The Four Examinations, Part 6 (Palpation Diagnosis)

Palpation

Pulse: (mostly TCM here, not Contemporary Chinese Pulse Diagnosis, except for a few concepts)


Left Right
Distal = cun (inch) = heart and small intestine lungs and large intestine
Middle = guan (bar) = liver and gall bladder spleen and stomach
Proximal = chi (cubit) = kidney (yin) and bladder kidney (yang)/san jiao and PC


Speed: hot/cold
Location: interior/exterior
Strength: excess/vacuity
Yin/yang

Pulse has a close relationship to HT
Depends on HT qi
Can reflect pathogenic changes in
The HT, yin, yang, qi, blood; as well
As viscera, bowels, and channels

Location, speed, strength, form tell
About location, form and nature of disease
And the strength of the evil and right qi,
Strength of disease circumstances and
Prognosis of patient

Rate, Rhythm and Stability

Rate and rhythm are considered “larger segments” of the pulse along with the Stability of the pulse, uniform qualities on the entire pulse, at all depths or in each burner. The qualities at individual positions are unreliable signs until the larger picture is addressed. It is possible to deal only with the larger issues and achieve the greatest impact on the patient in terms of their needs and treatment.

“Big is Big”.

Deviations from normal in the larger segments of the pulse are generally the most critical in terms of seriousness of disharmony and order of treatment. Rhythm, rate and stability are clinical issues that take precedence over any quality or combination of qualities in diagnosis and treatment. Frequently when rate, rhythm and stability are brought into order and balance, other qualities and findings will automatically change.


Rate

Alteration from a normal rate is much more often a sign of significantly more far reaching processes than Heat and cold influences. In Dr. Hammer’s experience the rate more commonly involves factors that affect the Heart function and circulation, such as shock, over-exercise, overwork, physical and emotional trauma.

Normal Rates according to Dr. Shen (Hammer, 152)
Age Rate
Birth to 4 years 84-90/min
4-10 years 78-84/min
10-15 years 78-80/min
16-40 years 72-78/min
40-50 years 72/min
50+ years 66-72/min

Rapid Rate—
Common causes are External: pathogenic factor (wind-heat), heat stroke or trauma (physical or emotional) or Internal: heat from Excess (Heat in Qi level, Heat in the Blood: heat or Thick, liver Qi stagnation with heat, Nervous system Tense or “vigilance” pulse).
--Deficiency heat—Tight and less rapid than with Excess heat.
--Trauma—Effects of trauma on the pulse will depend on the condition of the True Qi of the person at the time of the trauma and since then depending on lifestyle, whether the trauma was local or extensive, time elapsed since the trauma.
Extensive physical trauma causes the pulse to be Very Rapid, Bounding, Tight to Wiry.
Local trauma will produce a less Rapid pulse with Tight to Wiry quality in the area of pain.
Emotional trauma leads to a very Rapid Bounding pulse with a very Tight quality over the entire pulse, especially in the Pericardium position at first, and later the left distal position. Change in Intensity and Rough vibration may occur over the entire pulse. The tongue and eyes are normal. (Hammer, 154)

Trauma is a shock to the circulation. Circulation into and out of the area is compromised. If the True qi is strong the pulse will become Inflated, meaning the energy is trapped in an area and it can’t get out. If the True qi is deficient, the pulse will become Flat, meaning the outside energy can’t get in due to the diminished Qi.
If the stagnation persists without intervention for a long time, energy is gradually depleted and the pulse becomes increasingly Reduced. It will be Feeble-Absent in the position corresponding to the body site affected by the trauma.


Slow rate—External cause: Cold from external pathogenic influence.
Internal causes:
--Cold from deficiency of qi and yang (chronic disease, overwork, over-exercise, over-sex, protracted emotional stress)
--Heart qi and yang deficiency—Heart is unable to circulate qi and blood which leads to a slowing of the rate. If constitutional, the left distal and proximal positions are Feeble-Absent; if the cause of the deficiency occurs after birth, the entire pulse is Feeble and the left distal Feeble or Absent.
--Aerobic exercise
--Poisoning/Toxicity
--Shock—over time will lower the Ht rate if unresolved.

Rhythm

Rhythm is the single most significant aspect of pulse diagnosis. It is a measure of Heart and circulatory function. Instability in the Emperor is tantamount to chaos in the empire. This must be dealt with first. Irregularity is considered in terms of whether it occurs at rest or with movement, whether we are able to count a rate, whether the changes in rate are small or large, and whether it occurs constantly or occasionally.

Interrupted: Misses beats with no fixed cadence. If able to measure a rate, indicates moderate Heart qi deficiency. If unable to count a rate due to the arrhythmia, indicates Heart qi and yang deficiency.

Intermittent: Misses beats with regular cadence (every 2 beats or every 3 beats). Indicates Heart qi, blood and yang deficiency. (Hammer, 121)

Change of rate at rest: Heart Qi Agitation, if found occasionally (Heart Yin Deficiency, page 409). Heart Qi Deficiency if found consistently.

Rate on exertion: An 8-12 beat increase is normal. An increase greater than 12 denotes Heart blood deficiency. A decrease in rate on exertion is a sign of Heart qi and yang deficiency. The method for assessing the change in rate on exertion will be demonstrated in the hands-on portion of class.

Normal Pulse

The normal pulse is resilient, compressible, of moderate strength and with spirit. The qualities, intensity and amplitude are consistent over time and in each position. Seasonal variations occur in rare instances where there is little pathology. Normally the pulse is somewhat stronger on the right side in women, and on the left side in men.

Three features: (1) Stomach Qi: reflection of post-natal qi (even, calm, good rate)
(2) Spirit: orderly w/o chaos, not changing (in rate, rhythm, stability…)
(3) Root: reflects KI: prenatal qi. Is there a KI pulse?; also reflected in deep level of all positions

The following are some characteristics of the Normal pulse which serve as a baseline and standard for health:
1. Rhythm - Consistently regular
2. Rate - Consistent with age
3. Quality - Compressible, resilient and elastic
4. Shape - Long, smooth and continuous without turbulence
5. Strength - Moderate with spirit - luster
6. Spirit - Moderate Spirit (languid, Leisurely, Relaxed, Slowed-Down) depending on body build
7. Root and depth - Balanced between superficial, middle and deep. The greatest strength should be in the root, at the deepest or Organ depth and becoming lighter as one ascends to the Qi depth. There is strength in the proximal positions. The pulse is deeper in heavy people and more superficial in thinner people.
8. Balance - Balanced between positions with the middle position occupying the most space, the proximal position the next most area and the distal position being the most confined.
9. Intensity (buoyancy, elasticity and resilience of the pulse) - Stable over time
10. Amplitude (height of the pulse) - Stable over time
11. Consistency - Qualities stable and consistent over time.
12. Wave - Sine curve that begins at the Organ depth and gradually rises to the Qi depth, and then subsides again to the Organ depth.


Qualities, intensity, rhythm and rate are consistent over time and in each position. The pulse is resilient, compressible, moderate strength with spirit.

Pulses of women and children tend to be more rapid than those of men. Athletes tend to have slower rates. Normally, the pulse is somewhat stronger on the left for men and on the right for women. Seasonal variations occur in rare instances where there is little pathology.

Buoyancy: The normal pulse in a child and sometimes in a vegetarian may be more yielding. In a woman it may be more thin and in a man more wide.

Shape: Pregnant women usually have more slippery and more rapid pulses.

Wave Form: Normal is a sine curve that begins at the organ depth, gradually rises to the qi depth, and subsides again to the organ depth.
The wave form is the movement of the blood through the vessel. The fingers can perceive the shape of this movement. Abnormal waves give us information about the condition of the patient.

Depth:
Tells about location of disease
Floating: exterior disease (usually): can be internal wind
Deep: interior


Strength: tells of length of disease: chronic or acute
New onset will be forceful b/c evil and right qi are strong
Chronic and enduring, qi will be forceless due to evil qi and right qi weakened


Does pulse match signs and symptoms? If no, prognosis is more difficult.

Considerations in taking pulse:
Time of day: best time is b/w 3:00am to 5:00am
State of mind: of you and patient. Must be calm, concentration, etc.
Time:
Rate: count for 60 seconds
Each position: spend a few minutes, check for abnormalities, changes in qualities, intensity…
Position of Patient: should be sitting down with hands at height of just below HT. Pillow under arms
Pressure/Techniques:
See 3 depths.
Rolling methods to access aspects of both principal and complementary positions. Soulie de Morant and Maciocia document rolling the fingers as an integral part of pulse diagnosis. Maciocia states: “Nearly all ancient Chinese texts on pulse diagnosis say that the pulse is felt not by keeping the fingers absolutely still on the artery, but by moving the fingers in five different ways: (1) lifting tells you whether the pulse is Floating; (2) pressing (down) tells you whether the pulse is Deep; (3) searching (not moving the finger) is used to count the rate; (4) pushing (from side to side) tells you about the shape of the pulse (5) rolling (distally to proximally) tells you whether the pulse is Long or Short
Watch for abnormalities:
Fan Guan
San Yin Mai
Ganglion Cysts
Trauma
Sex and Age:
Men’s pulse usually larger, and stronger on left
Women’s pulse thinner and stronger on right
Menstrual cycle affects: weaker after period; stronger before
Kids: faster rates
Elderly: weaker due to decline in qi and blood
Emotions:
Excess joy damages HT and causes pulse to be vacuous, or in extreme conditions deep
Overthinking injures SP/HT and pulse becomes bound, when extreme, string-like
Anxiety damages LU/HT/KI and pulse becomes rough, when extreme, surging
Anger damages LV and pulse becomes soggy; when extreme, rough
Fear injures KI and pulse becomes deep, when extreme, soggy
Taxation/inactivity/poor diet:
With poor nutrition: weak and forceless
After meals may become surging, slippery
Alcohol: rapid (choppy LV)
4 seasons:
spring: string-like
summer: surging
fall: floating
winter: deep



Depth:
Floating
a. Floating: exterior, superficial, usually associated w/ Lung; cork floating on water
i. forceful: exterior repletion
ii. forceless: exterior vacuity

1. floating and moderate: wind damp in exterior
2. floating and slow: wind stroke
3. floating and tight: wind cold
4. floating and slippery: wind phlegm or food stag
5. floating and rapid: wind heat
6. floating and scallion stalk: blood loss
7. floating and scattered: extreme taxation
8. floating and rough: blood damage

b. Scallion Stalk/Hollow: floating and large, hollow in center; arrives softly, when pressed, center is empty
indicates severe blood loss and yin damage

1. hollow and rapid: vacuity heat
2. hollow and slow: blood loss w/ vacuity cold (shock)
3. hollow and skipping: blood stasis binding internally (usually from trauma)

c. Soft/Soggy: floating, fine and soft; like cotton floating on water
governs vacuity taxation and vacuity cold of SP/ST and warm damp diseases, ie (uterine bleeding, post partum bleeding)

d. Scattered: floating large and scattered. No root. Empty at middle level and disappears at deep w/ pressing. Abnormal rhythm and feels chaotic. May be seen before delivering baby; HIV
severe KI qi vacuity

e. Leather/Drumskin: floating stringlike and large. Tight on outside and empty inside. Hard and straight w/ light pressing, empty within as if pressing on skin of drum w/ heavy pressure. Like scallion stalk but also stringlike and tight
blood collapse, essence defic; uterine bleeding; chemotherapy, hemorrhage


Deep
a. Deep/Sinking: felt only w/ heavy pressure
interior diseases

1. deep and forceless: interior vacuity
2. deep and forceful: interior excess
3. deep and slow: interior cold
4. deep and fast: interior heat
5. deep and tight: cold pain
6. deep and stringlike: swelling and pain
7. deep and slippery: phlegm food accum
8. deep and rough: accum of qi (masses)

b. Hidden: deeper than deep pulse; deepest part of muscle/ b/w tendon and bone; need heavy pressure
1. hidden and forceful: repletion evil hiding internally and obstructing movement of qi and blood; can be accompanied by diarrhea, vomiting
2. hidden and forceless: chronic and enduring diseases

c. Confined/Firm: hard, confined and fixed; deep in muscle layer; replete, large, stringlike and long; vessel feels hard and fixed
chronic diseases w/ deep evil; usually masses, obstructions and stagnations

Speed:
Rapid
a. Rapid: can indicate heat (interior or exterior; repletion or vacuity) or can indicate HT shock, etc. (see Hammer)
1. rapid and surging: exuberant yang repletion heat
2. rapid and fine: vacuity heat
3. rapid and stringlike: phlegm fire or heat in LV/GB
4. rapid and rough: yin or blood stasis causing heat

b. Racing: usually infection or severe HT shock; extreme repletion of yang when yin is exhausted and can’t control yang. Or if racing and forceless, yin of lower burner is exhausted and yang of upper burner is hyperactive. Beginning of separation of yin and yang.

c. Spinning Bean/Moving/Stirred: only felt at middle position (I’ve felt it at special lung pulse); feels like spinning bean; slippery rapid forceful
very serious, impending death or illness in organ system; or with extreme pain, palps or w/ pregnancy (3 mos.)

d. Slippery: arrives and departs smoothly; round and slippery; pearls sliding under finger
strong qi and blood
overabundance of qi and blood, ie heat, phlegm, dampness, food accum

1. slippery and floating: wind phlegm
2. slippery and deep: phlegm rheum or food stag
Hammer: can be infection, damp heat in organ
3. slippery and rapid: damp heat or phlegm fire
4. slippery and slow: lower bowel problems (dysentery)

Slow
a. Slow: cold patterns (interior or exterior; repletion or vacuity) or can indicate HT qi defic; toxicity
1. slow and floating: exterior cold
2. slow and deep: interior cold
3. slow and slippery: cold phlegm
4. slow and fine: yang defic
5. slow and stringlike: pain
6. slow and forceful: cold damp obstructions

b. Moderate/Leisurely: rate neither fast nor slow. But when combined w/ other qualities can be abnormal. Can be slightly slow/retarded.

c. Rough/Choppy: opposite of slippery. Knife scraping bamboo. Feels rough, w/ edges
Stagnation of blood (in tissues). TCM says also stag of qi, food, phlegm.
Can also have change in rate or rhythm. If pulse consistently rough/choppy, look for masses. Can be stringlike and rough if qi stagnation.

Force
Deficiency:
a. Empty/Vacuous: slow large forceless. Felt w/ light pressure only.
Vacuity of qi and blood
1. empty/vacuous and floating: qi defic
2. empty/vacuous and rough: blood defic (can lead to stasis)
3. empty/vacuous and rapid: yin defic heat
4. empty/vacuous and slow: yang defic

b. Minute/Faint: extremely fine, extremely soft; sometimes disappears. Extreme qi and blood defic; serious loss of blood or fluids (diarrhea, sweating, vomiting)

c. Weak: deep fine and forceless. Vacuity of qi and blood, but more of an internal condition where original qi is being consumed.

Excess:
a. Replete: arrives w/ force, full and large.
Excess heat, fever, food stag, constip.
Watch for replete pulse w/ chronic condition. Can be separation of yin and yang
Good in healthy person

b. Tight: like a twisted string vibrating under finger and hitting w/ force
indicates cold, pain, fright-wind, cold phlegm, hernia

c. Flooding/Surging: comes w/ strength and goes softly like a wave. Usually large vessel and loose. Normal in summer.
Yang ming pattern: 4 Bigs (pulse, sweat, fever, thirst)
May also appear in vacuity patterns where it will be forceless waves

Rhythm
a. Abrupt/Skipping: rapid, skips beats w/o pattern
1. skipping and forceful: yang repletion w/ evil blocking flow of blood
2. skipping and forceless: HT palps or chronic vacuity cough

b. Knotted/Bound: slow and irregular
1. Bound and forceful: qi and blood stag; phlegm and food accum; masses; emotional problems (depression….)

c. Regularly Intermittent: forceless and skips w/ regular rhythm
indicates organ qi vacuity, esp Heart; extreme pain patterns or extreme fright; can be (normal if 3 mos. Pregnant?)

Form
a. Large: vessel is large
heat: repletion or vacuity
if forceful, beginning of disease
b. Fine/Thready/Small/Thin: clearly felt like a thread
qi and blood vacuity; yin defic
c. Long: exceeds normal pulse positions; soft and flexible, yet forceful
normal in spring
surplus of yang qi
repletion patterns

d. Short: felt in middle positions, but not in others
Lung or HT qi vacuity

e. String-like/Wiry: long and straight and stiff under fingers (violin string); like a tight pulse w/o vibrating. Usually thin and narrow
Liver pulse: liver stag, wind, fire; LV/GB heat
Slightly string-like is normal in spring
Phlegm accum or masses



Head:
Feel for temperature, quality (rough, smooth), moisture, lumps, bumps
Look for discoloration and visible lumbs
General color
Use back of hand to feel face
Feel forehead for heat and feel hands at same time
If palm is hotter than forehead: vacuity heat
If dorsum is equal or hotter than forehead: repletion heat

Neck/Head:
Look at fontanel in child/infant.
If protruding: liver wind stirring
If sunken: fluid depletion

Feel for lumps/bumps on neck. Are they soft and moveable (qi stag) or hard and fixed (blood stag)? Are they painful? Hot?

Forearms:
Feel for temp, moisture/dryness, swelling
Hotter on inside: yin defic heat
Hotter on outside: yang repletion

Skin:
Exterior heat: scorching when first touch, then diminishes
Internal heat: gets hotter and hotter
Heat blocked: don’t feel heat right away, then gets hot
Sweat on body: info on body fluids
Skin rough/dry: yin, blood vacuity
Skin swollen and sinks when touched: water swelling
Skin swollen and tight and doesn’t sink: qi swelling

Hands and Feet
If hot: hyperactive yang
If body and limbs are cold: yang defic
If limbs ice cold: reverting cold; yang exhaustion
Palms hot, body not hot: yin defic heat
Dorsum hot, body hot: external evil
Children w/ high fever: if fingers get cold watch for convulsions
If hands and feet both cold: SP/ST yang defic

Body
If sores on body, palpate sores: hot or cold? Soft or hard?
If protrudes the skin and hot and pain worse w/ pressure: yang type sore
If level w/ skin, not hot, only slightly painful: yin type sore
If hard and painful when press, pus hasn’t developed
If soft, pus has developed

Chest/Abdomen
Lying down comfortable w/ knees slightly bent (supported from underneath)
Make sure your hands are warm





HT


SP


LU LV

KI






If pain in abd relieved by warmth: cold pattern
If pain in abdomen relieved by cold: heat
If better when pressed: vacuity
If worse when pressed: excess

If lumps: where are they? What do they feel like:
If soft and moveable: jia: conglomeration (middle jiao)
Qi-type Ju: gathering (lower jiao)

If hard and fixed: zheng: concretions (middle jiao)
Blood-type Ji: accumulations (lower jiao)


Channels and Points
Palpate bilaterally (note differences)
Palpate 5 shu points; front mu; back shu; xi cleft; yuan source; luo connecting (tell about repletion/vacuity in channel itself and associated channel); lower he sea

Look for tenderness, abnormalities, lumps, muscle tone (tense=repletion; soft=vacuity), changes in color and temperature

Palpate A-shi points

Lung: LU 1, KI 27, UB 13, LU 6
HT: UB 15, Ren 14, HT 1
Women: SP 6,9, Ren 4
General Constitution: Ren 4,6