TCM Diagnosis

I recently gave a free in-depth introductory webinar on pulse diagnosis. We have since published it on Youtube:

Pulse diagnosis is a signature diagnostic method used in a number of traditional healing systems, notably Traditional Chinese Medicine (TCM), Ayurveda and Unani Greek medicine. In all of these traditional healing systems, mastery of pulse diagnosis is considered the pinnacle of diagnostic achievement. This is so much so that it is not uncommon for Chinese people, especially of the older generation, to hold their arm out for the physician to “read” their pulse before telling the physician anything about their complaints and symptoms.

The pulse may indicate current disease patterns but also serves as a reading of the overall vitality of a patient, and as such is considered a “root” analysis of underlying causes rather than a “branch” indication of current symptoms. Some expert pulsologists claim to be able to identify current pathologies including detecting the gender of an unborn fetus. In my experience, I find that such minute diagnostic indications are highly questionable; in fact, when a number of so-called pulse experts examining the pulse of patients with known diseases are held up to scrutiny, there is statistically little concurrence.

This does not mean that pulse diagnosis is of no clinical value. If this were so, than we would not find many of the same pulses used in TCM having corroborative significance by trained Western medical doctors.

For example, despite the increasing tendency for contemporary Western medicine to rely on more objective, technological criteria, it still gives significance to a fast (more than 90 beats per minute (BPM)) as opposed to a slow pulse (60 or fewer beats per minute). This is usually noted along with a current blood pressure reading at each office visit.

So what does a fast pulse mean clinically? Tachycardia, or a fast pulse, may point to an increased risk of stroke, sudden cardiac arrest or death (along with other clinical indications). It means that body metabolism is abnormally increased; based on other presenting symptoms, this can indicate inflammation or fever. In Ayurvedic medicine this is associated with excess Pitta or fire energy, while in TCM it is an Excess Yang condition.

Bradycardia, or a slow pulse (less than 60 beats per minute), can either indicate a high degree of fitness because the heart, which is a muscle, does not have to work so hard to do its job. On the other hand, it can be a sign of fatigue, low energy, low metabolism, and low thyroid. Most men and women 65 or older are most likely to develop a slower heart rate and may, from a Western medical perspective, require medical intervention such as the use of a pacemaker. While Western medicine describes most cases of bradycardia as a weakness of the heart’s electrical system, traditional Chinese medicine similarly views it as a deficiency of Heart Qi (if the cause is not Qi or Blood stagnation). Instead of a pacemaker, the Chinese physician would prescribe herbal Qi tonics such as ginseng or astragalus. Ayurveda would see it as an indication of low prana, also meaning vital energy or Qi. Western herbalists commonly recommend cayenne pepper and Hawthorn berries and leaf.

Individuals with an abnormally slow heart rate not due to athletic fitness may find it harder to exercise without feeling out of breath, confused, having trouble concentrating and with occasional bouts of dizziness or lightheadedness.

The rule here is that one does not make a diagnosis from only one symptom (slow or fast pulse), but other factors need also to be considered. In TCM, pulse diagnosis is only one of Four Diagnoses, namely interrogation, observation, listening to bodily sounds and palpation, which includes pulse diagnosis. This is part of what all good doctors, whether conventional or traditional, evaluate as part of a comprehensive approach to differential diagnosis. The most important training of a doctor or healer is the ability to know and implement a number of diagnostic signs and symptoms rather than relying on only one parameter. The same is as true for a Western medical doctor who relies solely on X-rays, sono-grams, MRIs or any other high-tech diagnosis as it is for alternative/complementary healers who use only chance-based systems such as kinesiology or overly simplistic methods such as iridology.

The point I hope to raise here is that by cross-checking various diagnostic systems based on Ayurvedic, TCM and Western conventional medicine, it will be possible to demystify pulse diagnosis. While it is true that proficiency requires many years of experience, the basic elements of pulse diagnosis are a lot more objective and therefore simple than many proclaim.

Pulse Speed

The method is simple. Simply count the number of beats per 30 seconds and multiply by two. With that you’ve easily succeeded in narrowing by one the total number of 28 pulse patterns that a skilled TCM clinician needs to learn.

Irregular Pulses

After determining speed, the next most objective quality to determine is pulse regularity. From a Western perspective, the following pulse qualities are irregular:

Regular Pulse or Heart Beat Irregular Pulse or Heart Beat
Steady and even Unsteady and uneven
Beats in a constant fashion Inconstant
Like the ticking of a clock Ticks erratically
Even pattern of beats Uneven pattern of beats
Uniform beats Many missed or extra beats
Same strength to each beat Some beats are stronger and some weaker

When checking the pulse for an irregular heartbeat one pays attention to whether the beats are evenly spaced and steady along with rate, or how rapidly or slowly the heart is beating. A normal heartbeat should be so regular and constant that one can predict when the next beat will occur. An irregular heartbeat is described medically as atrial fibrillation (AF). With AF, there may be may skipped, or extra beats and in all but one instance, one cannot predict when the next beat will occur.

Following is the pattern of a regular pulse represented by dashes.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Following is the pattern of an irregular pulse.

__ _ ___ _ _ _ ___ _ _ _ _ _ _ __ __ __ _ _

Notice how the beats are unsteady and uneven in frequency. You can see missed or extra beats and the interval between the beats is irregular and unpredictable. Also notice how some beats represented by a longer dash are stronger than others.

An irregular or uneven pulse could be the norm for a particular individual, or in the context of differential diagnosis, it can be an indication of an impending stroke. In TCM, an irregular pulse beat is an indication of either Deficient Qi or stagnation of Qi or Blood. Herbally speaking, these conditions require the use of herbs such as ginseng, codonopsis, astragalus or ashwagandha to augment Qi; or herbs that promote blood circulation, such as the anticoagulant Ayurvedic guggul, (which I believe to be the safest and best herbal compound for everyone 60 years or older to be taking on a daily basis). TCM prescribes anticoagulant, Blood-moving herbs such as tienqi or sanqi ginseng (Panax pseudoginseng) or Salvia milthiorrhiza (dan shen). Western herbalists most commonly prescribe garlic and/or hawthorn berries and leaves. Supplements such as nattokinase or serrapeptase may also be useful. In most cases, these are a heck of a lot safer than Western pharmaceutical blood thinners.

In TCM there are four irregular pulses.

Hasty pulse (Cu Mai) Fast and irregular, 80 BPM or faster with skipped beats. It indicates Qi and/or Blood Stagnation with excessively high metabolic effort.
Knotted pulse (Je Mai) 60 BPM or slower and irregular. It indicates low metabolism, low energy with Qi and/or Blood Stagnation.
Intermittent Pulse (Dai Mai) Comparatively relaxed and weak but stops at regular, intermittent intervals. These intervals can be remarkably long. It indicates Qi and Blood Deficiency and is common with tired and worn out old people.
Scattered pulse (San Mai) Floating, large, without root, easily changeable, becoming scattered and chaotic and disappears with heavy pressure. Therefore it is a variation of a floating or surface pulse. It indicates Qi and Blood Deficiency and weakness.

In addition to the above, there is the choppy pulse (Se Mai). While not considered an irregular pulse per se, it nevertheless partakes of a number of the irregular attributes. It is traditionally described as a ‘knife scraping on bamboo.” Most of us have little relationship with bamboo compared to the ancient Chinese, so it is difficult for us to imagine what this might be like. The uneven quality is apparent with a slight tendency to speed up and slow down and/or beat with slightly irregular strength. Since it is fundamentally a condition of deficient Blood, the pulse is always fine so any experience of unevenness is the result of Blood Deficiency such as the unevenness of a trickle of water in a drying streambed. Here the need is to both supplement and assist Blood to move. The major herb used in TCM for this is dang gui usually as part of the formula called Dang Gui Four (Si Wu Tang).

To envision the quality of the choppy pulse, imagine yourself trying to walk uphill with someone who is more fit than you are. Don’t you find yourself occasionally trying to scoot along occasionally, or breathing more deeply with the effort? Unevenness in terms of impulse of each beat as well as slight occasional rate, is what I think best characterizes both the description and meaning of the choppy pulse. It takes a little more effort to learn to recognize it and when combined with other qualities such as pulse rate and depth, it is clinically worth the extra effort to identify it.

Comparing pulse diagnosis with traditional pulse variations of Western clinical medicine helps to demystify this vitally important ancient diagnostic modality by offering a more objective Western medical perspective. Click on for a list of Western biomedical pulses and definitions. Among these you will find described with different terms, many or all of the same pulses of TCM and Ayurveda!

If you are interested in learning pulse diagnosis, make a commitment to feeling several pulses each day even if some of them are on the same person. First begin by ascertaining the most objective criteria of pulse rate and regularity or irregularity. From this you will eventually come to ascertain some of the other 28 pulse qualities which I will teach in subsequent blogs and webinars. These involve factors such as strength, depth, form and placement.

Leave a Reply