pleasure reading, enjoying some light music, quiet meditation, or sharing intimate time together with a partner.

Yin or Yang, Left or Right??

In an attempt to lay to rest a recurring question on the positions of Yin and Yang in pulse diagnosis, and in human physiology as a whole, I would like to offer an excerpt from LiShiZhen's The Lakeside Master's Study of the Pulse.

《濒湖脉学》 李时珍
心肝居左，肺脾居右，肾与命门居两尺部。魂魄谷神，皆见寸口。左主司官，右主司府。左大顺男，右大顺女，本命扶命，男左女右。

Trans: The heart and liver reside on the left, the lungs and spleen reside on the right, the kidneys and mingmen at the chi position. The hun, po, gu(1), and shen are all present within the cunkou pulses. The left control the zang organs, and the right control the fu sacs. The left strongly follows the male, the right strongly follows the female, each supporting its own innate nature, the masculine on the left and feminine on the right.

(1)谷gu: literally means "the valley" and is commonly used in classical texts to allude to food stuffs and digested nutrients as processed by the stomach

Simply proceeding one step forward in the order of allegorical associations, we can clearly see the masculine, or Yang, element on the left side and the feminine, or Yin, on the right. This is in keeping with the general movements of the qi mechanism as presented in the NeiJing, for example， “肝生于左，肺藏于右。” ("The liver arises on the left and the lungs store on the right.") 《素问·刺禁论》. Here we see the active process of creation on the left and the more passive process of storing associated with the right.

Homecoming

So after a several month hiatus from blogging that saw the passing of another season of final exams and a brief, but intense, detour into the world of business development (which has been truly fascinating from the perspective of amateur sociological exploration into the nature of office work), I am pleased to be returning here to focus on things a little closer to heart.

This post is actually more than just a little closer to heart, in fact, as I recount my most recent personal experience with the medicine and the astounding results it can produce when done with careful precision. About a week and a half ago, I noticed that the skin around the cuticles of my right hand had begun to look very dry and soon afterward, actually begun to peel. This was accompanied by the skin on my right palm, beginning around 劳宫 (PC8) and radiating outward until my entire palm had become red and slightly irritated as the young layers of skin beneath were exposed. Yes, another of those strange, slightly annoying, yet in no way life-threatening health problems that plague long-term residents of Beijing.

In addition, I had been sleeping somewhat restlessly, whether due to my own internal imbalance or the effects of the warmer Spring-like weather on my young male cat, it is difficult to say. Regardless, I found myself waking almost every morning from a vivid dream cycle just shy of 7 o'clock. This coupled with somewhat unpredictable bowel movements got me to thinking, though it wasn't until yesterday during my conversation with Sylvie Hu, our AWB representative here in Beijing and a wonderful resource on all things acupuncture related, that I finally began to connect the dots.

She suggested a simple, yet elegant (as AWB protocols tend to be) treatment: Tonify 合谷 (LI4), 曲池(LI11)，天枢(ST25); Disperse 大陵(PC7)，太溪(KI3).

A bit of crafty ambidextrous work on myself (as I still rely on the clumsiness of physical needling), an extended evening meditation and a great night's sleep have yielded some truly remarkable results. The peeling has stopped, and even seems to have begun to replenish itself across my entire palm and fingertips. A small victory, I know, but astonishing, nonetheless.

So what are the forces at work here? Sylvie explained that skin conditions such as this, including some rashes, excezema, and even psoriasis, are intimately related to the functioning of the Large Intestine and its ability to remove toxins from the body as well as the adequate strength of surface Yang enenrgy to retain internal energy from oozing to the surface. The digestive issues and the early rising, coincidentally during the Mao period of the horary cycle, further confirm this line of thought. The location along the Pericardium channel and the restless sleeping are generally indicative of excess energy in the Heart and Pericardium, thus the need to disperse 大陵，the Yuan and Earth Shu point of this channel. 天枢, or "Heavenly Pivot" is known to coordinate the respective digestive and assimilative/excretive functions of the upper and lower digestive tract, and has also been proven effective in treating various psychological conditions. All said, an incredibly useful point to investigate.

This basic treatment, tonifying 后溪(SI3) and 外关（SJ5) when necessary, can be used as a basic formulation of points for treating skin problems resulting from an accumulation of toxins in the body. For bowel irregularity marked by uncontrollable, painful spasms, combine with dispersal of 三间(LI3), or tonify 大肠俞(BL25) for constipation resulting from Large Intestine deficiency. These treatments may also require the patient to adjust their diet where needed. The more severe the skin condition, the stricter the diet should be, beginning with the elimination of fatty foods and alcohol and ending with all dairy and meat products.

The presentation, however, is secondary to the underlying pathology. Patients with Large Intestine deficiency and a build-up of toxins within the blood may also present with various allergies, for example. Constipation may be the result of disharmony between the Spleen and Stomach, or engorging of the Liver - it's all so wonderfully, frustratingly possible.

To conclude with a simple observation I hope you have already hit upon by this point, "Yes, acupuncture is very cool..."