Pulse Diagnosis in Chinese Medicine – Starting A Modern Scientific Method

Chinese Medicine is as much an art as it is a science. One of the strongest values of Chinese Medicine is how a practitioner can look deeply into each patient and find the causal factors driving their illnesses and tailor a treatment directly to them. There is an intuitive part to this, an artistic part and a scientific part – all of which are fostered by training and clinical experiences.

To uncover and ultimately treat these underlying diagnostic “patterns” the Chinese Medicine practitioner utilizes many diagnostic tools. The most common ones are described within the “examinations and diagnosis” section on our theory site.

Of these tongue diagnosis and pulse diagnosis are arguably the most important and most clinically valid. Tongue diagnosis has the benefit, in my opinion, of being far less subjective – in other words more practitioners will see the same things on the tongue in the same way when compared with how they might come to different conclusions with the pulse. The pulse, however, will show a wider range of imbalances and can be extremely useful in deciphering the root of mixed patterns.

In pulse diagnosis you are looking for certain qualities of the pulse (not just rate as most would assume). So terms such as “slippery”, “wiry”, etc. are used in conjunction with certain pulse positions. There are a few alternate pulse positions to check on the wrist and then others elsewhere on the body. A common positional understanding includes 3 positions on each wrist along the radial artery starting behind the wrist crease. On the left wrist closest to the crease you see relationships with the heart system, the liver behind that and the kidney behind that and on the right wrist you have the lung system at the crease, the spleen system behind that and the mingmen behind that.

Left Wrist Right Wrist
Cun (inch) - 1st position HT / SI LU / LI
Guan (barr) - 2nd position LV / GB SP / ST
Chi (foot) - 3rd position KD / UB Mingmen / Lower Burner

A basic diagnostic example might be as follows: For someone that we might reference as “stressed out” in the west – they might have what we call “liver qi stagnation” in Chinese Medicine. We wouldn’t, however, just assume they have this diagnosis because they describe being “stressed out” (see “treating the cause and not the symptoms” for more on this) – we would come to this conclusion from using all of the diagnostic tools referenced above. Their tongue might be purple which can indicate “stagnation”
particularly on the sides which is the “liver” area on the tongue, and their pulse might be “wiry” – particularly in the 2nd left wrist position which correlates with the liver system. That, of course, is a very simplified example.

Now one of the problems with pulse diagnosis as I hinted at above is that it can be quite subjective once you get beyond the more simple cases. You could line up 50 tcm doctors and have them all look at the tongue and pulse and with the tongue you would (just guessing here) get probably 40 out of 50 in agreement with only mild nuances differing, but with the pulse you might get 10 out of 50 – partially because it is offering more information admittedly and there are different systems of correlations. But, in my experience and opinion, it would be different (an interesting study to perform for those researchers that might be reading this).

To compensate for this arguable lack of precision a group of researchers from Taiwan recently conducted a study looking at more scientifically measurable pulse variations and trying to group them into diagnostic categories. Involving researchers from the division of cardiology at the Chang Gung Memorial Hospital and the Institute of Traditional Medicine at National Yang-Ming University among others they aimed to correlate a range of pulse wave parameters and heart rate variability with standard TCM diagnoses.

To perform the study they recruited 69 relatively healthy volunteers and utilized a wrist blood pressure cuff called “ANSWatch” and obtained pulse readings at the left guan position (the liver area). Utilizing a range of measurements including blood pressure, augmentation index and subendocardial viability index they tried correlating these to each volunteers diagnosis in Chinese Medicine terms.

The researchers found:

  • Those with qi deficiency had higher augmentation index scores and lower diastolic blood pressure.
  • This with yang deficiency had lower systolic blood pressure, lower pulse pressure and lower dP/dt max (a measure of ventricular contraction strength).
  • This with damp-heat had higher subendocardial viability index scores.

Now there are a million caveats with a study of this nature all indicating that there is much more research to be done before this would lead to clinically valid ways of obtaining or helping to confirm diagnoses in Chinese Medicine. But this is a nice approach to using modern western diagnostic tools with time proven traditional medicine tools. Particularly since proper diagnosis is so crucial within Chinese Medicine to obtain the best clinical outcomes.

Tongue Diagnosis – Study Explores Changes During Menstruation

theory-tongueThere are many diagnostic signs that are explored within Chinese Medicine when forming a diagnosis and treatment plan.  Two of the most important are pulse diagnosis and tongue diagnosis.  With tongue diagnosis we are looking at changes that your body describes by altering the body color, coating thickness and color and other aspects of the tongue.  These changes guide your practitioner to better understand how well your body is functioning internally and can help clarify complicated or layered diagnoses in Chinese Medicine terms (see “What Does Acupuncture Treat?” for general information on treating the causes/roots of your issues vs. the symptoms).

For a deeper theoretical exploration read our tongue diagnosis section.

Tongue diagnosis is particularly useful for issues which are present in the last few days to few months.  Although there are signs that can take years to develop (such as small horizontal cracks on a deeply red tongue that come from chronic kidney yin deficiency in most cases).  Some of these signs that come from more chronic issues give your practitioner insight into the depth of your issues.

The tongue is a useful tool, particularly for conditions which may not have as many obvious or at least daily symptoms.  One general set of issues where tongue diagnosis is particularly useful is in the treatment of menstrual/fertility issues.  This is partly for theoretical reasons which would require a lengthy discussion, but in more general terms it helps guide the treatments correctly in the absence of symptoms.  For example, in women with bad menstrual cramps and strong emotional issues before menstruation there are 2-3 good weeks and then a bad week or a bad few days.  Using the tongue can help tell the practitioner whether the treatments are creating the changes we desire which is better than waiting until the next cycle to gauge if the treatment has been effective or not.  This is all the more true when treating long-term conditions such as auto-immune conditions or cancers.

The study I am going to explore in this article performed detailed analysis of tongue color during different phases of a womans menstrual cycle.  This information could theoretically be used to see if changes in the tongue are from normal menstrual phase changes or are of more clinical signficance.  So a redder tongue post-ovulation may be more expected than pre-ovulation for example.  This could add to or subtract from the significance of what you are viewing as a practitioner.

The researchers from the China Medical University Hospital in Taichung Taiwan recruited 32 eumenorrheic women (women with normal menstrual cycles).  Besides normal, regular cycles the woman selected had no history of psychological issues, liver and/or kidney issues or other health issues that are known to show up significantly in the tongue.  So essentially the tongue in these subjects should be a healthy pink with a very light thin coating and no other markers such as teethmarks or vertical or horizontal cracks.

menstrual-cycle-diagramPotential modifiers in the tongue with women would be:

  • Both estradiol and progesterone are both high in the luteal phase
  • Estradiol is high and progesterone is low in the late follicular phase
  • High progesterone durin the luteal phase elevates basal body temperature (via hypothalamaus thermogenic effect)
  • Plasma volume, heart rate and cardiac output are larger in the luteal phase compared with the follicular phase
  • Muscle sympathetic nerve activity is greater in the menstrual phase compared with the follicular phase

All of these aspects should dictate changes in the tongue that can then be utilized to better quantify other issues that are apparent based on when in the cycle you are looking at the tongue.

An example of the tongue showing differences is below – (a) is follicular phase and (b) is luteal phase.  Whtongue-follicular-a-luteal-bile this study used RGB and CMYK scales to judge color and discusses it from this angle, you can see a redder tip and redder/purple sides in the luteal phase and the body itself is larger.  In general this indicates more circulation, warmth, and some possible stagnation which comes in varying degrees as the body moves from ovulation to menstruation.  In clinical settings the more purple you see the more likely in general terms the woman will experience menstrual cramps and/or PMS.  The redder the more likely the women may eperience night sweats or increased anxiety.

The researchers found in the RGB models the G and B values in the tip were signficantly higher in the luteal phase.  This is just one example.  Overall the researchers found the following:

  • The tip will generally be redder in the luteal phase indicating proper blood and temperature changes.
  • The coating may generally be a bit yellow during the luteal phase compared with the follicular phase (possibly as sulfur compounds in the oral cavity are higher during that phase – also possibly because there is more heat in the system which potentially disrupts digestion).  Clinically, if you saw a stronger yellow coat you would suspect they might have more digestive issues (nausea, bloating, reflux, etc.) during menstruation.

All in all this is a somewhat interesting way to try to explore the tongue in a healthy population to help clarify diagnoses in patients.  Limitations of this study would be that a computerized analysis of tongue color is hampered by the tongue coating.  A practitioner can generally see below the coating so to speak, but a computer cannot.  So some of the changes that are visible and important to a practitioner would be harder to analyze via these particular scientific methods.

Further studies ideally with more practitioner evoked signs would be helpful in describing these changes in more details.  A population of subjects with known issues would also be interesting to see what changes on top of their existing patterns are viewable in the tongue during their cycle.

As with all of Chinese Medicine, scientific exploration is very important and ultimately useful to varying degrees, but the skill and experience of the practitioner is the most critical aspect.  While it would be great to get everything in Chinese Medicine down to linear scientific signs, what you have at best is decipherable guide posts which take years to understand the significance of.

Study Finds Acupuncture Effective For Premature Ovarian Failure

Acupuncture is commonly used for a range of hormonal issues and related fertility problems.  Premature ovarian failure is a failure of the ovaries to produce normal amounts of estrogen or release eggs regularly and fertility issues are a common result.  In a recent study, researchers from Tianjin University and the Chinese Medical Sciences in Beijing conducted a pilot study to investigate the effects of acupuncture on premature ovarian failure.

Researchers recruited 31 women into the study and they were all given acupuncture every other day, three times per week for 3 months.  The following acupuncure points were used:

Researchers used serum levels of FSH, E2 and LH levels as well as the self-rating anxiety scale (sas) and a kupperman score for baseline and for end of treatment measurements.

At the end of the 3 months of treatment researchers found that patients serum FSH and LH were decreased, their E2 was increased and their SAS and kupperman scores were decreased.  Of the 31 women, 6 resumed normal menstrual cycles.  Researchers concluded that “acupuncture may decrease serums FSH and LH levels, raise serum E2 levels, relieve anxiety, reduce mental stress and improve ovarian function”.

Acupuncture Injections With Enercel May Help ALS (Lou Gehrig’s Disease)

ALS or “Lou Gehrig’s Disease” is a quickly debilitating and near exclusively fatal neuro-degenerative disease with no known cure.  Chinese Medicine including herbal medicine, acupuncture, Tong Ren Therapy, Tuina and other aspects has been used to help slow the progression of the disease, but has of yet to reverse it.  A small US study recently used acupoint injection therapy using enercel (an herbal preparation described below) to look for neurological improvement.

Researchers had only two patients and one, while they improved, dropped out of the study.  So these results should be taken somewhat lightly but anything that shows improvement of such a destructive disease should be considered at this point.

First, what is enercel?

“Enercel is an herbal preparation consisting of very small dilutions from plants of the desert and rain forests such as cactus (Cacti grandiflora), aloe, arnica, lachesis, and licopodium in a 2% to 8% alcohol base.” (source: American Cancer Society)

Enercel is thought to have a range of immune boosting effects and may be helpful in neurological diseases and cancer, yet except for this small study there is limited peer-reviewed medical journal study submissions at this time.

 

Within this study, patients were administered .25-.5cc of “Enercel Plus IM” (a trademark name for a commercial product) 5 days/week for 4 weeks to specific acupuncture points.  One patient showed neurological improvements in speech, swallowing and movement, yet did not continue treatment after the study and followed a progressive decline.  Another patient had significant improvement in speech and motor control during the 4 weeks of treatment and at a 3 month followup showed a maintained state of improvement.

Acupuncture points (with enercel dosages) that were used within this study include:

As Lou Gehrig’s has an autoimmune aspect to it, there can be modulations from various treatments and substances that appear to be helpful yet the decline continues after a period of time.  Further studies of this nature, however, should be considered and carefully evaluated by practitioners.

The Purpose of our Practice – Sun Ssu-Miao, Maimonides, and Practitioners of Chinese Medicine

As practitioners of Chinese Medicine we know that we are offering something unique. Day after day we see patients heal with help from the tools offered by our medicine. Often these patients have failed to respond to any other treatment – traditional or “alternative.” The techniques and knowledge we share are drawn from the collective wisdom accumulated by generations of practitioners. A wisdow that has also been tested by generations of patients. As practitioners, we are simply conduits of this information perhaps adding our own jewels from time to time.

While we certainly do not heal every case, some cases are remarkably fast and others take longer (many times at odds with our expectations), we have the capacity to always offer benefit to our patients. Not many forms of medicine can truly say this. It is a wonderful medicine to practice, to study, and to offer to our respective communities.

Our Purpose

Even with all of this inherent beauty of technique and whole person attention our understanding of the purpose of our practice is often cloudy. We all know that being a Chinese Medicine practitioner most often means much more than simply practicing medicine. You have to be an educator, a business person, a student, a counselor, often a legislator, a leader and an example, and more. Being a “practitioner” of Chinese Medicine in the west particularly is no simple feat. This is both incredibly stimulating and exciting but also a difficult skill set to live completely. We are in many ways, whether we like it or not, leaders of what is and will more so come to be a strong part of the future of medicine. Yet we are often avoided and even barred from full participation in our western systems of medicine. This will, of course, all change as time rolls on – but for now it is a intriguing position to be in.

For westerners, practitioners, students and patients alike, we are still learning and integrating this “new” medicine. We are limited to varying degrees by our own language, conditioning, cultural training, and time to hone and develop our skills – both technical and personal. While we certainly have our work cut out for us, I wouldn’t change my “career” for anything… It is truly a wonderful time to be learning so many deeply beneficial theories and tools to share with our patients and colleagues.

While the vast majority of us are strongly driven by the happiness we derive from helping our patients we can also draw motivation from leaders of medicine who have faced similar challenges in the past.  There words help to convey the magnitude of our task and the proper focus required to help our patients.  For this article I wanted to touch on two people who are inspirational to me – Sun Ssu-Miao and Maimonides.

Sun Ssu-Miao (~581-682 AD)

Sun Ssu-Miao is familiar to many practitioners of Chinese Medicine. He was a famous and influential practitioner during the early part of the Tang Dynasty ~600BC. We have many writings from Sun Ssu-Miao regarding herbal medicine particularly and all other aspects of Chinese Medicine. Personally I find his writings about the qualities and proper motivations that practitioners must develop both challenging and incredibly inspiring (much like our medicine generally). To convey his wisdom best I will let him speak….

 

…physicians should not rely on their own excellence, neither should they strive with their whole heart for material goods. On the contrary, they should develop an attitude of good will. If they move on the right path, concealed from the eyes of their contemporaries, they will receive great happiness as a reward without asking for it. The wealth of others should not be the reason to prescribe precious and expensive drugs, and thus make the access to help more difficult and underscore one’s own merits and abilities. Such conduct has to be regarded as contrary to the teaching of magnanimity. The object is help. Therefore, I enter into all the problems in such detail here. Who ever studies medicine should not consider these problems insignificant!…

 

Arguably ahead of his time he cautions tendencies (often strong within our western minds) to “treat” conditions externally with herbal medicines (“drugs”) so easily. His words about looking at our activities and diet first (the things we personally have control over) and then doing more if necessary are very important, in my opinion, for all of us to remember…

 

…those who practice medicine must first recognize the origin of an illness; they must know which violations have caused the suffering. Then they must treat it with dietary means. If dietary therapy does not cure the illness, only then can they employ drugs. The nature of drugs is violent, just like that of the imperial soldiers. Because the soldiers are so wild, how could anybody deploy them recklessly? If they are deployed inappropriately, harm and destruction will result everywhere. Similarly, excessive calamities are the consequence if drugs are thrown against illnesses carelessly….

As practitioners, then, our motivation must be the health of our patients. To do this properly we need to closely scrutinize both our lives and the lives of those in our society and care. This is because the primary causes of illness are “our lives” – not external threats, chemical factories, the economy, etc. Those things may not help but it is our day to day medicine (our food) and our day to day activities that have the most control. As practitioners we have the responsibility to explore these facets which will benefit ourselves, but more importantly our patients.

As you understand more of what is driving illness, compassion arises driving the motivation to help others without regard for fame, wealth, acceptance, etc. Exactly what Sun Ssu-Miao motivates us to do.

Moses Maimonides (1135-1204 AD)

Now onto someone likely unfamiliar to many practitioners of Chinese Medicine but very motivational nonetheless. Moses Maimonides is a highly regarded Jewish philosopher and physician. While I am far from knowing much about Maimonides myself or about many of his philosophical views and Torah scholarship – I have been personally motivated by the little I have read of his work. Early “western” medical theories have always intrigued me as a practitioner of Chinese Medicine as there are many similarities in theory and views (and, of course, many divergences).

A particular writing of Maimonides that inspires me comes from the “Prayer of Maimonides” – his personal prayer to provide inspiration, guidance and motivation within his work. Again, I will simply let him speak….

 

…inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent-minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures…

 

 

…should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death…

 

…imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!
Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding … … Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed…

 

My primary teacher, Master Tom Tam, told me often to never stop advancing, never stop learning. While it is difficult at times to remain a student yet convey and display the “mastery” required as a practitioner, it is crucial to do this nonetheless. Never stop…

As practitioners we are not in competition with anyone or any form of medicine we are simply here to help others. Our only competition is really with ourselves – our own ego, false confidence, and often petty personal tribulations.  These motivations inspire us to focus on our calling – keeping our true purpose in mind we can freely perform our work from day to day free of irrelevant concerns and worries. Challenging, yes, but these motivational thoughts inspire us towards something larger and ultimately far more worthwhile than anything we could imagine for our individual lives.

In our own way we are responsible for the lives of our communities.  While this is a serious responsibility, properly viewed it is an intensely motivational and driving force moving us to develop and share our skills and knowledge.  What a profession…