Many different diagnostic techniques involving body palpation and observation are recorded in the early acupuncture literature in China. Many of these techniques are not a part of the mainstream practice of Chinese medicine in either China or Western countries today.
However, evidence suggests that body palpation was once considered to be the critical link in the process of choosing the most effective channel and technique to relieve bodily pain and ailments. The author, and some scholars in China today, are convinced that physical palpation or observation of pulsating vessels, small blood vessels, skin tone and texture, and other pathological changes in the skin and soft tissue were essential in the early development of acupuncture theory and practice.
The channels as we know them today were originally conceived of as palpable and observable blood vessels that could be used to diagnose and treat ailments. Over time, the concept of the channel system as one continuous circuit came to define acupuncture practice and the channels were seen as carriers of qi and blood with links to every location and function of the human body. Palpation and the subsequent codification of the information obtained from it were critical steps in this historical process.
This is important because it tells us something about how physicians in Han and pre-Han times conceived of the nature of the channels and their effective use in relieving human pain and suffering. Understanding the origins of the channel system may help us to more skillfully utilize it in clinical practice today, and it may also point to fruitful ways to develop and expand its use in the future.
The Significance of Palpation in the Early Acupuncture Literature
"Pulse diagnosis" in early Chinese medicine originally involved palpation at multiple sites along the mai (vessels), or what later came to be known as the acupuncture channels. In the Ling Shu, (jiu zhen shi er yuan) it states, "If one is planning to use needles, it is essential to first examine the pulse [or pulses]." Several other passages in both the Ling Shu and Su Wen explicitly describe using a variety of hand techniques to examine various sites or channels in order to determine where to needle. For example,
- "Those who use needles must first inspect the channels [jing-luo] for emptiness or fullness [xu-shi, deficiency or excess]. Separate and follow, press and flick, and see which moves under examination. Then, take that one and needle into it." Ling Shu (zi jie zhen xie lun)
- "Therefore, when puncturing those with impediment (bi), one must first separate and follow the lower six channels [i.e. leg channels], seeing whether they are empty or full [xu-shi], ...then adjust them." Ling Shu (zhou bi)
- "Examine, separate, follow, glide along and press, and notice whether they are hot, cold, flourishing, or in decline, then adjust them." Ling Shu (jing shui)
- "One must examine and inquire about how the ailment began, as well as the state of the ailment today. Then, separate and follow the pulsations, noticing whether the channels [jing-luo] are floating or sinking. Follow upwards and downwards, moving with and against [the channels]. Those with rapid pulsations are not ill, those with slow pulsations are ill. Those with no pulsations moving back and forth will die. Those with translucent skin will die." Su Wen, Chapter 20 (san bu jiu hou lun)
- "As to the number of punctures, first inspect the channels (jing-mai), separating and following. Determine emptiness and fullness [deficiency and excess] and then adjust them accordingly." Su Wen (miao ci lun)
The Plurality of Palpation Sites and Techniques
Other references to manually examining the channels and various sites of pulsation on the body are scattered throughout the Yellow Emperor's Inner Canon, the Classic of Difficulties, the Treatise on Cold Damage, the Pulse Classic and the Records of the Grand Historian.
Some of these techniques are named and appear in multiple texts, while others are only mentioned in terse passages that are impossible to trace to other literature. Some of the better-known techniques are as follows: Comparing Renying (St 12) and the Wrist Pulse, Comparing Fuyang (St 42) and Renying (St. 12), Examining the Nine Pulses in the Three Areas (i.e. head, arms and legs), and Examining the Ends and Beginnings of the 12 Channels.
A lesser-known technique, examining the forearm, palms and nails, is actually the subject of an entire chapter of the Ling Shu, and is entitled "Discussion on Disease and Examining the Forearm." Other sections of the Ling Shu and Su Wen, as well as the Classic of Difficulties and the Record of the Grand Historian, refer to this technique in the context of diagnosis. The 13th Difficulty in the Classic of Difficulties in particular states that a physician should master color/demeanor (se), pulses, and the forearm. Those of lesser ability only master one, those of middling ability master two, and those of superior ability master all three. The Ling Shu, (xie qi zangfu bing xing chapter) asserts that "Solely by examining the forearm, one can name the illness. One knows the inside from the outside."
One feature that most of these techniques described above share in common is that they involve comparing at least two different sites on the same patient's body. In fact, the idea of an abstract, idealized "normal pulse" against which the pulses of real people should be measured or compared is absent from the earliest literature on palpating the channels or the wrist pulse. Instead, we find that any channel that exhibits qualities of any kind that are distinctly different from all of the other sites examined indicates that it is the channel with pathological changes that need to be addressed.
For example, in the Su Wen chapter on the Three Areas and Nine Pulses, it states: "Di asked, 'How does one know the location of illness?'. Qi Bo answered, "In examining the nine pulses [lit. indicators], when only one of them is small, that is the diseased one; when only one of them is large, that is the diseased one; when only one of them is hurried, that is the diseased one; when only one of them is slow, that is the diseased one; when only one of them is hot, that is the diseased one; when only one of them is cold, that is the diseased one; when only one of them is sinking, that is the diseased one."
These types of references echo something that many older physicians I have encountered in China emphasize, namely, that whenever a pulse on the wrist or a channel on the body stands out as significantly different from the others in any way that is most likely what needs to be addressed. I have found this to be almost invariably true, particularly when patients present with highly complex symptoms.
Palpation and the Development of the Concept of the Channels
Research on the Yellow Emperor's Inner Canon, as well as excavated medical texts such as those found at Mawangdui in Hunan, China, suggests that palpation determined the sites for bian-stone, moxabustion or needle therapy, and the results obtained led to the further elaboration of the connections between the upper and lower body. Initially, observations of palpable and visible blood vessels, skin temperature and texture, and pathological changes in skin and soft tissue were correlated with ailments and effective treatment sites. This eventually culminated in a system of channels and collaterals that incorporated ideas from astrology/astronomy, calendar science, musical theory and multiple views of the internal and external structure of the body.
Over time, palpating multiple sites on the body was mostly abandoned. The ascendency of organ (zang-fu) manifestation theory and herbal medicine led to the exclusive emphasis on palpating the wrist pulse and observing the tongue. This situation became particularly extreme in the 20th century, with mainstream education in China and the West "herbifying" acupuncture theory and practice. Fortunately, practitioners such as my mentor Dr. Wang Ju-yi have revived and expanded channel palpation and have shown us how it leads to outstanding clinical results. Japanese lineages of hara diagnosis are also rooted in this early tradition of palpation.
As a practicing clinician, I find that the textual resources on channel palpation are further confirmation that acupuncture must be rooted in a physical, visceral understanding of how the channels manifest and change in living bodies.
All translations are by the author.
Shelley Ochs is currently a PhD Candidate at Beijing's China Academy of Chinese Medical Sciences, Institute of History and Medical Literature.