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A Discussion on Wang Shu He Pulse Classic - Part One

by Leon Hammer

This paper can be summed up in a small story.

"A little girl once asked her mother why she cut off one end of the roast before putting it into the oven. The mother said, `Because that’s the way my mother, your grandmother, used to do it. We’ll have to ask her'.”

Off they went to grandmother’s house, only to find that grandma did it because her mother did it. The three generations then traipsed off to great-grandmother’s house in order to seek the wisdom of the ages. When posed with the question great-grandma simply chuckled, `Why, dear, the pan was too small'."

Chinese medicine needs a new pan for a roast that has grown since ancient times in size and shape, a metaphorical roast that we call the industrial and information revolution. Man has not changed, but the forces that impinge on him have enormously, and the signs which had particular meanings at one time in history are no longer the same. The Tight pulse is no longer a sign of internal cold, in our time it is a sign of an overworking nervous system.

I. Introduction
With the initiation of the new PhD programs sweeping through the acupuncture community has come the need to create new programs to fill the additional hours which will be required.

One of the tracks being developed for the PhD programs is the study of the classics. I have recently been a participant-observer in dialogues involving this seemingly innocent development in one area of Chinese medicine with which I am well versed, Chinese pulse diagnosis, and about which I wish to share my concerns. The following comments are restricted to the classics and Chinese pulse diagnosis. It is my impression that the following remarks are relevant as well to other aspects of the classics.

Before I continue, let me introduce myself. I have written Chinese Pulse Diagnosis: A Contemporary Approach published in November of 2001 by Eastland Press, which contains references to all known works in English available to me during the past ten years. I do not claim to be an academician. Therefore, these references have been reviewed by one editor who has advanced degrees in ancient Chinese language, which I believe makes him qualified to judge their accuracy and relevance.

My position on the classics is that they should be carefully studied. I have never discouraged anyone from this course. In fact it was my plan ten years ago before I was caught up with writing the pulse book to devote my old age to the quiet contemplation of my navel and all the classics available in English, and perhaps carry forth concepts from my first book, DRRBF, based both on what I read and my own thoughts. 

It would seem as difficult to assume a critical posture towards the study of the classics as it would to motherhood and apple pie. And yet there are dangers lurking there for the uninitiated which I wish to explore in this article.

What are the hazards? They fall into two principal categories.

II. The Dangers
A. The Classics Themselves
My first concern is with the classics themselves. There are two ancient paths in Chinese medicine. One involved the abstract and highly theoretical court medicine that spawned the books that come down to us through the ages as the classics. These have never reflected the second, the common practice of the time which was based on experience and that could not be recorded for posterity by the written word unless approved by the Emperor’s court physicians.

In fact, the practitioners of the actual clan medicine that was handed down from one generation to another preferred the spoken, not the written word. Thus they jealously guarded the secret and pragmatic Chinese medicine which has served the Chinese people for several thousand years largely independent of the classics.

It is interesting that this distinction between practice and theory existed at every level of Chinese society. While the naïve, especially in the West, have always identified Chinese civilization with Daoism, Confucianism and later Buddhism, under this dignified and exotic outer crust, the actual guiding principles of Chinese culture and life, according to Joseph Campbell, was embodied in a very different philosophical approach to life. Beginning around the same time as the idealized and lofty Lao Zi and Confucius and culminating in the dominance of the Chin dynasty in 221 B. C., were the Legal Pragmatists. They eliminated chivalry from feudal China and to this day have ruled the Far East with the basic principal that he who gives a sucker an even break deserves what he gets. Pearl Harbor and the depredations of the Japanese Empire in China and the Pacific are the best most recent examples of this philosophy. These are acts for which the Japanese have steadfastly refused to apologize, for the simple reason that Legal Pragmatism teaches that the wrong doer is not the destroyer, but those who allow themselves to be destroyed. To ignore a chance to ravage an enemy, using any method, is an unforgivable dishonor.
With regard to the verbal lineage outside of the clan, Dr. Shen remarked to me that when a Chinese doctor teaches, only sixty percent is true, “forty percent not true”. Another Chinese doctor told me “Chinese do not teach everyone”. Few outsiders were admitted until our time. Even now, and often at a high price, we are not certain how much of what these lineages share with the public is complete or correct. Torture by the mainland communists evoked some of these secrets, Yunnan Bai Yao for example, and more are coming because the price now is right.

Of course, some of these lineages, were familiar with the `classical’ writing, but for the most part they were guided by experience. Today there are in our midst a number of well respected teachers who come down through these ancient verbally transmitted paths who still refuse to write. Clinically there is no contest between the efficacy of these verbally transmitted traditions and often mystifying classics.

This mystification led one observer, James Ramholz O.M.D., Dipl.Ac., in an unpublished paper, “AN INTRODUCTION TO Advanced Pulse Diagnosis Theory and Clinical Practice in Light of the Nan Jing, Li Shi Zhen and Mai Jing” [Personal Communication, June ‘00]]  to state:

“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.”

Nevertheless, there is no one way to successful diagnosis and treatment. A sincere person who has spent years mastering a proven methodology will heal independent of the method. There is no question in my mind that there are some through the ages and now who practice with great skill according to the classics. To the best of my knowledge they are few and far between.

III. The Neo-Classicists

The classics are a precious aspect of our heritage and potentially a repository of wisdom, which, when carefully sifted and considered, can evoke new insights on old ideas.

However, the classics are an enigma, for which the meaningful reading is subject to the greatest scholarship as with Needham, Unschuld, Father Larre and Elizabeth Rochat de la Valle, Heiner Fruehauf, and the lesser known Dr. Chueng, Dan Bensky and Robert Johns.

Beyond the few mentioned above, and perhaps a handful more, how many people in this world are truly classical Chinese medical scholars? Who is going to competently teach it?

With seventy years of experience, perhaps Dr. Shen, who studied the classics, has earned the right to say, which he often did, “book wrong”, or parenthetically, if he chose, to say “book right”.

1. Wang Shu-he and the Choppy Pulse
a. Introduction
Let me illustrate my point with a discussion of Wang Shu-he and his recent interpreters regarding a subject with which I am familiar.

No single contributor to the literature on pulse diagnosis is better known or has had a greater impact than Wang Shu-he who wrote in the second century AD. Almost every commentator on the pulse since has repeated his descriptions of pulse qualities with little deviation. It is therefore important to examine at least one example of his work and see where and whether it is relevant to Chinese medicine in the twenty first century.

Wang Shu He [Pulse Classic, P. 4] describes the Choppy pulse as follows: “it is fine and slow, coming and going with difficulty and scattered or with an interruption, but has the ability to recover. (Other versions of the Mai Jing describe it as short and floating or another version describes it as short with interruption or scattered). When the arrival or departure is slow, there is a greater likelihood of disturbance in the flow of the fluids.” He never refers to the Nei Jing’s description of “scraping bamboo”.

As mentioned above, this mantra has been repeated word for word for 1900 years, at least by the following translated writers [into English] available to me: Kaptchuk, P. 309; Wu Shui Wan P. 20; Deng P. 119-121; Li Shi Zhen P. 70, though Li then offers some significant dissent as we shall see.

A recent commentator on Wang states, [paraphrasing but exactly the same message], that `since there are differing etiologies and pathologies related to blood stagnation, there must be differing qualities related to the condition of blood stagnation.’

Each "differing etiology" of blood stagnation, and there are many, is represented on the pulse by a distinct and separate quality. And while these qualities may appear simultaneously with signs of blood stagnation, they are not in themselves the sign of that condition. As stated above, the signs of the etiology and the signs of the condition with which they are causally related are distinctly different. In fact, even more often, these signs appear with none of the accepted criteria required to diagnose blood stasis.

b. Blood Stagnation
i. Definition of Blood Stagnation
What then are the criteria, and when do we know we have blood stagnation? Where is the threshold? Wang does not give a definition. Neither do the neo-classicists to whom I will be referring in the following pages find it necessary to provide this foundation for their thesis.

Kaptchuk [204] discusses “Patterns of Congealed Blood”
He states “this is an excess Blood pattern and is the most important example in that category. It may be preceded by trauma, hemorrhage, Stagnant Qi [which cannot move the Blood, or cold obstructing the blood]. The primary sign of congealed blood is pain. This pain is different from that of stagnant qi because it tends to remain fixed and is a stabbing pain. Other common signs of Congealed blood are tumors, lumps and hard, relatively immobile masses. Recurring, frequent hemorrhages [because blood flow is blocked, causing “spillage”], hemorrhages with clots of a dark, purple tinge, the color of congestion, a dark complexion, dark purple tongue material with red spots and a choppy pulse all point to the pattern of Congealed blood.”

Since all pathology causes some blood stagnation, and therefore all qualities are inevitably inadvertent signs of this condition, where do we draw the line when we make the diagnosis and say, `this is a sign of, and this is not a sign of blood stagnation’. Surely that line is not Wang and his protagonists “fine and slow pulse, coming and going with difficulty and scattered or with an interruption etc”.
ii. Clinically Tested Types of Blood Stagnation
There are several types of Blood stagnation classified by location and by etiology. None have the “fine and slow pulse, coming and going with difficulty and scattered or with an interruption” features.
A. By Location
i. Blood Stagnation in the Tissues
This is the only one of which is signaled by a Choppy ["scraping bamboo"] quality.
ii. Blood stagnation in the blood
There is Blood Heat and Thick, Hollow Full-Overflowing, Ropy and Liver Engorgement.
B. By Excess and deficiency
In this regard, there are two kinds of blood stagnation recognized in the literature [Kaptchuk P. 309], that are due to excess and that are due to deficiency.

Kaptchuk stated that “a choppy pulse can have aspects of either Deficiency or Excess. If a choppy pulse is also weak or thin, it is a sign of insufficient Blood or Jing to fill the Blood Vessels. If it is strong, resisting the fingers, it is generally a sign of Congealed Blood Obstructing Movement.”

Up to this point Kaptchuk is making a useful distinction between the sign, the Choppy quality, and the etiology, “that due to excess and that due to deficiency”.

He then joins Wang Shu He and his apologists and muddies the distinction between etiology and the signs of a resultant condition by saying, “On rare occasions, a choppy, strong pulse can even point Dampness Obstructing Movement, which is the same signification carried by its opposite type of pulse [i.e. slippery]".

He further contributes to the muddle by associating the Choppy quality, a sign of blood stasis, with another quality when he says “Some sources include an irregular pulse, [“the three and five not adjusted”] under this type of pulse". Here he repeats Wang’s error of including the Interrupted pulse in his definition of Choppy.

Here we see the ongoing confusion of identifying the etiology of blood stagnation with the result, beginning with Wang, perpetuated through the ages and continuing with his current justifiers. But the quality that represents the cause is not the same quality that represents the consequence.

Naturally the signs of the etiology will appear with the signs of the consequence. We still require proof of the consequence. The presence of a possible cause in no way is evidence of a preconceived result. All of the qualities mentioned by Wang Shu-he and his descendants appear frequently with no clinical sign or symptom of blood stagnation.

What is the danger? Using Wang's definition, recently promulgated by his current enthusiasts, we would be treating a person with a pulse that is “fine and slow pulse, coming and going with difficulty and scattered or with an interruption etc.” with herbs and acupuncture, especially herbs, for blood stagnation, when all that their condition calls for are nourishing and stabilizing treatment. In such a person blood moving herbs can do great harm.

c. Detailed Critique
Let us examine the thesis of many qualities for one condition that Wang, parroted through the ages and revived by current proponents, are prepared to place before you as fact.
i. Formal and Structural Problems
The interpreters of Wang are taking words with different meanings and imposing one meaning on the other because the word is spelled the same. This is not logical and is an opportunist use of the English language. It is a syntactical error to confuse a defined pulse quality, one of the 28 or more depending on the source, with the same term used in a different context, one here which refers to something entirely different as I shall illustrate.
a). The Words are the Same and the Meaning Different
For example, one commentator takes `scattered’, which is defined in the dictionary as:

“To throw here and there or strew loosely: sprinkle; To separate and drive in many directions; rout; disperse; scatter implies a stewing around loosely [to scatter seeds] or a force driving apart in different directions.”
and the same word Scattered, which defines a distinct quality with a specific sensation and meaning. And because they are spelled the same, the analyst imposes the context of the quality Scattered on the term “scattered” used by Wang, which I have just defined.

This commentator draws the conclusion that since Wang uses the word "scattered" in his description of the Choppy pulse, the Scattered quality must be a sign of Blood stagnation.
[Even Wang makes the distinction by describing the quality Dissipated as “scattered”, though he never defines the sensation of scattered. We do not know what he means.

 The quality Scattered is described in absolute terms as follows:
“This quality is felt only at the qi depth where it is more indistinct than the Empty quality. Instead of feeling continuous, it disperses on pressure into separate pieces, as if divided. This is especially true when the fingers are rolled proximally and distally along the radial artery. With light pressure the quality gradually disappears and is totally indiscernible at the deeper aspects.” (See below for more about the Scattered quality).
The Scattered quality is primarily a deficiency of yang, especially Kidney yang. Li Shi Zhen [P. 92] states “the main cause of this pulse is deficiency and damage of yuan qi” and elsewhere speaks only of yang deficiency, of the heart, kidney and spleen. In fact he writes of “scattered yuan qi”. This sounds very similar to the concept of the `qi is wild’ that I learned from Dr. Shen and have described in an earlier article in the OMJ [Towards A Unified Theory of Chronic Disease With Regard to the Separation of Yin and Yang and `The Qi is Wild’]. There is no hint anywhere by Li Shi Zhen in his discussion of the Scattered quality of it as a sign of blood stasis.

b). Taking incidental similarities between the meanings of words to imply their coincidence.
Another example of the pervasive confusion of concepts follows in which terms are employed whose meanings are totally altered to fit an argument. These terms in reality have no relationship to each other in sensation or meaning.

For example: to the bumpy aspect of the rough Choppy quality one commentator attaches `Changing Intensity’, a specific quality in my pantheon of qualities, with a specific sensation and interpretation unrelated to blood stagnation except as a possible etiology. They are drawing upon the incidental fact that both qualities vary in height. With one, the Choppy quality, the varying heights are static. With the other, the varying heights are constantly changing.

The Choppy quality is relatively stable and fixed in terms of the vertical movement and has little of the restive wave activity associated with Changing Intensity. The fact that there are bumps of different stationary heights has nothing to do with the quality Changing Intensity and Amplitude described by me and Dr. Shen, as a dynamic movement up and down of the intensity and amplitude of the wave. There is nothing in the terms “scraping bamboo” or “a washboard effect” that suggests the movement that characterizes the oscillation inherent to the qualities Changing Intensity and Amplitude.
With regard to interpretation `Changing Intensity and Amplitude’ are signs in individual positions of the separation of yin and yang of the organ represented by that position, and never a clinical sign of blood stagnation. As already mentioned, in the presence of other criteria of blood stasis as outlined above, it could be considered as an etiology.

Again, we see signs of either a genuine thinking disorder or signs of deviousness when the meanings and sensations of terms are distorted to further the argument of multiple qualities for a particular condition, in this case, blood stasis.

The contention is that terms describing new qualities with distinct interpretations such as Changing Intensity are really aspects of another quality, the Choppy, pathognomonic of a totally different condition, and therefore are artificially contrived by me.

ii. Medical Problems
Once more and indeed there are many different qualities that signal a wide variety of conditions that lead to blood stagnation, but they are not signs that blood stagnation has actually occurred.

And I repeat, that all conditions will inevitably cause some blood stagnation. Therefore, potentially, all qualities that represent these conditions could erroneously be called signs of blood stagnation. Any combination of qualities with the Choppy quality are possible and occur.

A modern writer from mainland China, Lu Yubin [Pulse Diagnosis; Shandong Science and Technology Press; Jinan, China, 1996 P. 70-74] dissents from Wang Shu He. He states:   
“although the uneven pulse is often seen together with the thready pulse, the slow pulse, the short pulse, the scattered pulse, etc. in the clinic, they are not the basic factors constituting the uneven pulse.."[70]

Under "Differentiation of similar pulses" he states: "Since the uneven pulse is felt unsmooth, some doctors in the history have suggested that it has intermissions. But their suggestions are not accepted by most physicians, because the uneven pulse, unlike the pulses with intermissions such as the intermittent pulse, the running pulse and knotted pulse, has not abnormal intermission, although it is felt unsmooth.

The uneven pulse is also different from the slow pulse. The slow pulse is marked by the slowing of the pulse rate, beating three to four times in one respiratory cycle; while the uneven pulse, although felt hesitant, has a normal pulse rate. As the uneven pulse is often seen in critical diseases marked by loss of Blood, consumption of Essence, stagnation of Qi and Blood stasis, it often occurs together with the thready pulse, the slow pulse, the scattered pulse or the short pulse. So, in history, many doctors advocated that the uneven pulse should have the changes of pulse like reduce or increase of the pulse size [Intensity and Amplitude], irregular changes of the pulse rhythm, or abnormal changes of the pulse rate. However, the uneven pulse is only defined based on changes of the pulse in its shape, or the unsmooth feeling on pulse-taking, so an uneven pulse occurring together with other pulse conditions mentioned above only indicates coexistence of these pulses. In essence, the uneven pulse has not these additional conditions.” [P. 71]

Li Shi Zhen repeats Wang Shu He’s phrases in his opening statement on the choppy pulse, and then goes on to say something totally the opposite, essentially agreeing with Lu Yubin, Shen and me. Under `Comparisons,’ Li states that:
“The choppy pulse must not be confused with the scattered, intermittent or minute pulses”; “The choppy pulse has a “root” and although it seems to scatter, it does not. This is its primary differentiation from a scattered pulse.” The choppy pulse does not stop periodically, unlike the intermittent pulse. “The choppy pulse can be clearly felt at the floating and deep levels, unlike the minute”

Lu, and apparently Li, recognizes the need for a more complete differentiation of qualities to obviate the use of one quality term to describe several different conditions as occurred often in the past and so clearly with Wang She He as we have just seen. Wang Shu He said in the preface to his book, "The Pulse Classic" that "The mechanisms of the pulse are fine and subtle, and the pulse images are difficult to differentiate."

Based on Dr. Shen’ work I have attempted to make that differentiation that Wang found obviously so difficult as evidenced by his confused definition of the pulse associated with blood stasis.

a). Attempts to Redefine, Reduce and Trivialize Recent Advancements in the Differentiation Of Pulse Qualities
The following is a response to an attempt by some to equate Wang’s qualities as stated in the Pulse Classic to those described in Contemporary Pulse Diagnosis. The attempt was made to demonstrate that Wang’s description of the Choppy pulse as variously “thin and slow, coming and going with difficulty and scattered, etc.” is quality by quality the same as my own, in different terminology.  And the thesis is, therefore, that these specific qualities not directly associated with blood stagnation by me are actually just that, on the authority of Wang’s definition. As we shall see below, nothing could be further from the truth or more potentially harmful to patients. Those making the assertions do not wish to be identified. The following are some examples.

1. “Interruption” and `Changing Rate at Rest’
Kaptchuk, referring to Wang Shu-He’s “interruption” mentions that “some sources include an irregular pulse, which in any one breath beats a different number of times [`the three and five not adjusted’]. He says “this is important because there is no other pulse category that includes this irregularity."

The assertion by the neoclassicists is that Wang’s “interruption” is identical to what I call `Changing Rate at Rest’. An Interrupted quality misses beats which is not the case with the speeding up and slowing down of the `Changing Rate at Rest'. In my pantheon of qualities `Changing Rate at Rest' is a sign of Agitation of Heart Qi if it is occasional, and a sign of mild Heart Qi deficiency if is constant. Especially with the Agitation, the person has great mood swings and an unstable life-style [the `grasshopper mind’]. The Interrupted quality is a considerably more serious sign of Heart dysfunction, even if only occasional, with greater signs of fatigue. The first error is one of mistaken identity.

What is implied is that I have plucked from the past a sign of blood stagnation and assigned it a new name and interpretation. The argument they make is that `Changing Rate at Rest’ is a sign of blood stagnation rather a sign of Agitated Heart qi.
Again, it goes without saying that some blood stagnation occurs with every form of pathology. The `Changing Rate at Rest’ is a sign of Agitation of Heart Qi, which, while it could lead to some blood stagnation, the accepted criteria for such stagnation must be present. `Changing Rate at Rest' or “the three in five not adjusted” is not in itself an automatic sign of blood stagnation. Once more the etiology is confused with the result. Once more we return to question, what are the clinical criteria for blood stagnation.

First published in the Clinical Acupuncture and Oriental Medicine; Vol. 3 No. 1, 2002.

Endnotes to I and II.

1. Wang Shu He Pulse Classic: P.4
2. Oddly, The Yellow Emperor [the first to use the term “scraping bamboo”] (Ilsa Veith: P.159-160) does not mention anywhere that I could locate in her volume “fine and slow pulse, coming and going with difficulty and scattered or with an interruption”.

Wang Shu He [The first to use the term `Choppy’ as far as I am aware.] (P. 4) is the first to use the terms “fine and slow pulse, coming and going with difficulty and scattered or with an interruption” which is repeated by rote throughout the centuries.

Kaptchuk: P. 309
“irregular in rhythm. In this case it is called “the three and five not adjusted sometimes three beats per breath and sometimes five beats per breath” This is important because there is no other pulse category that includes this irregularity. Note: There is such a pulse category in the Shen-Hammer system called Changing Rate at Rest.

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