Taut, Tight, Wiry- A Meditation on the Pulse
by Chris Powell
n the fall of 1994, I witnessed this Chinese man saying the most amazing things while feeling a patient's pulse. I sat in utter disbelief as I watched the patient confirm everything John Shen was describing in the pulse. It was that defining moment in my life that I decided I wanted to do what he was doing. Not because it would be fun at parties, but the diagnostic ability and insight was unmatched by anything I had witnessed to that point. Thus began a foray into the most difficult aspect of Chinese medicine...the pulse.
Wang Shu-He states in the preface to The Pulse Classic (脈經 mài jïng) that "the mechanisms of the pulse are fine and subtle, and the pulse images are difficult to differentiate." Most diseases can be quite subtle on the pulse because so much effort is paid to the pattern on the pulse rather than the individual positions or the qualities of that pulse. As we all know, pulse diagnosis is an incredible time consuming and extremely difficult art to master. However, once attention is paid to understanding the story the pulse is telling, a diagnostic window opens for the practitioner to help treat and prevent disease.
One of the most challenging aspects of pulse diagnosis is the notion that the "hard pulse" qualities such as Tight and Wiry are excess conditions. Many of us know that this is often not the case and can be equally, if not more so, a deficiency condition. Most often the Wiry quality is attributed to many pulses that are in fact NOT a Wiry pulse, but much more of a Taut to Tense pulse. The classic "bowstring" pulse is actually not a Wiry pulse, but a pulse that signifies a progression from a normal pulse to a wiry pulse. Much of this new examination of these pulse qualities is more a reflection of actual clinical presentations of chronic conditions and not the acute conditions witnessed in the past. A presentation will follow about the clinical significance of looking at pulses in this new light of clinical data and help one to understand pathogenesis and how it presents itself on the pulse.
SO MANY SCHOOLS, SO MANY NAMES
Over the past 12 years, I have had the honorable position of teaching and helping students, as well as practitioners, understand the pulse as a system of diagnosis. Using Shen/Hammer as a base, I have provided a working model with which one can discern qualities and kinesthetic descriptions of pulses so as to fully comprehend and appreciate what the pulse is telling the practitioner. So many of our past scholars in Chinese medicine, as well as the schools that promoted them, all have put their individual stamp on the pulse. A significant problem with understanding pulse diagnosis is that pulses are often described in metaphor, elemental, and cultural influences of the times. After a name or description is placed on that certain pulse quality, it is handed down generally by word of mouth and memorized as gospel often losing its significance over the centuries. For instance, Wang Shu-He described the Choppy quality of the pulse as:
"It is fine and slow, coming and going with difficulty and scattered or with an interruption, but has the ability to recover."
Physicians, teachers, and students have been memorizing that for nearly 2000 years. As Shen and Hammer point out with many of these examples from the past, the words themselves describe very specific and unique pulse qualities and meanings (Hammer, L., 2001). One of the most obvious problems in describing the above example as a Choppy pulse is that the words themselves become synonymous with the choppy quality. For instance, the quality Fine is generally associated with an early form of blood deficiency usually giving way to Thin and/or Thready. Slow is often an indication of qi deficiency; qi deficiency also can lead to blood stagnation since qi moves blood. The Choppy pulse does indicate Blood Stagnation, but a slow pulse -a sign of qi deficiency- does not indicate a condition of blood stasis (Hammer, L., 2001). It might appear to be splitting hairs here in this discussion, but the point is that many of the words used in the past to describe the pulse were indicative of what was felt at the time.
Those same words can easily define new characteristics and clinical presentations today in the modern clinic. It is true that our bodies have not changed much in the past 10,000 years, but our environs have changed drastically. A Tight pulse during Zhang Zhong-Jing's time most certainly indicated stagnation due to internal cold, but in our modern world it can clearly be a condition of heat from deficiency. This heat from deficiency is a condition of deficient yin (fluids) that is contained within the blood vessel and this heat from deficiency literally dries out the wall of the blood vessel and thus tightens the actual structure of that blood vessel. Much of this process can easily be the result of Liver qi stagnation, causing the tightening of the vessel, which weakens the blood vessel by causing them to dilate. This continued process and the eventual heating up caused by stagnation literally hardens the pulse and the pulse will become Taut to begin with and work its way from Taut, Tense, Tight, and eventually Wiry when all yin essences have been exhausted. Diseases of the past were often severe acute medical insults and the ancient physicians recorded every presentation, including pulses, giving a fairly accurate description of disease progression. Within that framework, pulse descriptions were born out of necessity to understand the body's response to those disease insults. The pulse was and is a clearer picture of what a disease will do to the body. During Zhang Zhong-Jing's day, disease was swift and deadly whereas today we are confronted with chronic disease largely based on stress, emotional, physical, or chemical exposure (Hammer, L., 2001).
Currently many of these modern issues are handled with pharmaceutical interventions. Thus pulse descriptions will be different from those of the past or at least their respective meanings. Using Tight in the above example is just such a change. Many of the pulse descriptions have defied understanding in our schools. We are taught multiple phrases like, "the Wiry String-Taut, Taut, and String-Like" pulse is a bowstring pulse and means wiry and indicates Liver qi stagnation. Use of this nomenclature can mean just liver qi stagnation, but it can mean far greater potential for pathologies. As I interview students currently in schools, they all complain about pulses. Even one school is doing away with learning pulse diagnosis since it is "metaphorical art" and replacing it with allopathic medical examinations and tests. How sad and unfortunate for all involved. Rather than know what the pulse is of a person that is undergoing a Wind Strike pattern, these students have asked me repeatedly "how do you fix a stroke?" The study of pulses, like all of Chinese medicine, is dynamic and growing as it has been for centuries. Learning to differentiate pulses and know what they mean is essential in the practice of Chinese medicine.
THE TAUT TO TENSE PULSE
Ibegin this discussion with Taut to Tense qualities since this is the progression from excess with mild heat. Even though I am using Shen/Hammer as a base, I will not regurgitate their respective descriptions too much as one can use their text on pulse diagnosis if they feel the desire to learn more. This Taut sensation is very similar to what most schools and books describe as a Wiry quality. This is also the infamous "bowstring" pulse written about for centuries as a wiry pulse. However, it is my contention that this is more a result of poor translation. Looking back far in the classics, such as Wang Shu-He's Pulse Classic and Li Shi-Zhen's Pulse Diagnosis, one can find the description of a Wiry pulse as feeling as if a hair has been stretched to the point of breaking. This hard, cutting and exceptionally thin pulse is the wiry pulse. Where the difference comes into play is that this particular translation was used for all harder pulses and became synonymous with the Wiry quality. Hammer differentiates this pulse as the Taut pulse and not a Wiry pulse and he associates the sensation as that of a G-string on a violin, which is the thickest of the strings, and I believe this to be a classical way of understanding how this pulse feels. For those readers not familiar with musical strings, this pulse would be the "bowstring" often described in the pulse literature. This quality represents the mildest form of qi stagnation, usually brought on by chronic stress, with the overall quality of the person's health being good. Historically the use of Si Ni San (Frigid Extremities Powder), with its herbs that move stagnation primarily, was administered to treat a building level of stagnation.
The Tense quality is just a little harder on the pulse, a little less flexible, and some evidence of heat beginning to develop. The physical sensation is stretched and somewhat thinner. It still maintains volume within the vessel and can feel similar to a stretched clothesline or, as Shen often described, the D-String on a violin. This progression means that the stagnation has lasted somewhat longer and the constraint of Liver qi is much more evident. This is the pulse that Shen and Hammer would equate with repressed emotions such as anger or resentment and often treat with Xiao Chai Hu Tang (Minor Bupleurum Decoction), instead of the typical Xiao Yao San (Rambling Powder). It is the heat clearing herbs such as huang qin (Scutellariae Radix) that enable this formula to break the likelihood of building heat. This is the classic pulse of the hepatitis patient, although this Tense quality can also develop a big or flooding sensation. In the clinic I have found this Tense sensation to be associated with a Floating pulse, which represents stagnation in the channels due to wind-cold. This cold has penetrated inside leading to greater stagnation of qi movement, which in turn causes the body to heat up to resolve the stagnation and floats the pulse.
THE TIGHT PULSE
The Tight and Wiry pulses probably cause the most consternation within Chinese Medicine. Mostly this is due to misinterpretation and multiple descriptions of those qualities over centuries. As we progressed from the epidemiological transition to the current problems with aging and chronic disease, these particular pulse descriptions most often are not correctly used. The Tight quality is much harder than the Tense quality as well as less flexible. It still maintains some volume within the vessel, thus indicating some resiliency. Shen describes this as the thinner A-string on the violin and I agree that this is an exact description as to the sensation one feels on the pulse. If one could stretch a piece of cooked spaghetti to the point of it becoming hard, this would be close to the Tight sensation. It is because one can still feel a sense of volume within the hardness. Shen/Hammer would often describe this as a pulse where the practitioner would need to use Liu Wei Di Huang Wan (Six Ingredient Pill with Rehmannia) or Xiao Yao San (Rambling Powder). I however do not agree with these formula choices. In the clinic I have found more often that this pulse represents more of a shaoyin conformation and that one should consider the use of Shen Qi Wan (Kidney Qi Pill) or Zhen Wu Tang (True Warrior Decoction) depending upon the level of tightness and where it reveals itself on the pulse. By this I mean where in the levels of the pulse does this tight quality appear? For instance, if the Tight quality is more evident in the qi layer then one should consider it evidence of acute cold invasion with joint pain, headache, and a slight fever. If this Tight quality is deep, then most often it indicates heat from deficiency in the yin organs. The Tight pulse is generally a thin pulse as well due to early stages of blood deficiency. The progression from the Taut and Tense qualities to Tight and Wiry demonstrate clinically the increased likelihood for blood deficiency. As the pulse moves from Taut to Wiry, the evidence points to an increase in the consumption of yin and fluids in most contemporary thought. Pain also increases the likelihood for the pulse to become tighter and less resilient as does cold, trauma, and infection.
The key to differentiating the Tense quality and the Tight quality is the thinness present. I have constructed models with musical strings so as to be able to consistently feel the difference between these two pulses. The nuance is there and the treatment difference can be quite profound. The pulse tells the practitioner what is happening and what herbs to use, we just have to listen.
THE WIRY PULSE
This quality has caused more confusion, more wrong diagnoses, and most misinterpretation than any other pulse quality in Chinese Medicine. So many of the "wiry" pulses out there do not feel anything like a wire. So many schools teach students that a Wiry pulse is the most common pulse in America and that it should be treated as Liver qi stagnation with acupuncture and Xiao Yao San (Rambling Powder). As was stated earlier, this pulse quality is more often a Taut pulse sensation and not a true Wiry sensation. This is the hardest sensation beneath the fingers and feels just like it sounds: like feeling a thin wire. Shen used the analogy of the tiny E-string (the thinnest and tightest on a violin) and I believe this to be incredibly accurate as well. Laying your fingers on a thin wire is the quality one is looking for when feeling a Wiry pulse. It feels thin, hard, cutting to the touch, long and continuous, and does not move away from the fingers when pressed. If the pulse does not feel like what was just described, it is not a Wiry pulse. Similar to the Tight quality in decreased essence and fluids, the Wiry stage represents the complete and final stage in the depletion of yin and blood.
Clinically, I have found the Wiry quality on the pulse in cases of extreme and severe pain. It has also been found to be present in cases where the exhaustion of yin and blood, coupled with stagnation, produces Liver wind in the channels. This Liver wind can become so extreme that the likelihood of a Wind Stroke is present, particularly when the Wiry quality is over the entire pulse. A Wiry quality also represents the jueyin conformation with herbal formulas like Dang Gui Si Ni Tang (Tangkuei Decoction for Frigid Extremities) being used to treat the extreme deficiency. Others believe that You Gui Yin (Restore Left Kidney Decoction) is an exemplary formula to use, but I have not found that to be the case in my practice. A pulse can be hard and wiry, but also have volume and appear to be "big" in sensation. I believe this is most often prevalent in cases of acute hepatitis. Cirrhosis, chronic hepatitis, liver cancer, and fatty liver all produce a wiry quality to the pulse, particularly in the guan position on the left side. This sensation is often given the term "big" and wiry at the same time. This particular sensation had eluded me for some time because it truly did not make sense. In a personal conversation with Dr. Arnaud Versluys about this "big and Wiry" sensation, he explained it as feeling a pulse with some amount of volume yet having a very hard surface. It then became apparent that these sensations can appear on the surface of the vessel, yet still be able to have some resiliency to it. I have observed several cases of multiple myeloma that can produce this big and Wiry sensation.
Individual positions and the qualities of Taut, Tense, Tight, and Wiry are beyond the scope of this paper. More importantly, it is necessary to understand the terminology of the pulse and the kinesthetic sensation beneath the fingers. These "hard" qualities of the pulse have often been misinterpreted within the framework of pulse diagnosis, yet people respond to treatment… an interesting phenomenon in all forms of medicine to say the least, but an important observation nonetheless. For example, with a Taut pulse (think wiry in most schools) one can needle the patient and give them Xiao Yao Wan (Rambling Powder) for the rest of their lives and they will always feel better as long as they are taking the herbs. Take them off, and "their treatment did not hold." Much of this is due to Xiao Yao San's (Rambling Powder) ability to ameliorate emotional stressors and add some blood tonifying properties to the patient. However, if their pulse is truly a Taut pulse, which indicates mild stagnation at a very early stage, then a formula such as Si Ni San (Frigid Extremities Powder) can help in a short amount of time. As Shen would often say in clinic, this is harder to understand because we were taught to think that the Wiry pulse needed the blood tonifiers in Xiao Yao San (Rambling Powder) for treatment; however it appears the use of Si Ni San (Frigid Extremities Powder) is able to stop the progression toward a more true Wiry quality because of its ability to break the early stagnation indicated by the Taut quality. The Tense pulse over a long period of time does indicate the progression toward exhaustion of yin, qi, blood, and yang. This particular quality if left untreated begins to show greater signs of Liver qi stagnation with much more binding sensation of the chest, sighing, distension beneath the ribs, and bitter taste developing. This pulse actually will produce harder sensations at the guan positions thus indicating the use of Xiao Chai Hu Tang (Minor Bupleurum Decoction) as the formula of choice.
Tight represents a long-term degradation of yin and blood.It can also indicate a recalcitrant Cold stagnation. This severe cold is often thought of as an external invasion, but in our modern world most intense cold stagnation is the result of pharmaceutical intervention. It is quite clear that use of allopathic medications does create Cold in the body. Antibiotics have long been known to create severe cold in the kidneys and that is evident on the pulse by producing a definite tightness in the chi position. Also, diabetes creates a tight pulse quality and will lead the pulse to a more wiry quality as the disease progresses. This tightness to the pulse can sometimes be missed as a faint and thready pulse, but this is a mistake. If one spends enough time on that particular pulse, the hard and tight quality will make itself known to the practitioner. It is easy to give the wrong herbs for this presentation, but in my clinical experience I have observed good results with Shen Qi Wan (Kidney Qi Pill), Zhen Wu Tang (True Warrior Decoction), and at times depending upon the other signs and symptoms one can use Ma Huang Fu Zi Xi Xin Tang (Ephedra, Asarum, and Aconite Accessory Root Decoction).
The Wiry quality is the ultimate depletion of all body fluids and yin and yang. It is the Dang Gui Si Ni Tang (Tangkuei Decoction for Frigid Extremities) pulse. This formula will change the pulse in a matter of days instead of weeks or months. If the pulse has become a true Wiry pulse, it is appropriate to treat the patient aggressively. I have witnessed this pulse change in less than a week on this formula. This formula is not one to be taken for months or years. When the pulse is Wiry, it is time to devise a rescue plan, as the patient has reached a dangerous level of health. If left untreated, the Wiry pulse will spread over the entire pulse and then become muffled which, in my experience, represents the development of cancer in the body.
The pulse as a diagnostic tool is one of the most important in our arsenal as Chinese medical practitioners. It truly is our MRI and CAT scan. Since Zhang Zhong Jing began feeling and recording pulses, the understanding of disease presentation and progression has grown exponentially. So many practitioners from the past have attempted to add their respective thoughts and findings on the pulse and there is where some misinterpretations have developed. Chinese Medicine is a dynamic system and we need to change it as our society changes as well as our environment. Our physical bodies have not changed that much, but how we respond to external stressors has changed. As we change in our response, so will the pulse. But the pulse will always tell us as practitioners what we need to do and how fast we need to do it. The pulse does not deceive. It is the window of the person from birth to death and we, as health care providers, get to participate in that patient's process.
Hammer, Leon. Chinese Pulse Diagnosis; Eastland Press, 2001.