The double take of the radial pulse in Nan Jing – smart health with Traditional Chinese Medicine

Sources: “Japanese Classical Acupuncture – Introduction to Meridian Therapy” by Shudo Denmei *

According to a saying attributed to BianThat, alleged author of Nan Jing, the one who could arrive at the diagnosis withouttouching the patient was considered a superior physician while thatwho had to rely on the palpatory examination was considered a doctorordinary.

Although palpation is the least sophisticated method of examination according to the classics, it remains the most important stage of diagnosis in the treatment of meridians. The results of all the other exam times are used primarily to confirm how we feel at our fingertips. Palpation is also crucial to locate and treat the points.

During the palpatory examinationgeneral, in addition to pulse diagnosis, the skin surface ofthe abdomen, back and limbs are caressed, squeezed, pinched and patted todetect deficiencies or excesses in the muscle layer. Informationobtained are used to confirm the results of the pulse diagnosisand the abnormal areas on the surface of the skin become themselvescandidates for symptomatic treatment.

Nan Jing refers more often to the diagnosis of the pulse than any other type of examination. If we were to follow Nan Jing's instructions to the letter, there would be no need for another form of palpatory examination. There is no doubt that pulse diagnosis has always been the most important aspect of the palpatory examination.

It is possible to practice acupuncture without referring to the pulse, but pulse diagnosis remains an essential means of determining the most appropriate diagnosis and treatments. However, it is unwise to base your diagnosis solely on the pulse. The final determination of the type of imbalance must take into account all phases of the examination including hearing, interrogation, palpation of the meridians and abdomen.

Two distinct types of pulse palpation are used to treat the meridians. The first is the six-position pulse diagnosis described in Nan Jing, which compares the strength of the six-position pulse on the right and left radial artery. The six-position pulse diagnosis is used to detect imbalances (deficiency or excess) in the meridians.

The other type of pulse palpation is the diagnosis by the shape of the pulse in which the quality of the pulse (slippery, tense, fine, etc.) is taken into account and where the precise position of the pulse is not too important. In the six-position pulse diagnosis, the location of the pulse positions must be very precise. In the six-position pulse diagnosis, all positions (three on each arm) are palpated at three levels: superficial, medium and deep. Almost no pressure is applied with the fingers at the surface level, moderate pressure is used at the medium level and substantial pressure is used to reach the deep level.

Theintermediate level is not used to diagnose meridiansspecific, but to check the general condition of the patient.

The first step in diagnosingpulse consists of placing the index, middle and ring fingers of both hands onall pulse positions, right and left, with thumbs in the backwrists. When the fingers are placed directly on the radial arteryand light pressure is applied, the pulse can usually befelt clearly with all fingers. The depth or level where thepulse can be felt most clearly in all positions of thefingers is called intermediate level. Thedepth of the average level therefore varies from person to person.

Thestrength and quality of impulse at the medium level reflect the Qi state ofstomach, which is the overall energy level or function of the zhongjiao.Although the intermediate level also reflects the condition of the organs andmeridians associated with each position it is primarily an indicatorstomach qi.

The mid-level pulse is considered the same in all six positions. We will always find a certain vitality in the pulse at the intermediate level as long as there are no serious disturbances of the vital processes. A patient with a weak mid-level pulse in the right middle position (spleen / stomach) should be carefully examined.

Palpate the surface level

After feeling the pulse atmedium level, the pressure on the fingers is released a little before the point wherethe pulse can no longer be felt. This is the superficial level.

When strong impulses can be felt in most positions at this level, it is called excess at the superficial level or excess at the yang meridians. When the impulses are weak in most positions at this level, we speak of deficiency at the superficial level or deficiency of the yang meridians.

The strength of the pulses at all positions is compared to the surface level to determine which of the yang meridians are deficient and which are excessive.

Excess pathogenic Qi as well asrelative excesses tend to appear most often in the meridiansstomach, gallbladder and bladder.

Thefinding excess pulse in yang meridians tends to have adirect correlation with patient symptoms. If the excess is in themeridian of the Gallbladder for example there are usuallysymptoms along the meridian, such as headache, stiff neck andshoulders, pain in the lower back or on the side of the limbslower.

Feel the deficiency of a meridianyang is more difficult. If the pulse at a position cannot be feltat all at the superficial level, it can be considered as deficient. Comparehowever, the strength of the pulse in the superficial position is not as simpleonly in the deep position. By pressing more deeply to feel the pulsefrom a deficient yang meridian, we often descend to the medium level.

Inthe treatment of the meridians, the diagnosis by the pulse with six positions ismainly focused on the identification of deficiency of yin meridians andexcess meridians in yang.

Themain thing to understand at this point is that it is clinically importantto identify the excess of a yang channel by the pulse, because an appropriate treatmentof this excess is very effective in relieving the associated symptoms on thepath of this meridian.

Feel the deep level

After feeling the pulse atsurface level, increase the pressure on the fingers to palpate the leveldeep. If the pressure is too strong, the pulse will weaken or disappearcompletely and it will be impossible to compare the strength of differentpositions. Hold your fingers just above the level at which the pulsesare starting to fade. It’s the deep level where the organ oryin meridians is examined.

When the pulsations are strong enough in most positions at the deep level, we speak of excess of deep level, or of excess of the yin meridians. When the pulsations are weak in most positions at the deep level, we speak of deficiency at the deep level or deficiency of the yin meridians.

Theforce of the pulses at all positions is compared to the deep level fordetermine which yin meridians are deficient and which are excessive.

The role of the thumb in diagnosing the pulse

Sit in front of the patient who is seated and feel the pulse on both sides at the same time. When the pulses are palpated with the patient lying on their back, they are weaker and more difficult to feel for a beginner. For patients who cannot sit or for those whose pulse rates are weak even when seated, perform a few superficial punctures on the upper abdomen.

Your thumb should go aroundwrist naturally to hold the opposite side. That way youpalpate the left wrist with the right hand and the right wrist with the handleft. Borndo not think of palpating the pulsations with the three fingers, but palpate them asif you perceived them with your thumbs. This is the secret of the pulse diagnosis.

When palpating the distal positions, be careful not to bend the patient's wrists excessively. Pulses cannot be accurately palpated in this position if the wrist is bent. The artery should be straight to get an accurate reading. In fact, the wrists should be very slightly extended when palpating this position. In this way, the pressure exerted by the thumb is distributed harmoniously over all of the fingers.

To palpate a position bycompared to others using this method, for example the kidney pulse(left proximal position), just direct your attention to yourright ring finger while holding all fingers at the deepest levelwith thumb pressure.

If it is still difficult todistinguish the strongest or weakest positions, try themfollowing solutions:

1. Examine the pulse with the patient seated.

2. Examine the pulses after having punctured superficially P9, the meeting point of the blood vessels.

3. Examine the pulses after pricking the abdomen superficially. Ren6 or Ren12 are used to raise the level of Qi and strengthen the pulse.

4. Examine the pulse after having superficially punctured the points of the skull like Du20, as well as the ear points which are used to raise the level of yang Qi and thus strengthen the pulse.

Inmy practice, when the pulses cannot be clearly distinguished Igo to the other phases of the exam and then I punctuate the head slightly andear points. Whenthe pulses are too weak to distinguish their relative strengths from othersqualities, I examine the pulse when the patient is seated. When the pulseare too strong to differentiate, I make the patient lie down.

Simplified method for comparing pulse positions

The control relationship is an antagonistic relationship in which one phase inhibits the activity of another phase. If the strength of two positions in a control relationship is relatively equal, there is a balance between the two phases represented by these positions . When a phase becomes weaker or deficient, there is an imbalance and the control phase tends to become excessive.

Comparing two positions tothe time allows to distinguish the differences between the six pulse positions.

Even if you compare twopositions at a time with this method, start by placing your fingers on thesix positions at the same time to palpate the pulses at the medium level.

movethe three fingers up and down in a unit on both sides to find thelevel where the impulses are most clearly perceived. This is the levelintermediary where the Qi of the stomach is felt and reflects vitalitygeneral of the patient. The quality of a healthy mid-level pulse issoft and resilient. This impulse must be felt clearly and must notbe neither too hard nor too soft.

Start by comparing the positions of the heart and lung. Press the index fingers just before the arteries are blocked and hold them there to compare the difference in strength. If the pulse in the two distal positions is of equal strength, the Qi of the heart and lung are balanced.

Supposethe pulse of the heart (left distal) is a little weaker than that of thelung (right distal).

Then compare the positions for the lung and liver. Release the index finger to the left distal position and place the middle finger on the left middle position. Compare the strength of the pulses in the right distal and left middle positions. Keep the other fingers of the artery while comparing the two positions.

Supposethat the pulse of the liver (middle left) is much weaker than thepulse of the lung (right distal).

Then compare the positionsliver and spleen. Release the index finger to the right distal position and place itmiddle finger on the right middle position. Compare the strength of the pulses inthe central positions on the right and on the left.

Supposethat the pulse of the liver (middle left) is much weaker than that of thespleen (center right).

Then compare the positionsspleen and kidney. The middle finger on the central left position is released andthe ring finger is placed in the proximal position. The right ring finger is thereforeused to palpate the kidney pulse.

Supposethat the pulse of the kidney (proximal left) is much weaker than the pulse ofthe spleen (center-right).

Last positions to compareare those of the kidney and pericardium. Place the two ring fingers on theproximal positions to compare kidney and pericardium.

Supposethe kidney pulse (left proximal) is slightly weaker than the pulsepericardium (right proximal).

Looking at the results, the lungs and spleen are strongest, the liver and kidneys are weakest, and the heart and pericardium are normal. This is a perfect example of the balance of forces of the pulse that would exist at the deep level of the six positions in the case of liver failure.

Palpation of the six positions at the superficial level tends to show an opposite pattern in the balance of pulse forces. In the diagnosis of the pulse, there is a general rule that the yin and the yang tend to be opposite; thus, the large intestine and stomach would be weak and the gallbladder and bladder would be strong.

Thedeficiencies and excesses tend to accumulate via the generation cycleof the five phases.In the above case, the earth (spleen) and the metal (lung) are excessive,water (kidney) and wood (liver) are deficient. Thefirst step is to learn the correspondences of the five phases andsix positions and to become aware of the relationships of generation andcontrol between these positions.

Compare superficial and deep levels

We compared the strength of the pulses between positions in a control relationship according to the five phases as the most basic approach to six-position pulse diagnosis. However, another aspect of the pulse intensity comparison has not yet been addressed. This is the difference between the shallow and deep levels at each position, i.e. the difference between the paired yin and yang meridians.

whenthere is an imbalance in a certain phase, the yin and yang meridianscorrespondents tend towards opposite extremes, that is to say that the meridianyin becomes deficient and the yang meridian is excessive, or vice versa. sameif the liver looks strong and the spleen weak, if the liver and gallbladderare strong and the spleen and stomach are weak, these two yin-yang couplesare balanced.

If we only pay attention to the differences in strength in depth compared to the five phases, the diagnosis will sometimes be inaccurate. For example, a pulse that appears to have a pattern of spleen deficiency and excess liver when examined at the superficial position often turns out to be liver impairment and excess gallbladder.

This usually happens because the pulse is not palpated deep enough and the average level reflects the state of the yang meridians more than that of the yin. Thus, the excess in the meridian of the gallbladder is interpreted as that of the liver, while the meridian of the spleen appears to be deficient. Paying attention only to imbalances between yin meridians can lead to this kind of error.

Throughtherefore, it is important to feel the pulse at all three levels and to keepmind the trend of opposite extremes of paired yin and yang meridians.

Seasonal and pathological pulses

According to the classics, each ofseasons is associated with a particular quality of pulse. ThePulse quality associated with spring is the tense and slightly fine pulse. Thepulse quality associated with summer is the overflowing pulse which is great,floating and slightly soft. The quality of the pulse associated with autumn issuperficial pulse, which floats on the surface in a fine and soft way. The qualityof the pulse associated with winter is the submerged pulse, which is deep and hard.

These qualities are those that oneshould normally see appear and disappear with the seasons in ahealthy individual. Those who are sick have non-pulse qualitiesadapted to the season: a submerged pulse in summer, for example, this means thatthe internal state of the body is close to that which normally occurs inwinter.If a seasonal pulse qualityextreme is also a bad sign: for example, an overflowing pulseextremely, without any sweetness during the summer, indicates a conditionexcess.

Intheir extreme forms, all seasonal pulses are pathological. Everyseason, the pulse should have the quality of the seasonal pulse, but shouldstill retain the softness and buoyancy

denoting the presence of the Qi stomach.

The qualities of the pathological pulse associated with the five yin organs are identical to the qualities of the seasonal pulse associated with the correspondences of the five phases. The pulse in rope indicates a pathology of the liver; the pulse overflowing from the heart; moderate pulse of the spleen; the floating pulse of the lung; and the submerged pulse of the kidney. The moderate pulse is characterized by softness and usually means the presence of stomach Qi. 

In the classics certain qualities of pulse indicate the death of the patient while other qualities indicate his survival. Pulse qualities wereused to determine the prognosis of the disease. The "pulsefatal ”seem in any case to be extreme forms ofdifferent pulse qualities. These pulse qualities all reflect the absence of stomach Qi.

Thehealthy pulse is therefore soft but with a certain resilience, its rhythm isregular.

* Shudo Denmei was born in Ohita, Japan, in 1932. As a child, he contracted pulmonary tuberculosis, but cured thanks to acupuncture and moxibustion from Miura Nagahiko with whom he then did his apprenticeship with Miura Nagahiko (the acupuncturist who saved his life) and will be trained in Sawada acupuncture. He opened his own practice in 1959. Dr. Shudo began to study and apply the concepts of meridian therapy in 1968. He is now one of the principal instructors of the Japan Meridian Therapy Association and a permanent member of its board of directors.

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