Friday, June 15, 2007

Pulse diagnosis

A significant amount of alternative medical modalities have taken the tact of “integrating” into the arena of mainstream medicine claiming supposed "complementary" benefits. These modalities seek to legitimize irrational therapies by association with proven practices. This in itself poses tremendous problems. However, it is important to note that many alternative practitioners actually still utilize methods of examination that stray far from rational pathophysiological approaches with some claiming that: “All Chinese medical treatments such as acupuncture and herbal prescriptions use pulse diagnosis as a basis to formulate treatment methods specific to the individuals needs.”

The practice of pulse diagnosis literally bases its foundation on highly elaborate and archaic philosophical belief systems that often vary in detail depending on their regional and historical origins (i.e., Traditional Chinese Medicine or Ayurvedic Medicine). There is little reliable literature regarding this practice outside of a historical context though there have been attempts to develop a methodological approach to using them that rely on dubious assumptions. Many of these methodologies utilize the practice of manually palpating the radial pulse of an individual to diagnose a patient’s malady. Apparently, in the right hands, this diagnostic modality yields an immense amount of information regarding a patient’s condition and disease process, including their emotional and mental conditions:

Any practitioner of traditional Chinese medicine (TCM) will tell you that the fine art of pulse diagnosis requires a combination of diligent study and innate talent. This essential diagnostic tool provides insight into the state of organ health, emotional and psychological functioning as well as concern for ones future health.”

The conceptual framework of pulse diagnosis seems to have different interpretations based upon a practitioner’s Traditional Chinese Medicme (TCM) schooling and unique personal impressions. "Modern" pulse diagnosis involves the palpation of the radial artery utilizing three specific fingers while applying varying degrees of pressure. The practitioner interprets the character of the pulse then diagnosis the patient’s problems drawing upon “energy flow” philosophies that describe nebulous associations of organs, energies, elemental qualities (heat, cold, wind, dampness…).

“In performing pulse palpation, the practitioner places the index, middle, and ring fingers on the radial artery. Three degrees of pressure, the light touch, the medium touch, and the heavy touch are applied to the region and correspond to the upper, middle, and lower areas of the body.

In traditional terms, there are 28 pulse classifications, which describe the way the pulse feels to the fingertip. Some examples of these classifications are:

  • Slippery - feels like a rolling pearl in a basin, very fluid and full
  • Choppy - has no strength and is irregular
  • Full - large and rounded, can be felt at all levels
  • Empty - hard to detect or felt only slightly at the superficial level when pressure is applied
  • Slow - slower than the normal rate of four to five beats per breath
  • Rapid - six to seven beats per breath
  • Superficial - easily felt on the skin surface
  • Deep - only felt with a heavy touch”

These palpation techniques were apparently far more elaborate in the past, but have been simplified, perhaps to satisfy the needs of western practitioners:

“Originally, pulses were felt at various locations, three on the head, three on the each arm and three on each leg. However, in modern times, the majority of TCM practitioners perform a simplified version which examines three finger positions at three depths referred to as cun, guan and chi.’

Practitioners rely on the quality of the pulse taking into account “frequency, rhythm and volume.”They claim pulse diagnosis reveals “internal and external factors” that cause a disease process while at the same time identifying the affected organ. The tired old canard that western medicine views each organ as functioning individually while eastern medicine “acknowledges” the relationships between all organs is also mentioned.

Pulse diagnosis is associated with belief systems that probably originate during the tumultuous pre-enlightenment period during the Han dynasty (2nd century BC-2nd century AD) when a cultural elite attempted to intuitively categorize elements of disease. The concept of natural correspondence; that is, creating associations with observable natural phenomena gave rise to differing and often competing theories such as philosophies using the five elements or those based on blockages of “Qi” flows:

A central feature of traditional Chinese medicine (TCM), the Zang-Fu theory represents a fine balanced network which is held between the interior organs of the human body and the conditions represented on the exterior due to imbalances between these organs. There are five Zang organs which include the heart, lung, spleen, liver and kidney…According to Traditional Chinese Medicine (TCM), the inner workings of our bodies, and Zang-Fu organs, are seen as a delicate balance held by the Chinese philosophical concepts of yin and yang - two opposing, yet inseparable forces… Any disturbance of this natural equilibrium results in blockage to the flow of Qi and the onset of disease…With a thorough understanding of the Zang-Fu organs and yin yang balance, a simple pulse diagnosis can reveal more than you think. It is with this ancient diagnostic tool that help traditional Chinese medical practitioners heal from the inside out.”

Another interpretation discusses hard to pin down "pattern associations reminiscent of "intuitive”correspondence. In other words, reflecting the fact that many of the foundational building blocks of interpreting a pulse diagnosis (and acupuncture points for that matter) were created during a historical period of time that, although active and dynamic, never reached an effective consensus of rational theory and reality based medicine:

“The hallmark of TCM as a style of Chinese medicine is its emphasis on treatment based on pattern discrimination (bian zheng lun zhi). This means that, although TCM practitioners first make a disease diagnosis (bian bing), treatment is based more on the pattern discrimination than on that disease diagnosis. In other words, the overall guiding treatment principles for the case at hand are based on the pattern discrimination, not on the disease diagnosis.”

It is these principles which guide the selection of the Chinese medicinal formula or main acupuncture points. Once these main principles are stated and a basic treatment protocol is erected based on these principles, medicinals or acupuncture points are then added to the base protocol depending on their empirical efficacy for the particular disease under treatment….”

Animals are not immune from this irrational thinking:

"Similarly to human acupuncture veterinary acupuncturists will check the pet’s smell, listen to any noise they make, examine the tongue colour and coating, and check the pulse and specific acupuncture points. A TCM diagnosis helps with point selection but more often that not an intuitive approach, sensing the points and checking pulse changes determines the treatment."

This commentary alludes to the fuzzy logic used in a vain attempt to create associations that categorize and identify diseases. This type of thinking is reminiscent of the empty justifications promulgated for today’s “modern” homeopathic practices. In an era of little pathophysiological knowledge this form of reasoning might be understandable. Today however, there is little basis, other than belief and cultural based rationalizations, to support medical therapies based on this approach.

The intuitive nature of how these medical modalities came about seems obvious. Intuition in and of itself can lead to great discovery. However ideas need to be followed up by corroboration and evaluation before incorporating them into reality based medical practices. In TCM, pulse diagnosis relies on essentially made up assumptions based on shaky conclusions and even shakier understandings of the natural world. This is indeed a weak foundation from where to build elaborate healing practices (including acupuncture).

This is further illustrated by the following statement (Like pulse diagnosis, tongue examination follows a similar strange and irrational logic):

“TCM patterns are discriminated by means of the four examinations (si zhen). These are visual examination (wang zhen), inquiry (wen zhen), listening and smelling examination (wen zhen), and palpation (qie zhen). It is by means of the combination of these four methods of examination (si zhen he can) that a TCM pattern is identified. However, most modern TCM clinical manuals describe this combined summation and analysis in terms of main symptoms (zhu zheng), examination of the tongue (she zhen), and pulse examination (mai zhen). In other words, in clinical practice, patterns are based on three broad groups of information: 1) signs and symptoms, 2) tongue examination, and 3) pulse examination. It is the comparison and corroboration of these three groups of information which differentiate one pattern from another, and it is extremely important that no one sign or symptom means anything except in relationship to all other signs and symptoms gathered by the four examinations.”

As supporters of pulse diagnosis attempt to justify their place as a legitimate practice they resort to familiar fallacious reasoning :

“…we as Western practitioners tend to see a disproportionate number of difficult cases which are either not self-limiting or have not been successfully treated by modern Western medicine and often other types of alternative medicine as well- Ad Hominem, Argument by Seletctive Observation, Ambiguous Assertion. This is because, here in the West, we are so often practitioners of last resort- Ambiguous Assertion, Argumant by Selective Observation, Appeal to Anonimous Authority. Further, because of the modern Western diet, the adverse effects of certain modern Western medical treatments, the ill effects of pollution, and the pervasive stress of our modern society, most of our patients suffer from complex, chronic conditions which frequently and I might even say typically do not display the nice, neat, simple patterns contained in beginners' TCM textbooks.”Argument By Scenario, Appeal to Compexity, Ambiguous Assertion, Appeal to false Authority, Bad Analogy, Appeal to widespread belief, Fallacy of Compostion, Begging the Question…

Elementary my dear Watson…

Today’s “traditional” clinical diagnostic techniques are built on the foundation of science based knowledge garnered from many disciplines (physics, physiology, biology, chemistry, pharmacology….). Patient diagnostics base themselves on logical threads comprising data collection that include histories, physical examinations, a solid understanding of pathophsiological processes, and the use of evidence based therapies.

The overall goal is concerned with identifying problems, discovering and understanding the disease process behind them, and working towards solutions by applying appropriate management and treatments modalities. Pulse examinations are also utilized- but in a completely different context. They comprise one of a plethora of tools utilized in a physical examination and other situations (pulse monitoring in surgery) that gather bits of information that will be used for problem identification. Unlike the TCM pulse examination, these pulse techniques are based on physiological, anatomical, and biochemical attributes of the body- not energetic or intuitive associations.

Pulse diagnosis as used in Traditional Chinese Medicine (including acupuncture) and other pre-scientific traditions, is an irrational and inconsistent diagnostic methodology and does not meet the standards of repeatability, plausibility, and efficacy for diagnosing anything other than imaginary disease.


Anonymous said...

Have you everr tried it? Find a good practitioner and try a treatment. Whether or not it can be explained properly doesn't mean it doesn't work. Whether or not one has a good chemical analysis of the herbs doesn't mean they can't work. Whether or not we understand the scientific basis of acupuncture doesn't mean it doesn't work. But of course a great deal of research has been done acupuncture and is showing that it does have good reasons for working. I use pulse diagnosis and find it works incredibly well. I haven't been to a doctor in almost 30 years and am healthy using only herbs and acupuncture. The proofs in the pudding.

Dr G said...

Problem is...your pudding's curdled. I have delved into many of the CAM modalities from ontological paradigms to all kinds of therapies...used to consult for a whole food nut. sup. comp.- came to realize its all mostly a paper tiger. Worked with many practitioners...not impressed.
Placebo is a fascinating should check out other posts here and on the links that discuss epidemiology, statistics, quantum physics, evidence and science based medicine.....
There are things that work and we don't know how...but we can establish that they work...not so for acupuncture nor pulse d. or most other CAM modalities.
Testimony, claims to complexity and misrepresenting the scientific method get one nowhere. The proof is in the science...alas, beleiving whatever you want it doesn't make it real

Anonymous said...

(This is the EGO at work.) "The proof is in the science...alas, beleiving whatever you want it doesn't make it real."
What is real? It seems you have defined TCM and 5000 years of history in your "science". Don't get me wrong I am all for the plight of truth but there is always something to learn.
I don't care about your degrees or experiences, trust me that you have no idea.
Perhaps it is this attitude which converts so many to alternative medicine.

Dr G said...

"(This is the EGO at work.)"

Huh, no...this is science (not religion or personal ontologies but a huge collaborative framework trying to make sense of the world...egos, mistakes, and incomplete theories change,flex & blend among other things with progressive learning unlike TCM for example.

"What is real?"

Sounds like a call for more fallacious postmodernist thinking. Do you have a better methodolgy than the scientific method & similar modalities to observe reality?... if so bring it out. science is all about that...

"It seems you have defined TCM and 5000 years of history in your "science"."

I suggest you break out those history books before you define what I might start with

Arguments by antiquity are very common...still not enough of a reason to be right though.

"Don't get me wrong I am all for the plight of truth but there is always something to learn."


"I don't care about your degrees or experiences, trust me that you have no idea. Perhaps it is this attitude which converts so many to alternative medicine."

Think I'll let that little ad hominem speak for itself.