Chapter contents
8.1 Same disease different pulse; different pulse same disease 179
8.2 External pathogenic attack versus internal dysfunction 179
8.3 Blood 188
8.4 Qi 196
8.5 Yin vacuity 198
8.6 Yang vacuity 198
8.7 Health 199
8.8 The Unusual or Death pulses 200
8.1. Same disease different pulse; different pulse same disease
A clinical complication for the use of pulse diagnosis is that there can be a range of quite distinctly different pulse qualities that form in response to apparently the same illness or dysfunction. Blood vacuity or anaemia is an apt example of this. Blood vacuity pulses can present with both increased and decreased changes in the arterial width. With this in mind, there is still a further complication with the similarity of some pulses; while they are similar, diagnostically they reflect different pathological processes and the general health of the patient. This situation is aptly described in the Chinese medical axiom:
Tong bing yi zhi,
Yi bing tong zhi,
Different disease, one treatment
Same disease, different treatments
8.2. External pathogenic attack versus internal dysfunction
External pathogenic attack (EPA) refers to pathogenic agents external to the body that give rise to illness and can cause dysfunction. From a biomedical perspective this can broadly relate to common colds and influenzas and encompass other viral, fungal and bacterial agents. In a CM context, categorisation of illness due to pathogenic agents is based on the resultant signs and symptoms, the body’s response to the pathogenic agent. In this sense, pathogenic agents causing fever are broadly classified as Heat; pathogenic agents causing swelling and oedema are classified as Damp. There are also Cold, Dry and Wind pathogenic agents in addition to Heat and Damp. Pathogenic agents can also combine to form complex conditions such as Damp Heat as seen in viral infections such as varicella (chickenpox).
A traditional assumption associated with the pulse when EPA attacks the body is the movement of the body’s defensive Qi to accumulate or move outwards to the superficial regions of the body. The pulse correspondingly becomes relatively stronger at the superficial levels of depth. EPAs are a perverse version of Qi, certainly pathogenic, but still Qi. In this sense, when a pathogen attacks the body then there is extra Qi, additional to the normal levels of Qi in the body. The addition of the Qi makes the overall force of the pulse increase. This occurs in addition to the increasing defensive Qi levels at the external parts of the body to counter the EPA and reflected in the pulse as being strongest at the superficial level of depth.
When the pulse is distinctly stronger at the superficial level of depth, and consecutively less strong at the middle and deep levels of depth, then this is termed a Floating pulse reflecting the movement of defensive Qi to counter the pathogen.
The Floating pulse also occurs with internal dysfunction causing conditions of hyperactivity such as seen in states of anxiety or stress. This is termed Yin vacuity (Yin deficiency). This occurs when the body’s ability to control Yang is compromised, causing increased activity of Yang. The Floating pulse occurs as Yang moves upwards and outwards, which is seen as pulling the Qi and blood with it. Another useful way of looking at this is via the control mechanisms of the autonomic nervous system; the parasympathetic nervous system’s counter control to the sympathetic nervous system, and the related feedback systems are no longer able to keep activity in check.
The Floating pulse can therefore occur in the presence of EPA but also with internal dysfunction. As there are two quite distinct aetiologies, the Floating pulse can be further differentiated by the related changes in other accompanying pulse parameters. In this case the Floating pulse due to an EPA is accompanied by an increase in pulse force, reflecting the increased metabolic demands of the body to combat the pathogen. The Floating pulse resulting from Yin vacuity will have a decrease in pulse force reflecting the empty-type hyperactivity occurring.
There are a range of pulse qualities that occur with external attack by pathogenic agents. Although most of these pulse qualities are strongest at the superficial level of depth, they will by no means all present as a Floating pulse. Depending on the changes in other pulse parameters, usually in regard to the type of pathogenic agent, several other traditional pulse qualities can develop. There are specific differences in the parameters of these pulses that differentiate them from the Floating pulse, as there are specific differences in the parameters of the Floating pulse to further differentiate it from other superficially occurring pulses. Additionally, not all acute pathogenic attacks will result in a superficially strong pulse, because sometimes the pathogen goes directly into the interior and affects organ function. The pathogen can also mutate, so one pulse quality occurs initially and as the pathogen mutates so the pulse quality also changes. The Tight pulse in response to Cold EPA moving to the Replete pulse occurs as the Cold EPA becomes warmed by the body’s heat. (Fig. 8.1)
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| Figure 8.1The likely transformation of an EPA of Cold to Heat and the formation of the Tight pulse and consequent formation of the Replete pulse. (Developed from information in Dinarello & Gelfand 2001). |
Following is a discussion on the pulses formed with different pathogenic agents. Additionally, some of these pulse qualities can also occur via mechanisms reflecting internal dysfunction of the body’s homeostasis or balance and are not necessarily due to an EPA; the discussion focuses on these differences and hence appropriate classification methods.
8.2.1. Pulse qualities reflecting Damp
The term ‘damp’ is used both descriptively and diagnostically. Descriptively it is used to describe any accumulation of fluids or moisture. This can be apparent as with the retention of fluid clearly seen with swelling of the ankles or face, overproduction of mucous, runny nose or coughing mucous from the lungs (Box 8.1). When the term ‘damp’ is applied diagnostically, it is used to describe the pathogenesis or cause of the illness as arising from Damp. In this sense, it is used to describe the symptomatic manifestation of Damp signs and symptoms. The term also loosely encompasses phlegm, which occurs when fluids congeal.
Box 8.1
Damp signs and symptoms
• Feelings of heaviness/fullness
• Lethargy
• Nausea/bloating
• Oedmea/fluid retention
• Copious urination
• Readily combines with pathogens of Cold and Heat
Damp illness can arise from internal and external causes. As an internal cause, Spleen Yang Qi vacuity or digestive weakness often gives rise to Damp accumulation as the distribution and transformation function of moving fluids and nutrients around the body is compromised and so fluid accumulates producing Damp. Diet-related causes are also common when particular food groups causing Damp are eaten in excess or are unable to be appropriately digested. For example, dairy products, raw foods, cold foods, oils and uncooked foods can be causes of Damp accumulation, often affecting the Spleen Qi and/or Yang. Damp formation also arises from external causes. For example, external pathogenic agents such as Cold have a congealing affect on the fluid in the body producing dampness, or Damp can arise from Damp pathogenic agents as well.
From a pulse diagnosis perspective, four of the traditional pulse types are associated with Damp:
• Slippery pulse (section 7.9.1)
• Soggy pulse (section 7.7.6)
• Moderate pulse (section 6.4.3)
• Fine pulse (section 6.12.1).
One other pulse quality can be categorised with Damp, and is associated with the formation of phlegm in particular:
• Stringlike (Wiry) pulse (section 7.5.1).
The first four pulses associated with Damp can be divided into two categories based on the parameters of their formation. The first grouping is that of Fine pulse and Soggy pulse, similar in width. The second grouping is the Moderate pulse and Slippery pulse, similar in contour. The two groupings are quite distinctly different. The first is a change in the physical characteristic of the artery, that of width, while for the second grouping it is a noticeable change in the pulse wave contour. Each is discussed in further detail below.
8.2.1.1. Fine pulse and Soggy pulse
The Fine and Soggy pulses are similar in their presentation, presenting with a reduction in arterial width and are forceless. In fact, as the Fine pulse is often used as a general descriptor of all superficial narrow pulses, the Soggy pulse and Fine pulse, in this instance, are one and the same for the presentation of damp. The Soggy pulse is a narrow pulse, an extension of the Fine pulse, because it has changes in other parameters which the Fine pulse does not.
The pathogenesis of the formation of these pulses arises from damp due to internal vacuity, or where damp has caused internal vacuity of Yang.
The Soggy pulse generally reflects vacuity of Qi and Yin/Blood but also presents with a further decreased force when damp is present. In this situation there is no distinct change in the contour of the pulse wave, as seen with the Slippery pulse and Moderate pulse. The forceless nature of the pulse which occurs in the Soggy pulse arises from the damp impairing the ability of the pulse wave or Yang to expand. Damp pathogenesis from an EPA is additionally reflected in the presentation of the Soggy pulse, felt strongest at the superficial level of depth where the body’s defensive Qi rises to fight the pathogen.
8.2.1.2. Slippery pulse and Moderate pulse
The Slippery and Moderate pulses are very similar in their presentation, both presenting with distinct contour changes in the accompanying pulse wave. They are differentiated by the parameter of pulse rate and also by the strength and speed of cardiac contraction. The Slippery pulse is described as occurring in the presence of heat and so the pulse rate is likely raised. There would additionally be an increase in the strength and speed of cardiac contraction so the pulse is also felt strong and distinct. The Moderate pulse has a pulse rate of 60 bpm – reflecting a relative cold pathogen. As such, both pulse qualities can represent damp but are differentiated by the nature of the damp, whether hot or cold. There are probably additional differences in the underlying mechanisms of pathogenesis which further differentiate the two pulses. For the Moderate pulse, the damp is seen as having a constraining affect on the body’s activity (Yang). This suggests that the constitutional strength of the individual has a distinctive role in whether the Slippery or Moderate pulse will occur. (The difference between the Moderate pulse and Soggy pulse in this instance is that there is sufficient arterial volume with the Moderate pulse, while with the Soggy pulse, blood is vacuous or of not good quality.)
The contour changes associated with the Slippery and Moderate pulses can be explained by the appropriate physiological strength of the Qi and blood, in spite of the presence of a pathogenic agent. The pulse can then be seen to represent relatively new illness. (For the Soggy pulse the Qi and blood have been affected or were already depleted when the Damp pathogen arose.)
When Qi and blood are abundant, and there are no apparent signs of illness, then a similar pulse presentation of the Slippery pulse and Moderate pulse can occur as a sign of health. In this instance, the Slippery pulse is differentiated from the Moderate pulse by the parameter of pulse rate. The Moderate pulse has a pulse rate of 60 bpm.
Possible parameter changes associated with Damp (Table 8.1)
• Arterial width narrows: The Soggy pulse and Fine pulse form because blood is already depleted so Damp compresses the pulse.
• Pulse contour and flow wave changes: The Moderate pulse and Slippery pulse form only when blood is abundant or arterial volume is full (whether from blood or fluid accumulation).
8.2.1.3. Stringlike (Wiry) pulse (Xián mài)
The Stringlike (Wiry) pulse can reflect the consequences of a particular form of damp termed phlegm. Phlegm occurs as a result of congealed fluids due to pathogenic factors such as heat or fire, or from the poor circulation of fluids causing these to collect and congeal. The Spleen and Lungs are often linked to internal causes of phlegm formation because of their functional relationship with circulating and transforming fluids.
Phlegm is an obstructive substance impeding the normal flow of Qi and blood through the tissue and organs, placing stress on the system. Phlegm causes obstructions, obstructions cause pain. An increase in arterial tension is therefore not an unexpected response. (Note that phlegm is divided into further complex patterns dependent on other signs and symptoms. Relevant texts should be consulted for further information.)
8.2.1.4. Clinical application of the damp pulses
Clavey (2003) notes that diagnosis of damp or phlegm conditions should not depend solely on on the pulse. He notes that a lack of a ‘damp pulse’ does not preclude the presence of damp (p. 296). The reason for this is that damp is often a symptomatic consequence of dysfunction. For example, when the body’s Yang warming function is impaired, moisture accumulates and congeals producing damp. In this situation, damp is secondary to the primary Yang vacuous condition. Lyttleton (2004) describes a scenario of infertility in a patient due to blockage of the reproductive organs due to Phlegm-Damp in which the damp pathology does not manifest on the pulse:
… if the accumulation of Phlegm-Damp is isolated in a discrete location (e.g. one fallopian tube) then it may not register on the pulse. If Kidney Yang deficiency or Liver Qi stagnation are contributing causes of the Phlegm-Damp, their characteristics may be felt on the pulse instead (p. 96).
8.2.2. Pulse qualities that reflect Cold EPA
Cold by nature contracts and obstructs, it congeals fluids and counters the warming nature of Yang. Heat produced from metabolism is an expression of the body’s Yang-related functions and so when a pathogen of Cold invades then the body’s physiological functions are affected. This can arise in signs and symptoms such as chills and aversion to cold (Box 8.2). Cold invasion affects the pulse in three ways:
• Pulse rate: Qi is seen as a motive force, giving rise to and ensuring the regularity of the heart contraction and movement of blood in the vessels. Pulse rate is a reflection of the functional activityof Yang to speed up or slow the heart rate. As Cold counters the Yang then the pulse rate slows (but importantly, heart rhythm is not interrupted as the heart Qi remains functional).
• Arterial tension: Cold has a contracting action on the flesh, and arterial tension increases as the Cold contracts the flesh. An increase in tension can also be viewed in this respect as the body’s attempt to maintain internal warmth, conserve the Yang, by reducing the area of the artery and Qi and blood exposed to the pathogenic Cold: a defensive mechanism to prevent internal invasion of Cold. Control of temperature regulation from a biomedical perspective is associated with the hypothalamus, which increases the body’s ‘normal’ temperature to a higher set point, and so the physiological response is an attempt to conserve body heat in order to raise body temperature to the new set point (see Fig. 8.1) From a CM perspective, an increase in arterial tension can also refer to the obstructive action of Cold on the normal flow of Qi and blood. Obstruction is associated with pain, and pain causes an increase in sympathetic nervous system activity further affecting arterial wall tension.
• Level of depth and strength: The level of depth at which the pulse is felt strongest with Cold pathogens is variable and depends on the body’s immune function and the intensity of the Cold pathogen. This is because acute Cold pathogens are known to affect the internal organs almost immediately, while other types follow a progressive movement from the exterior to the interior over time. In the former case the pulse is felt strongest at the deep level of depth and in the latter, at the superficial level of depth.
Box 8.2
Cold signs and symptoms
• Aversion to cold
• Chills
• Preference for warmth and warm drinks
• Clear coloured urine
• Combines with pathogens of Wind and Damp
• Pulse parameters:
– Slow rate
– Increased arterial tension
Five traditional pulse qualities are associated with Cold invasion or are attributable to the presence of a Cold EPA:
• Drumskin pulse (section 7.5.4)
• Tight pulse (section 7.5.2)
• Firm pulse (section 7.7.2)
• Hidden pulse (section 6.9.3).
Of these five traditional pulse qualities, the Slow pulse is the simplest to recognise and will nearly always be accompanied by signs and symptoms that reflect Cold. It is likely to combine with the other four pulse qualities when Cold pathogens are present. For example, the Tight pulse due to Cold will have increased arterial tension and a decrease in pulse rate.
The remaining four pulses range from those that form when there is an acute EPA Cold attack affecting the external regions of the body through to serious and chronic internal attack by Cold EPA. Of these the Tight pulse, Firm pulse and Hidden pulse can be arranged sequentially to reflect the continuation of a Cold EPA from the external regions of the body into the interior. (In addition to Cold EPA all three pulses also occur when there is stagnation of food, indicating a relationship/pathway between the pathology and their formation; see Fig. 8.2.)
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| Figure 8.2Progression of Cold EPA from the exterior to the interior and consequent formation of likely pulse qualities. |
8.2.2.1. Slow pulse
A decrease in pulse rate is a generic change in the parameter of rate that occurs when Yang is affected causing pulse rate to slow. If the pulse rate falls to 60 bpm or less then this is the Slow pulse. A decrease in pulse rate is likely to occur in combination with the other pulse qualities listed above, when caused by a Cold EPA aetiology.
The Slow pulse is the simplest of the five traditional pulse qualities to recognise associated with a Cold EPA. Yet, a decrease in the pulse rate with Cold need not be so great as to cause the rate to fall to 60 bpm or less, the range ascribed for categorising the pulse rate as the Slow pulse. The Slow pulse can also occur from internal Yang problems which slows the pulse. This is termed Yang vacuity (or Yang deficiency). (Yang vacuous pulses are discussed elsewhere.) In this sense the Slow pulse alone is not diagnostically specific enough to differentiate between a Cold EPA and Yang vacuity. It is necessary to assess the presentation of other pulse parameters to do this. Pulse force is an important additional parameter for this purpose: an increased force occurring with a decrease in pulse rate would likely indicate an EPA of Cold, whereas a decrease in both pulse force and pulse rate indicates dysfunction arising internally from Yang vacuity. When Yang is deficient the pulse sinks, being felt at a deeper level of depth than is normally felt for the affected individual.
Progression of Cold in the body
There are situations in which the body’s immune system is weak and so an EPA of Cold quickly goes internally and affects the organs directly. The digestive organs of the Stomach and intestines are prone to this occurring. In this situation, Cold continues to have its contracting affect, obstructing the free flow of Qi and blood. Fixed abdominal pain is symptomatic of this scenario. The formation of the Firm pulse or Tight pulse may result. The Firm pulse is a natural continuum of the Tight pulse when the Cold pathogen is either chronic or is causing severe pain.
The presence of Cold internally will counter the associated organ’s Qi or functional capacity, and eventually the body’s Yang. Eventually, a Yang vacuous condition will arise over time in spite of the initial problem having arisen from an ‘excessive’ Cold EPA. In time, the pulse continuum progresses from a pulse with strength to one without strength.
8.2.2.2. Tight pulse and Drumskin pulse
The two other Cold-related pulses are the Tight pulse and the Drumskin pulse. These are both complex pulse qualities, developing from changes in several pulse parameters. Both are distinctive pulses with their associated increase in arterial tension.
The Tight pulse can occur with general internal obstructive disorders associated with poor digestion, so needs to be carefully differentiated from its Cold causation with assessment of other signs and symptoms as well. Using the pulse parameters, a Tight pulse caused by Cold and the Tight pulse caused by obstruction (not necessarily Cold related) can be differentiated by changes in pulse rate. The Tight pulse will probably occur with a generic decrease in pulse rate when due to a Cold EPA. When food obstruction is due to Cold, which occurs in a situation where a Cold EPA goes internally and causes obstruction, then the Tight and Slow pulse will also manifest.
The Drumskin pulse can also occur in the presence of a Cold EPA, as is apparent in the increase in arterial tension due to vasoconstriction, but its formation is primarily due to tensile stress in other layers of the arterial wall due to underlying blood vacuity. When the blood and fluid levels are normal and a Cold EPA invades, then the Drumskin pulse will not occur (Box 8.5).
Box 8.5
Drumskin pulse and a Cold EPA
The Drumskin pulse is not necessarily about diagnosing blood vacuity, rather its main indication is that relating to Cold EPA. Clinically, treatment should be aimed at addressing the Cold EPA, not Blood vacuity. Herbs required for treating Cold EPA differ from those for Blood vacuity. If Blood-tonifying herbs are used, they may aggravate or cause a delay in resolution of the Cold EPA. Once the Cold EPA is expelled then the Drumskin pulse is likely to resolve into a pulse whose parameters are more typical of Blood vacuity.
8.2.3. Pulse qualities that reflect Heat
Heat by nature is expansive and supplements the normal functional activity of Yang in the body. Feeling hot, fever, sweating, flushed face are signs of pathogenic illness arising from Heat (Fig. 8.3). Heat additionally agitates blood and Qi, thus affecting the pulse.
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| Figure 8.3Affect of an EPA Heat on pulse parameters and the formation of traditional pulse qualities with consideration to the relative strength of Qi and Blood (fluids). |
Heat affects the pulse in three ways.
• Pulse rate: Pulse rate is a reflection of the functional activity of Yang. As Heat adversely supplements the Yang, then pulse rate increases. From a biomedical perspective this is an increased activity of the cardiac cells in response to an increased metabolic rate affecting core body temperature.
• Pulse length: Heat adversely affects the normal flow of Qi and blood via its expansive heating quality. This is sometimes described as heat agitating the blood and Qi. The result is a pulse which extends beyond the Cun, Guan and Chi pulse positions. That is, the pulse becomes more apparent with palpation along its entire length and not just at these three pulse positions at the wrist.
• Pulse contour: Heat produces a variation in the pulse contour with a more distinctive pulse wave. Heat causes cardiac cells to contract more quickly and strongly, resulting in a more forceful pulse. From a CM perspective the change in the pulse from Heat EPA reflects the agitating affect of heat on Qi and Blood as core body temperature increases.
• Pulse force: Pulse force increases and is a direct reflection of the increased strength of contraction of the cardiac cells and subsequent increased stroke volume.
• Arterial width: By increasing the surface area of the artery the body attempts to lose more heat to the environment: a defensive mechanism to prevent heat from damaging the body’s Yin. Heat has an expansive action on the flesh and blood flow so the pulse wave contour comes to dominate the pulse quality and is felt wide.
• Level of depth: As a Heat pathogen invades the body so the body’s Qi responds by rising to meet the invading EPA. The pulse becomes relatively stronger at the superficial levels of depth. With Heat pathogens, the pulse is likely to be felt with strength at the other levels of depth as well.
There are five traditional pulse qualities attributable to the presence of a Heat EPA:
• Rapid pulse (section 6.5.2)
• Slippery pulse (section 7.9.1)
• Replete pulse (section 7.7.1)
• Vacuous pulse (section 7.7.3)
• Surging pulse (section 7.9.3).
Of the five traditional pulse qualities, the Rapid pulse is the simplest to recognise and will always reflect Heat. It is likely to combine with the other four pulse qualities when Heat pathogens are present. For example, the Slippery pulse due to Heat will have an increase in pulse rate, when this is >90 bpm, then the pulse is Slippery and Rapid.
The remaining four pulse qualities can be subdivided into two further categories. The first category includes pulse qualities in which the underlying Qi and blood are agitated but remain abundant:
The second category contains pulses that are also associated with Heat pathology but have injury to the Qi and blood from the Heat pathogen:
8.2.3.1. Vacuous pulse and Surging pulse
The formation of the Vacuous pulse and Surging pulse is described in the classical literature as occurring as a result of Heat agitation of the Qi and blood but differs from the Slippery pulse and Replete pulse as Heat has also caused injury to the Qi and blood. This is reflected in the Vacuous pulse parameter of arterial occlusion, in which the pulse is easy to occlude. When pulses are easily occluded this indicates that the arterial or pulse volume (blood and fluids) is impaired. Impaired arterial volume causes decreased blood pressure, so that the resistance of the artery to finger pressure is also lessened. This is additionally noted by the lack of increased arterial tension that usually accompanies blood vacuity, indicating that the Qi is equally injured.
For the Surging pulse, the injured state of the Qi and blood caused by Heat pathogen is reflected in the diastolic segment of the pulse wave contour and in the parameter of pulse length. Unlike the Replete pulse and Slippery pulse, the Surging pulse is not felt beyond the Cun or the Chi pulse positions. That is, although heat is agitating the Qi and blood, these substances are not abundant enough to lengthen the palpable pulse beyond the three pulse positions.
The diastolic segment of the Surging pulse wave is described traditionally as ‘debilitated’, giving the sense that cardiac contraction should be strong causing a distinct sudden rise in the pulse wave hitting the fingers during systole, but because the blood and fluids are injured, no substance is present for the pulse force to continuing moulding the pulse contour during diastole, and so the pulse wave is not apparent.
The Surging pulse is sometimes described as felt ‘coming but not going’. This could also be interpreted as the pulse wave being felt hitting the proximal (body side) of the finger when palpating the pulse, but not felt going under the finger to the distal side (finger side).
An additional perspective on the formation of the Vacuous pulse and Surging pulse is that rather than Qi and Blood being damaged as a consequence of the heat Pathogen, the Qi and blood were already deficient before contraction of the Heat pathogen. As with the formation of the Drumskin pulse, it is the underlying vacuity of Qi and blood that may give rise to the Vacuous pulse and Surging pulse when Heat EPA occurs. When Qi and blood are abundant, then the Replete pulse and Slippery pulses are likely to occur instead.
Also, the Vacuous pulse and Surging pulse can indicate a prognostic and temporal progression of a Heat EPA. For example, if Qi and blood are abundant, then the Replete/Slippery pulse will form. As the heat injures these, then the Surging pulse and Vacuous pulse may arise.
As a continuum, the Vacuous pulse and Surging pulse can arise from the Slippery pulse and Replete pulse when the heat begins to injure the blood, fluids and Qi. From this perspective there are prognostic guides that can be derived from these pulse groupings. For the Slippery pulse and Replete pulse, the Qi and blood remain uninjured so the patient will recover back to normal health and function once the pathogen is resolved. In contrast, the Surging pulse and Vacuous pulse represent an injury to the Qi and blood so recovery will be slower (Fig. 8.4).
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| Figure 8.4Temporal progression of a Heat EPA and consequent formation of likely pulse qualities with respect to the relative strength of Qi and Blood (fluids). |
8.2.3.2. Slippery pulse and Replete pulse
Both the Slippery pulse and the Replete pulse form in the presence of Heat via the agitation of Qi and blood. Although the Qi and Blood are agitated by Heat, the formation of the pulses indicates that the Qi and blood remain strong and prognosis is good.
Both pulses are similar in the filling of the vessel, but the Slippery pulse has a distinct change in the pulse contour and is strong whereas the Replete pulse is felt equally strong at all three levels of depth. Characteristics of the two pulses may combine to form a unique pulse quality not adequately defined by either the Slippery pulse or Replete pulse definition.
8.2.3.3. Rapid pulse
The Rapid pulse is the simplest of these five pulse qualities, defined simply by an increase in the pulse rate parameter. The Rapid pulse can also occur from internal Yin problems; that is, dysfunction within the organs can lead to impaired Yin function causing a hyperactivity of the Yang and increasing the pulse rate. This is termed Yin vacuity (Yin deficiency). In this sense, increased pulse rate alone is not sufficiently diagnostic to differentiate between a Heat EPA and Yin vacuity and it is necessary to assess the presentation of other pulse parameters to do this. Pulse force is an important additional parameter for this purpose: an increase in force occurring with an increase in pulse rate is likely to indicate an EPA of Heat, whereas a decrease in pulse force occurring with an increase in pulse rate indicates dysfunction arising internally from Yin vacuity. Furthermore, the increase in pulse rate is pronounced for an EPA Heat, whereas for Yin vacuity the rate may increase but not substantially so.
8.2.4. Pulse qualities that reflect Wind
Only one pulse quality occurs with an EPA Wind attack, and even then, it is a generic pulse quality that can form in the presence of any EPA attack. This is the Floating pulse.
According to CM theory, Wind as a pathogenic agent often combines with other aetiology factors producing combinations of EPAs. For example, Wind can combine with Cold, Heat or Damp producing EPAs of Wind-Cold, Wind-Heat and Wind-Damp. In this scenario, a likely response of the pulse is to form pulses that reflect the other accompanying EPAs. This is a likely explanation for the paucity of Wind-specific pulses.
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