The Herbalist’s Corner
Acupuncture Today, October, 2009
Jake Paul Fratkin, OMD, L.Ac.
Often, a new patient comes into the clinic with a variety of complaints, each layered on top of each other. A woman’s main complaint might be fatigue, but in interviewing her, we find that her periods are irregular, she has abdominal bloating and gas, poor sleep, and headaches once or twice weekly. In traditional Chinese medicine (TCM), we herbalists work best when there is an isolated complaint. So where do we start in this case; what is our TCM diagnosis? Headache, menstrual irregularity, abdominal distension, insomnia? If we could isolate a chief complaint, then TCM presents us with various differentiations, which then guide our formulation of a prescription or choice of an herbal product. Too often, like this patient, the complaints are multiple and coexistent. My recommendation is to ignore the complaint picture, and use your diagnostic skills to determine excess or deficiencies in the various zang-fu organs. This information will help you decide which prescription to begin treatment with.
Prioritizing the first formula is best done by pulse taking, supported by abdominal palpation. In pulse, we are looking at two different paradigms. The first is general pulse, and the second is excess or deficiency on the various pulse positions.
The key step is reading the pulse correctly. My method is as follows. The patient should not be wearing a watch or heavy jewelry on the wrist. Batteries in most watches, as well as cell phones and even car keys, can affect the pulse, and are better removed prior to pulse taking. The patient can be seated or lying down. If seated, the use of a soft pulse pillow is recommended. If lying down, use your free hand to cradle their hand.
The patient’s arm should never be raised vertically, because gravity can affect the pulse reading. Keep the arm horizontal. Cradle their hand in your hand – the one that’s not taking the pulse –and gently pull and extend the hand so that their thumb points forward, in line with their arm. This keeps their thumb from pointing upwards, and the elongation allows better access to their cun-distal pulse. Your hand should cradle their hand, with your thumb gently holding down their thumb. I do this with both seated and lying-down patients.
Whole Pulse Diagnosis
Whole pulse diagnosis refers to feeling the whole pulse with three fingers on each wrist. Some practitioners, especially those in Japan, prefer to feel both wrists at the same time, but I prefer to take one wrist at a time. While there are 28 aberrant pulses detailed in TCM training, ten are particularly important. These are the three pairs of Floating-Sinking, Rapid-Slow, Excess-Weak, and then the special qualities of choppy, wiry, slippery and tight. I do not need to go into detail here, because this is part of everyone’s TCM training. It’s good to do whole pulse diagnosis first, before proceeding into individual positions. I carefully examine the whole pulse, and pose the same questions, in the same sequence: Is this pulse floating or sinking? Is this pulse fast or slow? Is this pulse showing excess or deficiency? Is there any quality of wiry, slippery, choppy or tight? While the answers influence my treatment, whole pulse is not my primary interest. They provide a backdrop against the information I look for in positional diagnosis.
Pulse Diagnosis for Zang-Fu Positions
In zang-fu positional pulse diagnosis, the most important observation concerns excess versus deficiency in each of the twelve positions. I recommend using the middle finger for the guan-middle position, the index finger for the cun-distal position, and the ring finger for the chi-proximal position. (When doing yourself, come under your arm so that your index finger goes to the cun-distal position, which is the same as for a patient.)
I start pulse diagnosis by looking at the guan-middle position of one wrist only. Find the high point of the radial stylus, and allow your middle finger to find the pulse. Go to the middle level of the blood vessel, the dead center of the vessel. This represents the qi and blood of the associated element/phase, Wood on the left, and Earth on the right. Feeling the middle of the pulse, raise you pressure slightly so that you come to the surface of the vessel, the upper outer skin of the artery. This will be the yang aspect of that position (eg, Wood or Earth, if in the guan-middle position.) If you leave the surface of the radial artery, you are not on the pulse anymore. You are in the interstitial fluid and tissue, and this is not the pulse. Go back to the middle position, and now go deeper and find the lower border of the radial artery. This is the yin aspect of that element/phase. If you go too deep, you are not on the pulse anymore, and again are in the interstitial fluid and tissue. Of course, if you hit bone, you are way too deep. So, just to be clear, the upper outer edge of the sleeve of the artery is the yang aspect, and the lower edge of the artery is the yin aspect. I usually walk back and forth several times, like climbing up and down three stairs, on each finger position to confirm what I am feeling.
After examining the guan-middle position with your middle finger, I next go to the index finger to determine the yang and yin aspects of the cun-distal position, either Metal, if the right hand, or Fire on the left hand. The cun-distal pulse is more superficial then the guan-middle position, because the artery is coming closer to the surface. Again, it is most important to find the middle of the artery first, and then to lighten the touch to feel the superficial aspect, going back to the middle the find the real pulse, then slightly deeper to find the bottom sleeve of the artery position.
Finally, I go the chi-proximal position (Kidney mingmen fire on the right or Bladder-Kidney on the left). Here, the pulse dives rather deeply and it is important to find the middle part of the pulse first, then determine yang and yin aspects.
Using Pulses to Determine Excess and Deficiency.
The information I am most concerned with is excess and deficiency. In excess conditions, certain zang-fu positions of the pulse will be wiry. This wiriness can be in either the superficial aspect of the pulse (the yang), or in the deeper aspect of the pulse (the yin). If all of the superficial pulse positions are in excess, there is an exogenous pathogenic wind invasion, or acute trauma or shock. Normally, the excess will be in isolated pulse positions. Accordingly, I look at each position in isolation. In chronic cases with multiple complaints, wiriness is often found in the guan-middle position, either on the left side, the right side, or both. If excess is found only in the left guan-middle position, this shows excess in the gallbladder meridian, or the Liver organ. Pressing deeper to the bottom edge of the vessel, in the middle position left side, will show more about the status of the Liver. If this position is wiry, we can confirm that there is stagnation of Liver qi and/or blood. If there is a weakness in the deeper Liver position, we can say that there is Liver stagnation of qi and/or blood (taken from the superficial wiriness), plus a deficiency of either Liver blood or yin. Liver blood deficiency would be confirmed by dryness in the skin or hair, pale conjunctiva, or ridges in the finger nail, plus signs such as amenorrhea or light menses. Liver yin deficiency would be deduced by the absence of blood deficiency signs. In more pronounced cases, we would find the patient reporting dryness of the eyes or vagina.
If the wiriness is not found on the left wrist, but on the right guan-middle position at the superficial aspect, this implies stagnation of Stomach qi, and the failure of Stomach qi to descend. Examining the deeper portion of the Earth pulse, if this position is normal, then Spleen qi is not necessarily involved. If the Spleen position is weak, then we diagnose a deficiency of Spleen qi.
If both the superficial Wood and Earth pulses are excess, we can diagnose Liver qi stagnation causing Stomach qi stagnation. In this case both Liver and Stomach aspects would need to be addressed in treatment. If deficiencies also appear in either the Spleen or Liver, these need to be taken into account in the final construction or choice of the herbal formula.
In conclusion, most complex-layered cases that enter the clinic will show excess/deficiency patterns affecting the Liver, Stomach and Spleen. Our job, as herbalists, is to evaluate the various stagnation and deficiency patterns and to apply the appropriate herbal formula.
In Part 2, we will discuss and analyze six relevant herbal formulas for the various presentations of this constellation.
JAKE PAUL FRATKIN, OMD is a Doctor of Oriental Medicine in practice since 1978. After seven years basic training in Japanese acupuncture and Chinese herbal medicine in this country, he went to Beijing for one year to do advanced hospital training in herbal internal medicine, pediatrics and medical qi gong. He is the author of CHINESE HERBAL PATENT MEDICINES, (2001), a respected reference work of 1200 Chinese herbal products available in this country. In 1999 he received the national award, Acupuncturist of the Year, from the American Association of Oriental Medicine, and 2006 he received the award as Acupuncture Teacher of the Year. He is a recognized expert in the treatment of leaky gut syndrome, chronic respiratory and digestive disorders. Jake lives and practices in Boulder, Colorado.
©2009 Jake Paul Fratkin. All rights reserved.