Thought, History and Critique: An Appreciation of Chinese Medical Canon Relative to Pulse Diagnosis
Thought, History and Critique provides a critical analysis of Leon Hammer’s article, Tradition and Revision (2002), republished as Discussion on Wang Shu He Pulse Classic, Parts One and Two (2009a, 2009b). In this critique, I adopt three vectors of rhetoric. First, I discuss medical epistemology (how we think and build knowledge) relative to pulse diagnosis. Second is an exploration of canonical lore and traditions relative to medical knowledge. Thirdly I discuss contributions that Hammer has made to the field. He is a teacher with whom I taught and studied between 1993 and 2000. This paper continues a debate and provides a critique of commentary contained in what I will call Tradition and Revision for the rest of this article and where I address the two pulses that the author highlights, the tight pulse and the choppy pulse (2002). The three points of view of knowledge, history and critique are woven throughout this piece.
Matters of Thought: Can we really separate theory from practice?
Pulse diagnosis is not a purely pragmatic discipline where philosophical considerations have no import. Rather, theory and philosophy are critical as theory and practice have informed each other throughout the history of Chinese medicine as a medical science (see note 1). Theory helps people to make some sense of reality, enabling us to make assumptions and predictions about the world. It contains methods for selecting and arranging, prioritizing and legitimating what we see and do. The language of a theory can be used as a way of organizing and determining action (Smith, 1999). It helps us to interpret what is being told to us through the complex of signs and symptoms. Perhaps more importantly, theory helps us to deal with contradictions, uncertainties and resistances (p. 38).
In his Discussion on Tradition and Revision, which is also presented in Chapter 1 Preliminary Reflections: Tradition and Revision (Hammer, 2001, p. 3), Hammer divides the transmission of Chinese medical knowledge into two paths. One “abstract and highly theoretical court medicine,” and the other, “based on experience … that could not be recorded for posterity by the written word unless approved by the Emperor’s court physicians” (p. 3). Resolving this dualism and the valuing of family practices over the canonical literature, I make the assertion that there is practical value in both literary and family traditions.
We cannot separate abstract and concrete thinking for the purposes of valuing one form of knowledge over another. The act of pulse diagnosis involves both abstraction and pragmatic clinical applications. Correspondingly, it is important to acknowledge that the theoretical model is not the pulse, just as the map is not the territory (Korzybski, 1921). It is a form of naive materialism to assume a real external world that directly causes our perceptions (Petrilli & Ponzio, 2008). An example of this latter point is the way that a stick seems to bend when half is in water, and half out. Yet, we do use pulse models to inform inquiry and direct interpretation. Models can be useful tools, but the information obtained tends to be comprised of binary distinctions and are descriptive in a limited way. Further, knowledge evoked by models can become separated from experience and lost in reified concepts and theories. This may turn our attention away from direct inquiry and toward regarding the assumptions of the models themselves as more real than their subject (Tulku, 1984). The point here is that the risks and benefits of models are shared by both family practices and those rooted in literary traditions.
Pulse diagnosis methods are subject to the same vulnerabilities as any other model or map, in that they are constructions of reality. The difference is that Hammer’s construct provides an anatomical map, whereas, the canonical literature is built in part from a plural conceptual framework that involves content such as the Shang Han Lun, five phases, six divisions, channel theory and the cycles of essence, nutrient and protective qi.
It is important to have a critical understanding of the tools for inquiry, not just the obvious ones that fit our world view, but also to consider those that make us feel uncomfortable, which we avoid (Smith, 1999). For instance, if one were to have bias along the lines of this debate, Hammer’s construct has little capacity for analyzing the involvement of the eight extraordinary vessels or the six channels. By the same token, Wang’s eight extraordinary vessel methods are not very helpful for diagnostics relative to cardiopathology. The ability to select the correct tool for the job has impact on outcomes.
The Difficult Classic (Nan Jing) was the first text to specify the radial artery at the wrist as the primary location for collecting pulse diagnosis data, and contains 22 chapters focused on pulse diagnosis. The Difficult Classic (Unschuld, 1986b) is a relatively homogeneous work when compared to The Yellow Emperor’s Classic (Huang Di Nei Jing) (Wu & Wu, 1996), which is an often self-conflicting and heterogeneous body of manuscripts. The Difficult Classic (Nan Jing), however, consistently applies a doctrine of correspondences in which seasons, organs, emotions, pulses, and other factors are correlated systematically (Unschuld, 1985). The Difficult Classic (Nan Jing) provides the core theoretical basis for contemporary Japanese acupuncture practices.
During the late Han Dynasty (c. 200 CE), Zhang Zhongjing compiled one of the greatest formularies in the history of Chinese medicine. His manuscript, the Damage by Cold and Miscellaneous Disease Treatise (Shang Han Za Bing Lun) was eventually split into two documents, the Damage by Cold Treatise (Shang Han Lun) and the Synopsis of the Golden Chamber (Jin Gui Yao Lue). Although these two texts deal primarily in Chinese formulary, they are also representative of a highly skilled and experienced practitioner’s record of pulse diagnosis. In creating the Damage by Cold Treatise (Shang Han Lun), Zhang Zhongjing, combined the schools of medical thought that were based upon the Book of Changes (Yi Jing) with the oral traditions (Jing Fang). This led to a six-channel description of pathophysiology and a corresponding herbal formulary. Zhang’s work revolutionized practice. Zhang’s synthesis of family based knowledge and a literary tradition remains an important area of focus for contemporary scholar-physicians. Without a strong basis in both Book of Changes (Yi Jing) theory and access to the practices of oral traditions, Zhang Zhong Jing would not have compiled the Treatise on Damage by Cold (Shang Han Lun) and the Golden Cabinet (Jin Gui Yao Lue).
The practices that are based upon literary traditions of Chinese medicine have strong ties to imperial traditions. State officials had the influence to collect manuscripts and information from family traditions and knowledge passed through apprenticeships. Wang Shuhe was such a state official working in the Han Dynasty (c. 200 CE). His writings were kept somewhat intact and received few changes from later authors because of the credibility his work enjoyed due to the wide-ranging and authoritative collection of work in that time frame (Miki Shima, personal conversation, March 2008). Some of the most significant contributions to Chinese pulse diagnosis literature were made during that period of time, including the Difficult Classic (Nan Jing) (Unschuld, 1986a) and the Pulse Classic (Mai Jing) (Wang, 1997).
The Jin-Yuan Dynasty medical reforms sustained through a synthesis of canon and family lineage. We can locate similar stories regarding the family lineage attributed to Liu Wan Siu (Wu, 1993-94). In this article, Wu translates a quote from Liu Wan Su in the Su wen bingji baoming ji:
When I was twenty-five I directed my aspirations to the Inner Canon. Day and night I never put the book aside. When I was nearly sixty I chanced to meet a celestial man, who gave me a beautiful wine to drink. I had only about a chestnut-hull’s full, but my face turned red as though I were drunk. After I woke my eyes were perceptive and my mind keen; I had been greatly illuminated.
Liu’s statement demonstrates a life steeped in classical lore prior to transmission from his teacher. His enlightenment had a foundation. Whether this foundation is contemporary state sanctioned programs, family practices or classical literature, there must be a basis for the illumined practice of medicine.
The Yellow Emperor’s Classic (Huang Di Nei Jing), the Yi Jing and the Difficult Classic (Nan Jing), provided Li Dong Yuan a foundation for the creation of the Spleen Stomach Classic (Pi Wei Lun) in the context of family lineages. The flourishing of both direct transmission and the canons of Chinese medicine led to a new body of written lore.
A contemporary example of synthesizing family lineage and classical lore is the work of Young Wei-jieh. He is the senior disciple of Master Dong and has a PhD from Beijing University of TCM in Shang Han Lun. Young is a master of Yi Jing theory and remains influential for both Chinese and Western practitioners.
There are many more contemporary practitioners who employ the canons of Chinese medicine safely and in an inspired fashion. Here is an incomplete account of the current standards of practice with respect to the use of canonical literature. There are the current lineages of Kanpo practitioners. This lineage is rooted in the Shang Han Za Bing Lun – the Treatise on Damage by Cold (Zhang, 1999) and Miscellaneous Diseases (Golden Cabinet) (Zhang, 1995). The Kanpo system is covered by government insurance programs in Japan. There are numerous Kanpo practitioners in Japan, US, Europe and other parts of the world such as Australia.
As for the Japanese acupuncture tradition, it is rooted in the Nan Jing (Difficult Classic . Schools based on the Difficult Classic include the Toyo Hari and Shakuju systems (Kobayashi, 2001). There are other practitioners who base practice upon the canons such as Kiiko Matsumoto, Koui Kouahari, Shudo Denmai (Denmei, 2003), Ikeda Masakazu and Stephen Birch. Tran Vietduc’s students all practice on the basis of classics. The Academy of Oriental Medicine at Austin (AOMA) also has course work in the core curriculum that involves the Yellow Emperor’s Classic, the Treatise on Damage by Cold and the Golden Cabinet, taught by doctorally prepared faculty from Chengdu TCM University. Other US institutions that make classical studies available as core curriculum content: Southwest Acupuncture College (SWAC) and the New England School of Acupuncture (NESA) pursue classical studies in the Japanese traditions focused upon the Nan Jing. Further, The National College of Natural Medicine (NCNM) also has a program focused upon the classics. Thus, there appears to be a standard of practice in the field with respect to the application of the canon in clinical practice.
Whether the knowledge presented is from state approved programs, classical literature or clan based thought, it is important for me to deconstruct that which is presented. My preference in subsequently building knowledges related to practice, is a triangulation between the three rivers of classical literature, family lineage and contemporary practices of medicine, identified by Volker Scheid in Chinese Medicine in Contemporary China: Plurality and Synthesis (2002). Through a participatory world view, I seek to validate the work by cycling between a contemplative hermeneutic analysis of the literature, practice, teaching, peer dialogue and publications. These processes protect against the many distortions that can occur from a mono-view in the transmission of knowledge. This shift of perspective provides depth of perception and reduces errors of assumption (Bateson, 1979).
The Rough Pulse (sè mài) and the Tight Pulse (jǐn mài)
We now turn to the literary and practical discussions of two pulse diagnostic images, the tight and the choppy pulses (see note 2). Based upon my study and practice of pulse diagnosis since 1980, combined with a critical analysis of the literature, I present a perspective distinct from that put forth in Tradition and Revision.
Hammer seeks to abandon the complex for the simple image of the rough pulse. In his words: “Based on Dr. Shen’s work I have attempted to make the differentiation that Wang found obviously so difficult as evidenced by his confused definition of the pulse associated with blood stasis.” Yet, Hammer does not address the same complexities that Wang Shuhe pursued for a pulse that represented qi, blood and essence depletion along with blood stasis. It would appear that Hammer is not using the same criteria for sign, symptom and pathology as Wang. This, the notion that Wang is confused becomes a matter of perspective.
Lu Yubin is also an advocate of the simple rough pulse (sè mài) image, and Hammer turns to him for support, “though 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." These are important distinctions; not one of these features is salient to a rough pulse (sè mài). Lu goes on: "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” (1996, p. 70). This is also important since the rough pulse does not refer to the arrhythmias. Lu, however, uses a tautology, defining the uneven pulse as unsmooth, in the end providing no solution for the problem of definition for the rough pulse (sè mài). The question remains, what aspect of the pulse is rough?
The historic use of the term rough had two common interpretations, blood stasis and depletion of essence, qi or blood. There are complexities that qi, blood and essence depletion with blood stasis create in the pulse presentation. From my perspective and in my experience, such conditions affect the shape, state and timing of various features in the pulse and the state of unevenness may occur in any of these three domains. Wang’s depiction of the rough pulse is consistent with blood stasis and essence depletion. Hammer’s assumptions hold up only if the interpretations of the rough pulse are limited to certain forms of blood stasis. The debate remains, however, and the description of the rough pulse (sè mài) requires further dialogue within the Chinese medicine community.
Here, we address the tight pulse (jǐn mài), which is an essential quality for identifying cold pathogens in pulmonary conditions, women’s health, gastro-intestinal and other conditions where cold pathogens may be latent or expressed. The tight pulse (jǐn mài) has these features: it strikes tightly, and with force, its strength is like a twisted rope, unevenly stretched, and snapping back and forth. Tietao Deng quotes from the Zhen Jia Zhi Jue suggesting that the cold evil causes the vessels to contract and the pulse becomes small and firm “shaking is a trembling movement, snapping back and forth, with a force like a twisted rope; with pressure it is like rolling, not even, but with bumps” (Deng, 1999, pp 128). The theme can also be found in the writings of Li Shizhen, “the tight (jin mai) pulse is either pellet revolving or twisted like a rope or without taking a side” (1999). Deng quotes Li Zhong Zi, “A tight pulse has force, it snaps left and right, like a large twisted rope, or a tight cutting string” (Deng, 1999, p 29). In my experience, the ability to identify the tight pulse (jǐn mài) is critical for the purposes of identifying the presence of cold pathogens.
The ‘Tight’ pulse employed in Tradition and Revision is not the conventional tight pulse (jǐn mài). Hammer describes the ‘Tight’ pulse as a “totally new category, which most clearly corresponds with wiry in the literature.” Further:
The Tight quality may be best identified as feeling like the next to the thinnest A string on a violin. (The thinnest E string is descriptive of the wiry pulse.) It is harder, less resilient and flexible, and usually thinner than the tense quality. However, it still has both some flexibility and resilience, in contrast to the Wiry quality, which has neither. With pain, the Tight quality has a sharper, biting quality (Hammer, 2001, p. 337).
The ‘Tight’ pulse that Hammer describes does not suggest the presence of a cold pathogen. Yet, a conventional tight pulse (jǐn mài) does suggest the presence of cold, even in complex cases where heat transformations have begun. For the pulse that Hammer refers to as ‘Tight’, we might draw descriptors from the more common bowstring pulse (xián mài) series. Shen’s distinctions were more closely aligned with conventional practices. They are the replete bowstring pulse (shì xián mài), deplete bowstring pulse (xū xián mài), and moderate bowstring pulse (huǎn xián mài), (see note 3).
Hammer’s characterization poses a conundrum that is furthered by his interpretation, “The Tight pulse is no longer a sign of internal cold, in our time it is a sign of an overworking nervous system” (2001). If we take as a basis for practice, the tight pulse to be that which most clearly corresponds with the wiry pulse (xián mài), then what image is used to identify the presence of a cold pathogen? What shall we use to translate the term jǐn mài, which is a common clinical presentation? Without the tight pulse (jǐn mài) to which Deng, Zhen and Zi refer, we do not have an effective method of identifying the impact of cold pathogens. This is a loss for clinical epistemology because cold is a common occurrence and can easily be identified by those who have experienced and understand the salient features of the tight pulse (jǐn mài).
Hammer conceives of his project regarding classification and nomenclature as an attempt to relieve confusion and discouragement for the learner. His laudable goal is to “present a uniform nomenclature based upon sensations easily recognized by those familiar with the English language” (2001, p. 6). This project has similarities to the world view of logical positivism, (see note 4). Hammer’s method has integrity for those who operate in the clan, and poses problems for translation for those operating with the professional-technical language of Chinese medicine.
Hammer makes excellent points, such as verification of the pulse images that one works with. He also makes significant contributions to the practice of pulse diagnosis. Among these are the “ropy” pulse for characterizing damaged vessel walls, the “cotton” or “sad pulse”, and Shen’s anatomical model. My purpose in this statement is not to be thorough, but rather to highlight a few of Hammer’s contributions.
He seeks to clear up what he calls Wang Shuhe’s confusion regarding the “Choppy” pulse. He distinguishes what he considers to be a mistaken and dangerous amalgamation of distinctly different qualities and reduces them into one. The dangers that Hammer poses regarding Wang’s conception of the rough pulse (sè mài) require an assumption that professional practitioners of Chinese medicine make clinical decisions based upon a single sign. To do so, however, requires the practitioner to abandon standards of practice. While there are stories of practitioners who perform miraculously on the basis of a single sign, this is the exception rather than the rule. Were one to practice using Hammer’s assumption of diagnosis based upon the single sign, the medical-legal risks that Hammer identifies would remain for users of his system, just as they do for those who adopt the standards of practice as taught in the core curriculum of the major Chinese Universities and schools of acupuncture and Chinese medicine throughout the US. Rather, the single sign presents an opportunity for further inquiry in the critical analysis of a properly conducted history and physical. This with appropriate referral is the professional and safer way to practice.
Additionally, there are findings for which Hammer has no discussion. Yet, there are methods that permit making meaning about those events. Take for example, distortions of the radial artery towards the radius in the right distal (cun) position. While Hammer does not interpret this finding, this event may be assigned meaning and has potential clinical benefit. Such a distortion may be interpreted as accumulations and depression in the tai yang channel (this can be musculoskeletal problems located along the trajectory of the Urinary Bladder and Small Intestine Channels), or an involvement of the yang wei mai if the trajectory of the vessel is transverse. Further, if we employ the compass model, the metal is assigned to this area, and since it correlates with the lung, it relates to a metal imbalance within metal, where one would select the metal point on the metal channel which is the “channel ditch” (jhan qú, LU 8), and the pulse tends to centralize (Morris, 2002a, 2002b, 2003). Single findings have meaning in the context of a larger field of assessment and are useful only to the degree that they improve clinical outcomes.
As both Hammer and I have established in different language, models are abstractions that are used to parse reality into meaning, yet, they are necessarily incomplete. This is true of the Menghe-Ding family anatomical model as taught by Shen and Hammer, just as it is true of the models located in the canonical traditions such as the eight extraordinary vessel and six division pulse systems of Wang Shuhe.
Hammer has spent time on the teachings of John HF Shen, biomedicine and psychiatry. He admits no time to the study of canonical literature, yet, claims the authority to affirm that, “clinically there is no contest between the efficacy of these verbally transmitted traditions and often mystifying classics.” In my opinion, such judgment has greater weight when rendered by scholars who have studied the relevant points of view. Thus, the voyage into commentary on classical literature by a practitioner who acknowledges no experience with or attention to the matter poses problems when it comes to a critique of the canonical literature.
Hammer’s attempt to create a new nomenclature was performed without participation with stakeholders within the field of acupuncture and Chinese medicine. This is not a problem for pulse images that are unique to his system. Nor is it a problem for those who choose to think inside his methods. However, if we are to arrive at a nomenclature that functions for a wider community, there must be a public dialogue. What is needed here is a participatory and co-operative form of inquiry with respect to policy and knowledge building for the profession. The profession at large must have a voice in the development of the languages that compose practice. Through such methods, new knowledges can be built in a way that sustains the current dialogues.
Will Morris has a master degree in medical education, a doctorate in acupuncture and Oriental medicine and a PhD in transformative studies. He has developed two doctoral programs in acupuncture and Oriental medicine and two institutional review boards. As president of the AAOM, he was part of the unification movement that led to a single national professional association in the US. With an academic focus on the subject of pulse diagnosis since 1980, he is the founder of www.pulsediagnosis.com. Dr. Morris also serves as president of the Academy of Oriental Medicine at Austin (www.aoma.edu), where he has special programs and clinics devoted to the study of Chinese pulse diagnosis in early and contemporary forms.
Note 1: I define science as an applied and systematic abstraction of phenomena, using qualitative and quantitative means. This definition could provide indigenous ways of knowing a presence in scientific dialogues, and may help to decolonize the discourse.
Note 2: As a point of clarification, the pulse that Hammer calls choppy, I translate as the rough pulse (sè mài), which conforms with Nigel Wiseman’s glossary (Wiseman & Feng, 1998). I use the term choppy when identifying Hammer’s idea. Further, I do not use Wiseman’s term vacuity for (xū), rather, I use depletion.
Note 3: I use the term bowstring pulse (xián mài) here in order to separate the discussion from Hammer’s use of the term wiry, since his application is idiosyncratic to his nomenclature, referring to what is more commonly called a thready bowstring pulse (xì xián mài).
Note 4: Logical positivism, also called logical empiricism: the idea that all knowledge should be the project of "rational reconstruction," in which ordinary-language concepts are to be replaced by more precise equivalents in that standard language (here, it is the confused translations of Chinese medicine that are replaced). Until the 1950s, logical positivism was the leading school in the philosophy of science.
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