A Discussion on Wang Shu He Pulse Classic - Part Two
2. “Uneveness” and `Changing Amplitude and Intensity’
The Choppy quality has small `hills’ and `valleys’ as one rolls one’s finger along the pulse. One commentator mentions that since the `hills’ or “bumps” are of differing height, this is the equivalent of a quality I describe as `Changing Intensity or Amplitude’, which also varies in height. The argument is, therefore, that Changing Intensity and Amplitude are signs of blood stagnation because like the Choppy quality, there is a variation in height.
As mentioned above, 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 `hills’ and `valleys’ are stationary. `Changing Intensity and Amplitude’ are moving & dynamic which you can feel while the fingers are stationary, while with the Choppy pulse one need to roll the fingers to feel the differing heights.
There is nothing in the terms “scraping bamboo” or “a washboard effect” that suggests the movement that characterizes the movement inherent to the qualities Changing Intensity and Amplitude. Another case of mistaken identity.
Again, if the stability of the circulation is compromised there will be some blood stagnation. That does not mean that `Changing Amplitude and Intensity’ is a sign of blood stagnation. Endless times I have felt pulses whose Amplitude and Intensity are Changing and simultaneously in the same position have a Choppy grating to the finger like rubbing ones finger across a washboard.
Similarly, even more times, I have felt `Changing Intensity and Amplitude’, signs in individual positions of the separation of yin and yang of the organ represented by that position, and with absolutely no clinical sign or symptom of blood stagnation. Again, where, how and when do we determine the threshold of blood stagnation.
As indicated above, liberties have been taken with the word “scattered” attempting to equate it with the quality Scattered which Wang calls Dispersed. We have already said that the definition of “scattered” in the dictionary is: 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.
The Scattered quality has been described in the literature as an Empty pulse, one found only at the qi depth and not below, which, as one rolls ones fingers on the distal-proximal axis is discontinuous. This is very different from the rough stationary hills and valleys of the Choppy quality. And once again the false assertion is that the Scattered quality is by itself a sign of blood stagnation, this time by using a word with two separate meanings and imposing the meaning of one on the other.
I have heard it called “broken”. Because of its “broken,” discontinuous sensation, some practitioners mistake this quality for the Interrupted pulse. However, with the discontinuous quality it is the rhythm that is discontinuous. What is a disturbance in the continuity of substance feels like a disturbance in the continuity of cadence.
I have already said that the Scattered quality is primarily a deficiency of yang, especially Kidney yang. Li Shi Zhen [P. 92] says that “ 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 talks of “scattered yuan qi” which sounds very similar to the concept of the `qi is wild’ that which I learned from Dr. Shen.
One person asserted that the Slow pulse is a distinct quality of the Choppy pulse as opposed to the Rapid quality of the Slippery pulse. Since a Slow pulse is often a sign of Qi deficiency, especially of the Heart, the assertion was made that the Slow pulse is a distinct sign of blood stagnation, since a qi deficient Heart will cause circulation to decrease and stagnation to increase.
First, in reality, the Choppy pulse is not characteristically Slow or for that matter is the Slippery quality characteristically Rapid. It is just that the Choppy pulse is stationary and the Slippery pulse is moving. Either can and do appear with either Rate.
As for the Blood stagnation associated with excess in the blood, we have accounted for that with the Blood Thick quality which is one kind of blood stagnation mentioned above, [in the blood, not the tissues], but is not Choppy.
Secondly I, and others, have observed a Slow pulse without clinically relevant signs of blood stagnation of any kind. And while they can occur simultaneously, again, the aetiology is not the same as the result.
In the literature the term `Fine' is used synonymously with a confusing variety of sensations including Soggy, Faint, Weak, Thin, Thready and Small involving many disparate conditions. Using the term Fine which has so many different meanings is a step backward to confusion. I have replaced `fine' with several qualities each for the many different aspects of what is `fine' in the literature.
There is also a great clearly undefined overlap between Deng’s categories of String-like, Tight, Faint, Fine and Small despite his section of `Comparison and Differentiation’ with each quality. This confusion runs the gamut of the literature.
The `fine’ quality I call Thin because this is how it feels. There are two kinds of Thin pulse, one Thin and Tight [Blood and Yin deficiency], which is referred to in the literature as String-like [Deng]. The other is Thin and Feeble, or Blood and Qi deficient. It is the latter that Maciocia and others identify as `fine’, because it is not only Thin but also Yielding as `fine’ implies. They claim that this pulse is a sign of only qi deficiency, but clinically it proves to be just one kind of Thin quality, a combination of both Blood and Qi deficiency.
A paradoxical very Thin quality is a common finding in young men with severe chronic disease such as HIV and Aids, who are characteristically treated more for qi deficiency. The pulse says treat blood deficiency at least equally. It is long since known that blood deficiency can lead to blood stasis, but the stasis aspect still feels Choppy. The pulse feels Thin and Choppy. Again, someone is confusing aetiology with the consequences. The Thin [fine] quality appears frequently without the Choppy quality, or any other sign or symptom of blood stagnation, as defined above.
6. Changing Qualities
Another commentator makes the argument that each `bump’ of a Choppy quality differs from the other bumps regarding width and relative roughness and asserts that this is the same as what I, in a totally different context, have described as `Changing Qualities”.
There is nothing in the literature that states that the many sensations ascribed to the Choppy quality are constantly changing with each other, which this commentator is implying by using the term `Changing Quality’.
`Changing Quality’ is a term applied by Contemporary Chinese Pulse Diagnosis when in any one position, Principal or Complementary position, the qualities change from one to another. For example, at the right distal position we might have a Tight quality which shifts to an Absent quality and back and forth. This is a sign of simultaneous Yin [Tight] and Qi [Absent] deficiency of the Lung.
Once again, the commentator is confusing an etiology with a quality. The `Changing Qualities’ is a sign of separation of yin and yang, often due to severe qi deficiency, and blood stagnation could result, but because it can cause blood stagnation does not mean it is a specific quality for or sign of blood stagnation.
In a similar vein, with the modern neo-classicists, other qualities not mentioned by Wang or other classical writers have descended upon us as signs of blood stagnation.
a. Qi Stagnation
Another commentator reports that the Taut quality is a sign of blood stagnation. Indeed, qi stagnation does lead to blood stagnation. Again, this does not mean that the Taut quality is a sign of blood stagnation. Another instance of confusing the etiology with the consequence. For us to say that there is blood stagnation according to the Taut pulse, the pulse would feel Taut and Choppy.
b. Damp Heat
Still another opinion has it that since Damp Heat can cause Blood Stasis, and since Damp is often attended by the Slippery quality, therefore the Slippery quality is a sign of blood stagnation. With Damp Heat where are the signs of heat? Surely one would expect Pounding to be included as a quality in a discussion of heat, and given this curious logic would be counted as another sign of blood stagnation.
The slippage here is in logic, once more with the confusion of aetiology and the result. With stagnation of blood in the blood circulation we have the Blood Thick condition and pulse quality, attended usually by the quality which I have delineated as a sign of turbulence in the blood, the Slippery quality, but only when it appears at the blood depth.
c. Qualities Confused with the Choppy Quality
The sensation of the Choppy quality is sometimes confused with the Vibration quality. The former is a rougher sensation, the latter finer. However, the sensations of the Choppy and of Very Rough Vibration qualities are at times difficult to distinguish. When unable to make a clear distinction I sometimes call the quality Choppy or Rough Vibration depending on the location and the depth.
However, even the roughest Vibration has a more delicate quality than the least coarse Choppy quality. While “buzzing” is closer to the sensation of Vibration, “grating” more aptly captures the feeling of a Choppy quality, [which is the exact opposite of the smooth sensation associated with the Slippery quality].
While there are exceptions, an important distinction between palpating the Choppy quality on the one hand, and the Vibration and Slippery qualities on the other, is that to access the washboard sensation of the Choppy quality one has to roll one’s finger along the position. With the Vibration and Slippery qualities, the movement occurs while one’s finger is stationary on the position.
The contrast between the Choppy and Vibration qualities, in meaning as well as feeling sensation, more than warrants their division into two separate and distinct classifications. The Choppy quality is a sign of stagnation, primarily blood stagnation (and toxicity when felt over the entire pulse), and Rough Vibration is often a sign of severe physiological and parenchymal disorganization of the organ in which it is found (and Heart shock when felt over the entire pulse).
It is my contention, therefore, that Kaptchuk’s and Porkert’s ‘choppy strong’ pulse, by definition, is the same as my Choppy quality, and that their ‘choppy weak’ pulse is partially equivalent to my Vibration quality.
8. Reflection and Recapitulation:
A. Blood Stagnation Defined There are four kinds of blood stagnation, that due to excess and that due to deficiency, that in the blood [all excess: Blood Unclear, Heat and Thick, Ropy and Hollow Full-Overflowing etc.] and that in the tissues, excess and deficient. Those in the tissues all have the Rough Choppy aspect, but depending on the type of deficiency they can, for example, also be Thin (fine) [blood deficiency], Scattered [yang deficiency and yin and yang separating] or Slow [qi deficiency] etc., signs of simultaneous deficiency, but not themselves of blood stagnation.
B. Criteria for the Diagnosis of Blood Stagnation
If any of the qualities listed above and attributed to Wang appear without any of the accepted signs of blood stagnation [purple tongue, Choppy quality] or symptom [intractable pain] we do not have blood stagnation. None of the qualities listed by Wang Shu-he, or for that matter any other are essential to the appearance of blood stagnation except as Lu mentions, “the uneven pulse”. And he, referring to Wang’s list, unequivocally states that “In essence, the uneven pulse has not these additional conditions.” [P. 71]
C. The Danger
To treat for blood stagnation especially with herbs when there are no other concrete signs other than qualities that which inform us only of possible aetiologies, contradicts the basic precepts of Chinese medicine. Therefore, and most importantly to this discussion, if we treat using Wang’s and some neo-classicists identical list of qualities as if they are signs of blood stagnation with herbs that move the blood when there is no serious clinical sign or symptom of blood stasis, we may do the patient irreparable harm.
It has been my intention to analyse the thought process of the modern neo-classicists. The purpose is to demonstrate how, among other things, Wang Shu-he’s understandable confusion of aetiology with consequences is being currently perpetuated and reinforced, thereby setting pulse diagnosis back 1900 years without the benefit of the advances and distinctions made since.
What the traditionalists cannot accept is that this one remarkable man, 1900 hundred years ago, made an error when he was unable to make the distinction between qualities which are potentially associated with the aetiology of blood stagnation from those which are actual specific signs of that condition. For those who have a stake in justifying their investment in the classics it has been incumbent upon them to make them relevant to our time. Some of their attempts, such as those herein catalogued, are confused and dangerous to the unsuspecting who can be easily seduced by flowery metaphors feeding a hunger for tradition which the spiritually starved of our time crave.
This example emphasizes the need for the classics to be studied with a critical eye, tested clinically as well as logically and not be used without great discretion. I have tried to meet this need by re-framing tradition for our time and at least the near future, and make it practically available to modern practitioners. I am referring to Contemporary Chinese Pulse Diagnosis.
III. The Solution
Soulie De Morant stated the case concisely when he said "The knowledge of the pulses is absolutely indispensable for the practice of true acupuncture, which is based on treating the root condition. Using only memorized formulae and treating only visible problems does not constitute true acupuncture".
1. The decline of pulse diagnosis
Knowledge of Chinese pulse diagnosis has diminished steadily at least since the onset of the Qing dynasty and especially during recent past centuries. Consequently its capacity to perceive the earliest stages of patterns of disharmony and the process of disease is sharply curtailed.
Increasingly, Chinese medicine has lost the ability to serve its highest purposes, especially the power to predict and thereby prevent illness. Explanations have included the influence of the West and the gradual deterioration of an old civilization weakened and dominated by foreign less highly developed cultures.
However, a much more important reason is that the world has changed in remarkable ways since the eighteenth century and Chinese pulse diagnosis has not kept pace. The forces of nature, of hot and cold and wind; of ice ages and vast changes in climate; of volcanoes and earthquakes; of fire, flood, drought and famine; of the need for adequate food and shelter for which it might be necessary to fight. All these were the unchanging stresses to which we were subject and to which we were adapted for eons of time. And our medicine evolved to meet these exigencies according to the culture of the time as described in detail by Unschuld in “Medicine in China”.
In the past three centuries, the industrial and information revolutions have made demands on every aspect of our physiology, especially our nervous systems, demands that are remarkably sudden and cataclysmic. This has occurred to a creature, homosapien, who has evolved in a remarkably stable slowly changing cultural environment for at least the last ten thousand years, until three hundred years ago.
The human organism is constant, but the stresses to which it is subject have changed exponentially during these past three centuries.
Currently, pulse diagnosis relies on information gathered in a largely agrarian culture expressed in a largely archaic language almost incomprehensible to the twentieth century practitioner. What is available today is material passed down 1900 years from civilizations whose daily life is so variant from our own that the information is often no longer clinically relevant. The following is a quote from a book by Martin Prechtel, who lived in Guatemala in the 1970's and 80's, and studied with a Mayan shaman there. These words are some thoughts that Martin's teacher, Chiv, spoke to him: "If God gives us life and we continue as we have, someday when I'm a pile of ashes and the smell of smoke in your memory is all you have left of these days, then you will see situations and sicknesses never seen before. I've no idea what they may be; I have no way of recognizing them with our very old ways and traditional root. But you're the new one who's going to have to find special medicines to deal with them, instead of just using the old things because they're old. You must find new ways to do old things, and new medicines with old roots to cure the bad times made by new things”.
2. The mainland Chinese experiment
In the late nineteen fifties the Chinese government set up an experiment in which many well known masters of Chinese pulse diagnosis were asked to examine a patient. Their findings varied widely and pulse diagnosis was therefore considered to be an unreliable scientific diagnostic tool. Others have questioned its reliability because of the wide variety of pulse methods within the Chinese tradition and especially between the Chinese and other pulse systems used by other cultures such as the Tibetan and Ayurvedic where the positions are in great variance from the Chinese.
What is difficult to contemplate and absorb is that each of the Chinese masters who failed the government test and each different pulse system is correct, providing not contradictory information, but different information.
No one diagnostic system by itself is so highly developed that it can access the myriad messages being broadcast by a human organism. No single theoretical model of existence is capable of encompassing all reality. Each pulse system has developed within the framework of its culture and medical theoretical models to achieve a limited perspective of the whole. A pulse diagnosis based on a `five element’ model will be seeking different information and making different interpretations of what it finds from an `eight principle’ model or one such as the Ayurvedic which is operating within the system of fire, water, earth, air, and ether.
I reiterate that each individual system provides us with different but equally valid information. Collectively, pulse diagnosis is a reliable source of vital diagnostic data and a profoundly effective system of preventive medicine.
3. Senses, humanity and the machine
As the twenty-first century begins, those of you who have chosen to practice this profession are relatively unique in this culture. You have undertaken a task that operates largely outside of the burgeoning mechanical and electronic technology into which we have become more and more deeply immersed, especially during the past hundred years.
Those who require unity and a deep personal connection to their work through their senses as well as their intelligence, and for whom impersonal detachment is anathema, are people who will be drawn to and gratified by the practice of Chinese medicine. You, the practitioner, are traditionally the only diagnostic instrument. Your intelligence, intuition, experience, common sense and especially sensory awareness are the tools with which you access the inner human world.
One of the gratifying aspects of travelling and teaching is getting to know many of you who have made this choice. It is a privilege, as I get older, to draw upon your sincere energy, your vision of a more harmonious collaboration with nature, and your good will. All this has helped restore my faith in the possibility that the human race can retain its humanity.
Amber wrote that "The Chinese use sounds to describe their pulse findings; e.g., music of the lute; the rustles of the reeds." Though the sound associations of a twentieth century person will most likely be different from those of a second century B.C. physician, I find myself saying "I hear" rather than I feel, in reference to a quality on someone's pulse.
More to our point, Amber added that this is "a glorious symphony of the body to which some people are tragically tone deaf". Each of us is privileged to be born to a receptiveness to one sense in particular, and especially privileged to have the opportunity in our life, and especially through the medium of Chinese medicine, to develop the other senses.
E. In Summary
The Normal pulse is the most sensitive, reliable, existing indicator of good health. Of all diagnostic modalities, the pulse can give us the most precise picture of even the most subtle and complex deviation from this standard of health. The pulse record is an instant picture of the current status of a person’s voyage from birth to death. Clinically it preserves us from the distraction of and fruitless pursuit of symptoms and keeps us focused on the reality of the individual’s condition and being.
In addition, the pulse gives information about the events in a person’s life that which create this deviation from the Normal, allowing our client the opportunity to change their life and their habits, or adapt to constitutional deficits, in the direction of health. The precision of the diagnosis permits a rational therapeutic regime for the patient and as importantly is a tool for prognostication and prevention.
When practised with dedication, quiet patience and consistency, becoming attuned to pulse qualities is an ongoing meditation, a training ground for awakening and awareness, into total focus and concentration. As such, pulse diagnosis is an opportunity for practitioners to obtain the ultimate satisfaction of being one with their clients, one with themselves, one with the diagnostic process and perhaps one with the universal forces that which are expressed through the pulse.
For those who have a stake in justifying their investment in the classics it has been incumbent to make them relevant to our time. Some of their attempts, such as those herein catalogued, are confused and dangerous to the unsuspecting. Who is immune to flowery metaphors feeding our hunger for tradition that which the spiritually starved of our time crave? The danger, as we have seen, is passed on to our patients. Once again, this example emphasizes the need for the classics to be studied with a critical eye, tested clinically as well as logically and not be used without great discretion.
First published in the Clinical Acupuncture and Oriental Medicine; Vol. 3 No. 1, 2002.
Endnotes to II.
Wu Shui Wan P. 20
The movement of this pulse is felt as rough and choppy. It is not fluent. It is slow and thin. The wave of this pulse is short.
Deng P. 119-121
“it should feel slow and uneven, fine, small, short”
Li Shi Zhen P. 70 [See above for dissent]
“A pulse which feels thin, minute and short and has an uneven flow, beating three and five times with irregular rhythm, is called choppy.” “It feels like a knife scraping bamboo, rough and jagged. It is easily scattered like rain falling onto the sand. It also moves very slowly and at irregular depths, like an ill silkworm eating a leaf.”
Endnotes to III. 3.
J. Krishnamurti; Commentaries on Living 1st series; Edited by D. Rajagopal; A Quest Book; The Theosophical Publishing House, Wheaton, IL 1960 “Truth is the understanding of what is from moment to moment w/o the burden or the residue of the past moment”. Page 20
J. Krishnamurti; Commentaries on Living 3rd series; Edited by D. Rajagopal; A Quest Book; The Theosophical Publishing House, Wheaton, IL 1960 “The ways of tradition lead to mediocrity and a mind caught in tradition cannot perceive what is true. Tradition may be one day old or it may go back 1000yrs”. Page 3
“Everything about us is impermanent in a constant state of flux. Being aware of this the mind craves permanency. There is only one fact: impermanence”. Page 253 Wang Shu-he. Translated by Yang Shou-zhang. The Pulse Classic. Pp. 4. Blue Poppy Press 1997. Wang Su-he; The Pulse Classic; Translated by Yang Shou-zhong; Blue Poppy Press, Jan '97; Boulder CO. Soulie de Morant; Chinese Acupuncture; Translated by Lawrence Grinnell, Claudy Jeanmougin and Maurice Leveque; Paradigm Publications, Brookline, 1994. Rabbi Nachman, Rabbi Nachman's Stories, trans. Rabbi Aryeh Kaplan (New York and Jerusalem: Breslov Research I