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Demystifying the Mystic: The Pulse and TCM

One of the most unique aspects of Traditional Chinese Medicine is how the pulse is used in diagnosis. Modern use of the pulses for medical purposes are typically restricted to seeing if it is present (many patients jokingly ask if they are alive or not), or to measure the heart rate. Lack of understanding combined with the mysterious nature of Chinese/East Asian medicine often causes people to exaggerate the ability of pulse-taking to mythical or supernatural proportions. Some believe that doctors can simply feel the pulse and subsequently know everything about a patient’s body and health. When family members or friends in Taiwan find out that I am a Chinese Medicine practitioner, they would instinctively stick out their wrist and ask me if I can feel anything from their pulse, perhaps hoping that I would be able to guess what ails them without them directly telling me. In reality, while the pulse can provide insight into the physiology and condition of a person’s body, I use it more so to refine and zero-in on a diagnosis rather than base the diagnosis directly on just this singular data point. For example, if I feel a “Weak” pulse in the Cun position of the wrist, this might lead me to ask questions about sleep quality or if there is any fatigue. While for me, these questions help me reach a more conclusive diagnosis to guide the treatment strategy; the patient might experience a “how did you know?” moment, which may further fuel the view of the supernatural abilities of pulse-taking.

Someone who was reading about Chinese medicine once asked me about how practitioners measured the heart rate. Ancient texts used the practitioner as a reference and instructed them to count the number of beats per respiration of the practitioner (one cycle of inhalation and exhalation). The normal rate was considered to be 4 to 5 beats per respiration cycle. The person was mainly wondering if this was still how practitioners measured the rate and if it was a consistent method. I believe this was used during a time without fine timekeeping technology. In modern times, we can reference a clock to properly calculate the beats per minute. The concept of “Slow” or “Rapid” pulses in TCM now are mostly taught using the biomedical definitions of bradycardia or tachycardia with the normal range being within 60-100 bpm at rest. However, there is still an experiential and intuitive aspect of pulse-taking. After feeling enough pulses, one can eventually detect outlying rates, which may lead them to actually count it to realize it indeed falls out of the normal range.

What then are practitioners feeling for if not just the rate? There are many pulse types that are described in Chinese medicine literature. Each pulse type is associated with some sort of pathology or physiological phenomenon, which helps guide diagnosis. Usually there is a specific quality that these pulses are defined by. For example, as mentioned before, the “Slow” and “Rapid” pulses take the heart rate as the main factors. Another group of pulses are defined by depth, as in how hard one has to press into the wrist to feel the pulse the strongest. These pulse types are accordingly named “Floating” or “Sunken”. The relative strength of the pulse can also be perceived, which sets the basis for “Excess” or “Weak” pulses.

Personally I find that the most unique group of pulses describe the rhythmic movement of the pulse. For example, the “Surging” pulse is described by Li Shi-Zhen, a famous Chinese physician in the Ming dynasty, as “on arrival, the beat of the surging pulse is perceived. Its departure is debilitated, its arrival exuberant, like billowing waves.” Another interesting pulse is called “Choppy”, where it can feel “stagnant, like a blade scraping bamboo”. 

Pulse taking and being able to make a diagnosis with it is considered a basic skill in TCM, but in reality it is very complex and takes a lot of time, experience, and studying to become competent. School and textbooks often describe the pulse as an objective sign of something happening in the patient’s body, however I had a teacher that jokingly said that it is actually subjective in the sense that it is subject to the practitioner’s ability to correctly identify what type of pulse they were feeling! 

How does a student approach learning the art of pulse taking then? When I was starting out in clinical shifts, one of my supervisors required all interns to note down what pulses they felt on each wrist position on every patient. While some supervisors required this to help build habits in writing medical notes or diagnosis, this supervisor was different as she primarily took it as a form of practice. She would personally go into every room to check the pulse herself and correct the intern if there were any mistakes. This secondary confirmation from a seasoned practitioner certainly helped me be more confident that I was becoming better at identifying pulses.

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