Reading the River of Life

     Of all the traditional diagnostic methods, none is more fabled and legendary than pulse diagnosis.  And of the great masters of pulse diagnosis, none are so well-known as the Chinese.  With nothing more than hearing the patient's chief complaint and taking his/her pulse, the master of Chinese pulse diagnosis can arrive at a complete and accurate diagnosis of the patient's condition.
erasistratos     Yet, the Chinese were not the only ones to master this difficult and demanding diagnostic art.  Centuries earlier, in ancient Rome, the great physician Galen was the great master of pulse diagnosis, and wrote a treatise on the subject entitled De Pulsibus.
     But even Galen candidly admits of his struggles in mastering pulse diagnosis, as he writes in the following passage:

     For many years, I was doubtful about clearly discerning the movement of contraction by touch, and I shelved the question until such time as I could learn enough to fill the gap in my knowledge.  After that, the doors of the pulse were open to me.

     Avicenna includes this passage from Galen in his Canon of Medicine, and goes on to add:

     Whoever allows these words to be true and not fabulous will benefit very greatly; despair will not touch him or frighten him in the pursuit of his study, even though he makes no progress for many years.

     The moral of this story?  Pulse diagnosis may be difficult to master, but practice eventually makes perfect.
     Avicenna discusses pulse diagnosis extensively in volume I of his Canon of Medicine, which has become the basic clinical manual for practitioners of Unani Medicine.  Unani physicians say that Avicenna studied the Chinese system of pulse diagnosis extensively, and based his own system on it; Dr. O. Cameron Gruner's translation of the pulse diagnosis chapters in Avicenna's Canon is filled with extensive commentary and comparison to the Chinese system.
     Unani practitioners claim that the Chinese system was Avicenna's main model and inspiration for his system of pulse diagnosis.  But from my own experience, however, there seem to be great differences between the Chinese and Unani systems of pulse diagnosis.
     The great virtue and advantage of pulse diagnosis is that it enables the physician to read this River of Life in real time, and perceive directly the action of the vital principles, the condition of the humors, internal organs and their physiological functions as they happen.  Taking a medical history covers the origins, history and development of the patient's condition, but pulse diagnosis presents it in the present moment, in dynamic, kinetic motion.
     In my opinion, the greatest disadvantage in communicating and teaching the art of pulse diagnosis is mainly a problem of the words and semantics used to describe the various types of pulses.  Two different authors could use vastly different words to describe the same feeling or quality in the pulse; or, they could use the same word to describe two quite different qualities, or parameters.
     Describing qualities and feelings in the pulse is quite like the different blind men feeling the same elephant.  But once a master of pulse diagnosis shows you directly, in a clinical setting, a certain quality by feeling a certain patient's pulse, you know it precisely by direct experience.  That's the Zen of pulse diagnosis!

What is the Pulse?

     The arteries are rooted in the heart, the principal organ of the Vital Faculty.  With each beat or pulsation, the heart infuses the blood with the vital principles: the Innate Heat and Vital Force.
     Because the arteries are seamlessly connected to, and extensions of, the heart, with each contraction or beat of the heart, the arteries pulsate.  Because the arteries carry fresh blood infused with the vital principles to every cell, organ and tissue of the body, you could say that the arteries pulsate as an expression of the Vital Force they contain.
     Blood is the gross, humoral vehicle for the subtle vital energies - the Innate Heat and Vital Force.  The flow of the Vital Force guides the circulation of the blood, and in the healthy body, they run seamlessly together in perfect union and harmony.  In certain pathological conditions, however, the blood and the Vital Force can fall out of sync, or out of balance with one another, which is discernible in the pulse.
     There are two phases of the heartbeat, or cardiac cycle:  contraction, or systole; and relaxation, which is diastole.  With each systole, or heart contraction, blood is pumped out of the heart into the arteries, which swell, or rise.  With each diastole, or heart relaxation, blood enters the heart, easing pressure on the arteries, which deflate, or fall.
     And so, the pulse rises with each systole, and falls with each diastole of the heart.  The relative quality, feel and discreteness of the arterial rises and falls is another dimension of pulse reading.  Avicenna also tells us that there are pauses or transitional phases between the rise of systole and the fall of diastole, the quality and discreteness of which can also be read and interpreted.

The Technique of Pulse Taking

     There are many different arteries at which the pulse can be felt - in the temples, the carotid arteries on the side of the neck, and the dorsalis pedis pulse, to name just a few.  But in Greek Medicine and most other traditional medical systems, the radial artery at the wrist, just medial to the radius bone and proximal to the thumb, on the prone side of the wrist, is used.
     Taking the pulse at the radial artery has several distinct advantages:   
     A relatively long stretch of artery is exposed, lying close to the surface, for easy palpation in many positions.
     The artery can be easily presented to the physician, without undue difficulty, discomfort, embarrassment or distress.
     The radial artery branches out fairly closely and directly from the heart, receiving a strong, robust flow and pulsation of blood.  It is also in the middle part of the body, not too high and not too low, and therefore is representative of the whole organism and all its major organs.
     The physician's middle finger is placed on the radial artery, directly across from the prominence of the radius bone, with the other two adjacent fingers falling naturally right next to it.  The big difference is that, in the Unani method, the index finger lies closest to the heart, whereas, in the Chinese system, the fingers are reversed, with the index finger lying most distal from the heart, and the ring finger closest to the heart. 
     Sometimes Unani physicians, in taking the pulse, will dispense with the ring finger, and just use the index and middle fingers, adjusting their relative pressures to see how the pulse responds.  When this is done, it's not so much the organ pulses that are being felt, but rather the overall quality and gait of the pulse.  This, I have gathered, is the most important aspect of Unani pulse diagnosis.
     In Unani Medicine, the pulse is called Nafs.  The different qualities, gaits or types of pulses are designated as Nafs - this, or Nafs - that. 
     Ideally, the pulse should be taken on an empty stomach, and not immediately after eating.  It also should not be taken when angry, upset or tired; after a bath; or after sex.

Finger Positions and Organ Pulses

     The position where the middle finger goes, directly across from the radial prominence, is called the Median position.  It corresponds to organs in the middle epigastric and hypochondriac (underneath the ribs) region of the torso.  The Median position pertains mostly to the Natural Faculty, and to the process of digestion, or pepsis. 
     The position most distal and closest to the base of the thumb is called the Carpal position.  It corresponds to noble and principal organs in the upper thoracic cavity of the torso, the lungs and heart, which are felt deeply.  You could also say that the Carpal position pertains most directly to the Vital Faculty. 
     The position most proximal to the heart is called the Cubit position.  It corresponds, especially on the deep level, with the noble or principal organs of the genitourinary tract, and the pelvic cavity.  The sexual function and the Generative Faculty are most represented here.  The Cubit position also has an affinity with the Water element, which is heavy and always flows downwards, as well as with the Phlegmatic humor and temperament.
     The organ pulses are felt both deeply and superficially.  The deeper noble and principal organs, like the heart, liver and kidneys, are felt at the deep level.  The organ pulses felt at the superficial level are those of the hollow visceral organs and attendant vessels, like the stomach, bladder or gall bladder.  Sometimes the associated superficial visceral organ pulses are closely related to their underlying deep organ pulses both functionally and/or anatomically, and sometimes not so closely.
     The distinction between right and left wrist is somewhat more ambiguous and subtle.  The right side is more masculine, energetic and Yang in nature, according to Chinese thinking, whereas the left side is more feminine, substantial and Yin.  If you were to translate this into Greek medical terms, the right wrist is more vital and energetic, whereas the left wrist is more humoral in nature.
     Now, let's map out the particular organ pulses right and left, superficial and deep, in the Carpal, Median and Cubit positions:
     Carpal Position:  The heart lies deeply on the left wrist, whereas the lung pulse lies deeply on the right wrist, since it is more pneumatic and energetic in nature.
     Superficially, the small intestine pulse lies in the left Carpal position, associated with the heart.  The large intestine pulse lies in the right Carpal position, associated with the lungs. 
     Median Position: 
In the Chinese system, the liver, being more humoral in nature, lies deeply on the left side.  In Greek Medicine as well, the liver generates the humors.   The spleen, the liver's complementary epigastric / hypochondriac organ, lies deeply on the right side, opposite the liver.
     However, some authorities on the pulse, like Dr. Vasant Lad, have the liver and spleen pulses reversed, with the liver pulse deeply on the right wrist, and the spleen pulse deeply on the left.  The reason for this designation is chiefly anatomical - the liver lies on the right side of the torso, and the spleen on the left.  In my experience, there seems to be validity in both the Chinese and the Dr. Lad systems.
      Superficially, the gall bladder pulse is associated with the liver pulse, on whichever side you place it.  Similarly, the stomach pulse is associated with the spleen pulse, and always found on the opposite side from the liver and gall bladder pulses.  The stomach pulse is on the same side as the spleen pulse because the stomach lies adjacent to the spleen anatomically.
     Cubit Position:  Deeply on the left wrist lies the kidney pulse, with the bladder pulse associated with it superficially.  Deeply on the right wrist lies the adrenal pulse, whereas superficially in the right Cubit position can be felt the condition of several factors:  circulation, the sexual function, and especially the condition of the body fluid metabolism.  Chinese authorities say that the pericardium pulse can be felt superficially in the right Cubit position.
     A perfectly healthy, balanced pulse will be felt equally and moderately in all the organ pulse positions.  Disharmonies and imbalances of organ function will produce organ pulses that are similarly disturbed, unbalanced or unequal.  Basically, an excessively strong or full organ pulse indicates a fullness, congestion, or obstruction, either humoral or energetic in nature, occurring within that organ, depending on its quality.  Conversely, a weak or deficient organ pulse indicates a weakness or deficiency of the corresponding organ.
     Let me repeat that organ pulses are not an essential component of pulse diagnosis.  Even more basic is the overall character or gait of the pulse.
     Unani Medicine, as I said earlier, has several different types of general pulse gaits, which are called Nafs.  These different pulse types are characterized or broadly categorized according to affinities of humor and temperament; in addition, each pulse type has certain specific indications particular to itself.

Basic Qualities or Parameters of the Pulse

     There are certain basic qualities or parameters of the pulse that are obvious and immediately apparent to anyone who has ever felt the pulse.  The clinical significance of these various qualities is that they are analogous to similar qualities or states prevailing within the organism.  These basic qualities or parameters are:
     1)  Speed, also known as frequency, or tempo.
     2)  Force, also known as strength, or pressure.
     3)  Depth, or level at which the pulse prevails.
     4)  Width, or breadth, also known as volume.
     5)  Definition, also known as contour, or discreteness.
     6)  Quality of Expansion, or rise / systole / pulsation.
     7)  Quality of Interlude between Pulsations.
     8)  Rhythm,
cadence, or Gait.
     9)  Regularity
     10)  Tension

     The speed of the pulse is the frequency of its pulsations, measured in beats per minute.  A normal or moderate speed is about 70 Beats Per Minute (BPM); slow is under 70 BPM, to 60, or even below.  A fast pulse is 80 BPM or higher.
     Basically, a fast pulse is indicative of excess heat or physical activity.  The heat can be from an infection, inflammation or fever, which is often systemic.  Exercise and digesting food also speed up the pulse.
     Conversely, a slow pulse indicates coldness or hypoactivity.  Those of a cold, Phlegmatic temperament also tend to have slow, deep pulses.  However, those who are exceptionally fit, with aerobically trained and hyperefficient hearts can also have a slow pulse.
     The force of the pulse most obviously indicates the strength of the Vital Force, and the overall vitality and energy level of the organism.  The stronger the pulse, the more energy and vitality there is; the weaker the pulse, the weaker and more devitalized the body is.
     A pulse that is extremely forceful and feels like it's bursting at the seams is not healthy, however; it indicates a condition of congestion or excess.  A healthy pulse will also have all the organ pulses of equal, balanced, moderate strength; any undue force in an organ pulse indicates excess or congestion, whereas any undue weakness indicates emptiness or deficiency in that organ.
     Depth refers to the level at which the pulse is felt.  There are three basic levels, or depths, at which the pulse can be felt:
     Superficial:  right underneath the skin, with light or no pressure.
     Moderate:  middle depth, in between superficial and deep.
     Deep:  felt with heavy pressure, right above the bone.
     In taking the organ pulses, the pulses of the visceral organs, or attendant vessels, are felt at the Superficial level.  The pulses of the deeper noble and principal organs are felt on the deep level.
     In addition, there are certain commonly seen pulse types, or qualities, concerning depth that have clinical significance:
     A Superficial Pulse, also known as a Floating Pulse, is one that is felt only or primarily at the Superficial level, fading or weakening drastically under deeper pressure.  It generally indicates a superficial pathogen or dystemper, like the common cold.  A superficial rapid pulse indicates exogenous heat, whereas a superficial slow or constricted pulse indicates exogenous cold.
     A Deep Pulse, which is felt only at the Deep level, can indicate two things:  disharmonies of the deeper noble and principal organs; or excessive interior cold sinking the pulse.  A pulse that lacks sufficient heat will often lack sufficient vitality and exuberance to rise to the higher levels. 
     A Prominent Pulse is one that is felt most prominently at the Superficial level, but which also has good underlying strength and vitality at the other levels as well.  It generally indicates abundant vitality and exuberance, and, in extreme cases, an excessively exuberant state of hyperexcitation.
     A Rootless Pulse is one that is felt only at the Superficial and Moderate levels, but disappears at the Deep level, having no "root".  It generally indicates a weakness or deficiency in the deep noble and principal organs, especially the kidneys. 
     The healthy pulse, in terms of depth, is felt most strongly at the middle depth or Moderate level, but also at the Superficial and Deep levels as well.
     Width refers to the volume or breadth of the pulse.  Is the pulse fat or skinny?  Does it feel like a fine thread or a thick rope?  A thin or skinny pulse is usually called a Thready Pulse, whereas a fat, broad pulse is usually called a Full Pulse.  Most obviously and directly, a Full Pulse is associated with conditions of fullness, excess or superfluity; conversely, a Thready Pulse is associated with conditions of emptiness, or deficiency.  The thinner the pulse, the greater the deficiency; the thicker the pulse, the greater the fullness or excess.  The healthy pulse is moderate in width or breadth.
     Definition refers to the clarity of the pulse's contour, or outline.  Basically, conditions of dryness create a very clear, stark outline of the pulse.  Conditions of moisture or wetness create a softness or fuzziness of pulse boundaries.
     Closely related to this quality of definition is the continuum of hard versus soft, with hardness indicating dryness, and softness indicating moisture.  Sometimes the hardness or softness of the artery walls can be felt, discernible and separate from the blood and other humors flowing through the artery.  Atherosclerotic changes can often be felt in hard artery walls.
     A Soggy Pulse has a special kind of softness that feels like an excessively soft and soggy overcooked noodle.  It indicates a generalized lack of tone and consolidation of the Vital Force, and conditions of excess moisture and devitalization prevailing in the digestive system and Natural Faculty.
     The healthy pulse should be adequately crisp and defined, but also have some softness, suppleness and "give" to it.
     Quality of Expansion refers to the quality of the rise, or pulsation of the artery.  Aside from the pulsation's force, which has already been discussed, how long does the pulsation, or beat, last?  How does it rise, and how does it fall?  Are both the rising and the falling discrete and perceptible?  Does one predominate over the other?  The quality of the expansion or pulsation is a key factor in determining pulse gait.
     The quality of interlude between pulsations is also an important factor to consider.  How long is the gap between pulsations, relative to the duration of the pulsations themselves?  Can the pulse still be felt, and maintain some perceptible level of pressure and contour between pulsations, or does it seem to disappear altogether?  A pulse that is too weak or scattered in between pulsations can indicate systemic devitalization and insufficient consolidation of the Vital Force.
     Rhythm, or Gait is the overall characterization of the pulse, its particular feel, rhythm and cadence.  You could say that the pulse gait is a synthesis of all the preceding factors, plus other particular traits, or idiosyncrasies.  Pulse gaits are often described in terms of natural phenomena, like waves breaking on a beach, or the hollow stalk of an onion.  Or, pulse gaits can be likened to the movement of certain animals, like a leaping gazelle or crawling ants.  Some common pulse gaits will be covered later.
     Regularity is an important factor in the pulse, as irregularities can point to weaknesses or dysfunctions of the heart, whose contractions generate the pulse.  Many of these heart weaknesses can be chronic or relatively mild in nature, and don't necessarily indicate an imminent acute cardiac crisis or major arrhythmia.  However, a weak heart is indicated, which should be strengthened and supported with the right herbal tonics.
     There are different types and degrees of irregularities in the pulse, with varying levels of seriousness and severity.  Irregularities in the pulse can manifest in three basic forms, or aspects: in strength, or force; in speed or rhythm; and in skipped or missed beats.  Of these three, the last is the most serious, and the first the least.
     Do the irregularities follow a regular, predictable pattern, or do they happen at random?  Of course, irregular or random irregularities are more serious than regular ones.  And yet another dimension to consider is:  How frequently do the irregularities occur?  Obviously, the more frequently irregularities occur, the more serious the condition.  And so, the most serious type of irregularity is one of frequent, randomly occurring missed beats; regularly occurring or less frequent missed beats would be preferable.
     Irregularity of pulse force usually consists of occasional or alternating weak beats interspersed amongst normal ones.  Irregularity of speed or rhythm consists of periodic slowdowns and speedups of the pulse rate, or occasional hesitant  or hasty beats.  Episodes of a Racing Pulse are commonly associated with heart palpitations.
     Pulse tension refers to the relative degree of tautness or laxness in the pulse.  The healthy pulse should have sufficient relaxation and suppleness without being too lax.  Excessive tension in the pulse is more problematic than excessive laxness. 
     A Tense or Wiry Pulse, also called a Twisted or Cordlike Pulse in Unani Medicine, feels like a taut violin string or bow string.  It is associated either with chronic pain or emotional / psychosomatic stress and tension; or, it indicates Melancholic conditions of liver congestion and stagnation, portal hypertension, or gastrointestinal colic.  A Tense Pulse can also indicate arterial hypertension.
     Pulse length is closely associated with pulse tension, because a tense pulse is often long, being palpable even beyond the Cubit and Carpal positions.  If the pulse is long, but also supple and relaxed, however, this is not particularly pathological or abnormal.
     A Short Pulse is usually felt in one position only, which is usually, but not always, the Median position.  If the pulse is detectable at all, it can usually be felt in the Median position.  A Short Pulse denotes a deficiency of the Vital Force.

Pulse and Temperament

     The Four Basic Qualities are detectable in the basic parameters of the pulse.  By mixing and matching these pulse parameters, you obtain the pulses for the compound temperaments.
     The pulses indicative of the four compound temperaments are not necessarily constitutional in nature.  They do, however, indicate conditions of compound temperament currently prevailing in the body.
     A Hot temperament is primarily indicated by a rapid pulse.  Pulses that are prominent, forceful or bounding also tend to be hot in that they are energetic and exuberant in nature.  Sometimes, the heat can even be felt directly, as when the artery itself feels hot or warm to the touch.
     A Cold temperament is primarily indicated by a slow pulse, especially if the cold is endogenous or chronic.  Chronic or endogenous cold can also sink the pulse, making it deep.  A weak pulse can also be a sign of cold, since it indicates a lack of energy.  Acute or exogenous cold, as in catching a cold or a chill, can constrict the pulse; the quality of constriction is something akin to tension, but not quite.  A longstanding cold dystemper can also produce a tense pulse.
     A Wet temperament, or excessive moisture, is primarily indicated by a soft or soggy pulse.  A full pulse could also possibly be classified as wet or moist, since it indicates and excess, abundance or superfluity of blood and/or other humors.
     A slippery pulse is another distinctive pulse type, or gait, that's usually associated with excess dampness and phlegm.  It's found in pregnant women, who need increased amounts of the moist, flourishing Phlegmatic and Sanguine humors to nourish their growing foetus.  The pulsations of a slippery pulse aren't felt pushing vertically against the fingers as much as they are felt slithering by laterally; when you try to pin it down, it rolls out from under your fingers like pearls in a porcelain bowl.
     A Dry temperament is indicated primarily by a pulse that is clearly defined, crisp and hard, or firm.  Sometimes, the hardness or firmness can be felt in the artery wall, rather than in its contents.  A thin pulse is also Dry in temperament, since it denotes a lack or deficiency of moist flourishing humors; it's even dryer if it is also clearly defined.  Roughness is another quality commonly found in dry pulses, and is contrary to the smoothness of the slippery pulse.
     A choppy pulse is rough and abrupt, and is often associated with a Dry temperament.  Its pulsations come in short blips, like a knife scraping against a bamboo stalk and hitting its nodes.  If a choppy pulse should also be thin, it denotes a deficiency of blood and the Radical Moisture.  Otherwise, it indicates a systemic stagnation of blood.
     As with heat, the relative moisture level of the artery can sometimes be felt directly.  The artery of a wet pulse will often feel moist or clammy.
     By mixing and matching some of these basic pulse parameters, you can obtain composite pulses characteristic of the four compound temperaments, as follows:
     Sanguine (Warm and Moist):  moderate speed to slightly rapid, and moderately soft and relaxed, with good vitality.
     Choleric (Hot and Dry):  rapid, forceful and clearly defined.
     Melancholic (Cold and Dry):  slow or weak, tense or constricted, thin and clearly defined.
     Phlegmatic (Cold and Wet):  deep, slow and soft.

Pulse Quality and Position

     Sometimes, you may find that an individual's pulse has different qualities in different organ positions.  This denotes different conditions of humor, temperament and/or vital function prevailing in the different internal organs, and must be interpreted accordingly.

Pulse Animals and the Four Temperaments

     The most famous animals in Ayurvedic medicine are the three animals used to describe the basic pulse gaits for the different prakriti, or constitutional types.  These, of course, have their equivalents in Greek Medicine.
     The Vata pulse slithers like a snake; in Greek Medicine, it denotes someone of a Melancholic temperament.   The snake or Serpentine pulse tends to be felt most commonly and prominently in the Carpal position.  The Serpentine pulse is firm, clearly defined, and often thin, indicating dryness.  It also tends to be fast, not so much from heat as from an excess of nervous energy.  The Serpentine pulse also tends to be weak.
     The Pitta pulse jumps like a frog; in Greek Medicine, it denotes someone of a Choleric temperament.  The Choleric pulse is forceful and bounding.  It can also be slightly rapid but, paradoxically, not as rapid as the Melancholic Serpentine pulse.  The Choleric pulse is most commonly and prominently felt in the Median position.
     The Kapha pulse glides gracefully like a swan; in Greek Medicine, it denotes someone of a Phlegmatic temperament.  The Phlegmatic pulse is slow, soft and deep.  It is felt most commonly and prominently in the Cubit position, where the increased depth and thickness of the flesh covering the radial artery favors the qualities of depth and softness.
     But what about the Sanguine temperament?  Since the Sanguine temperament is the most equable and balanced of all, the Sanguine pulse is moderate in all its aspects.  If I had to assign an animal to it, I'd have to say that it undulates freely like a playful dolphin.  The Sanguine dolphin pulse combines the graceful, flowing smoothness and fluidity (Wet quality) of the Phlegmatic swan with the energy and exuberance (Hot quality) of the Choleric frog.  You might say that it combines the best aspects of both.  The dolphin pulse is relaxed and supple, and is felt equally in all positions.

Other Important Pulse Gaits

     There are several other pulse gaits that are distinctive and important.  I will discuss a few of them here.
     An Empty Pulse is big in width, but lacks strength or forcefulness; it is also felt superficially, and tends to be slower than normal.  It denotes a deficiency of blood and the Vital Force.
     A Hollow Pulse also feels empty; it feels hollow, like the stalk of a green onion that can be rolled beneath the fingers.  It is usually seen after an extreme loss of blood, which can no longer adequately fill the artery.
     A Flooding Pulse surges up like a wave breaking upon the shore, quite big and strong, but falls with considerably less force.  It denotes that heat has injured the Phlegmatic humor, serous fluids and Radical Moisture.
     An Unani pulse that is similar is the Waving Pulse, which also has a wavelike quality.  However, the waves are weak, irregular in largeness, rhythm and degree of rise, and often break one upon the other.  A weakness of the Vital Force is usually the cause; the Waving Pulse can also indicate that a healing crisis, either by perspiration or diarrhea, is imminent.
     A Disappearing Pulse is one that rises up clearly and then disappears after reaching the top of the pulsation; its rises are felt, but its falls are absent.  The outlines of this pulse can also be a little rough and diffuse.  It indicates a critical deficiency of both the blood and the Vital Force, and is usually seen in extreme exhaustion, or after feats of severe physical exertion.
     Another Unani pulse is the Gazelle Pulse, which is like the leap of a gazelle - hopping up quickly, obtaining a level plateau, then abruptly rising and trailing off at the end.  A distinctive feature of this pulse is that the next beat, or gazelle leap, starts before the previous one is finished.  Its cause is the heat associated with fever; it can also indicate pericarditis.
     A Hurried Pulse is one that is both rapid and intermittent, occasionally skipping beats at irregular intervals.  It indicates that heat is agitating both the blood and Vital Force. 
     A Minute Pulse is both weak in force, thin in width, and nebulous in its contour, being indistinct and barely perceptible.  It indicates extreme weakness, devitalization and deficiency.
     A Scattered Pulse is like an Empty Pulse because it is big or wide, superficial and weak.  However, its contour is fuzzy, scattered and diffuse, and it falls or recedes much more strongly than it rises.  It indicates extreme adrenal exhaustion.
     An Ant-like or Formicant Pulse feels like a line or swarm of ants crawling up a tree, and is extremely feeble, scattered and diffuse.  Hakim Chishti says that it indicates a weakness of peristaltic action, but I feel that it indicates extreme exhaustion, marasmus and scattering or depletion of the Vital Force.

Spikes, or Micro-Pulses

     One particularly fascinating aspect of the pulse that Dr. Lad opened my eyes to is the phenomenon of spikes, which could also be called micro-pulses.  These constitute a kind of microsystem within pulse diagnosis.
     Spikes, or micro-pulses, can be felt coming out of the main flow, or stream, of the pulse and impinging on the pulse taker's fingers.  The microsystem aspect is due to the fact that these spikes can impinge on any one of the pulse taker's fingers from either the distal, medial or proximal sides, which are analogous in microcosm to the Carpal, Median and Cubit finger positions, respectively.  This microsystem of spikes essentially deepens and multiplies the possibilities of pulse diagnosis by at least threefold. 
     Since Ayurveda has three doshas, or constitutional / pathophysiological types, Dr. Lad's system naturally has three types of spikes, which he has named after the three doshas - Vata, Pitta and Kapha.  Since, in my understanding, the phenomenon of spikes principally concerns humoral superfluities and disharmonies in the various organ positions, I will name these spikes wind, bile and phlegm spikes, respectively, with wind pertaining to black bile, or the Melancholic humor.
     A wind spike (Melancholic / Vata) is thin and thready, like an electrical buzz, a wiggling worm, or a jagged, frayed wire.  Its natural home is on the distal side of the finger.
     A bile spike (Choleric / Pitta) is sharp and pointed, like a triangular pyramid pressing into the finger.  Its natural home is on the medial, or middle aspect of the finger.
     A phlegm spike (Phlegmatic / Kapha) is round and soft, like a squishy bubble.  Its natural home is on the proximal side of the finger.
     But what about blood, or the Sanguine humor?  Does it have its own spike?  At this point, I'd like to invite my Unani colleagues to join me on a noble quest: the search for the Sanguine spike! 
     My own feelings and observations lead me to believe that the Sanguine spike is midway between the sharpness of the Choleric and the roundness of the Phlegmatic.  I believe that I have felt them on occasion, but I would like others to advance their views and observations, and join me in corroborating these findings.
     Now - exactly how do these spikes work?  When a certain type of spike is in its natural home - for example, a phlegm spike on the proximal side of the finger - then the superfluity or disturbance in the respective organ pertains to that humor only, which is, in the above example, phlegm.
     But if the spikes leave their natural homes and travel to other parts of the finger, it indicates an excess or disturbance involving multiple humors in an affected organ.  For example, a wind spike appearing on the proximal side of the finger indicates wind, or black bile, obstructing phlegm.
     And so, the possibilities are as follows:
Wind Spike
wind disturbing phlegm; wind-phlegm.
     medial:  wind disturbing yellow bile; conglomerations of black and yellow bile.
Bile Spike
heat and choler blocking wind; yellow bile corrupting black bile.
     proximal:  heat and choler invading and corrupting phlegm.
Phlegm Spike
phlegm obstructing wind; phlegm corrupting black bile.
     medial:  phlegm obstructing or corrupting yellow bile; hot phlegm.
     Say, for example, that you felt a wind spike on the proximal side of the finger in the Carpal position on the left wrist.  This would indicate wind disturbing phlegm, or wind-phlegm obstructing or agitating the heart.  A phlegm spike on the medial side of the finger in that same organ position would indicate phlegm corrupting yellow bile, or hot phlegm, in the heart.  If that phlegm spike were on the proximal side of the finger, however, the disturbance would just involve phlegm.
     Pulse spikes can also be used to get a feel for someone's constitutional makeup of humor and temperament.  The technique is actually quite simple:
     If diagnosing a man, use the right wrist; if diagnosing a woman, use the left wrist.  Go down to the deepest level possible, with as much pressure as you can, that still allows the pulse to be felt.
     Then, simply count the spikes and their types.  The most numerous type of spike indicates the person's primary or dominant temperament; the next most numerous, or second place, indicates one's secondary temperament.
     This material on spikes has been presented last because this is a relatively subtle and difficult aspect of the pulse to master.  First, get a solid foundation in the basic qualities and parameters of the pulse before getting into spikes; master the generalities before getting down to the fine points.

Training and Preparation for Pulse Diagnosis

     Pulse diagnosis requires that you first clear the mind of all extraneous thoughts and distractions, then focus it completely on feeling the patient's pulses through your fingertips.  Meditation techniques follow a similar process of first clearing the mind, and then focusing it on the breath, or the subtle spiritual energies within.  Therefore, meditation is a good preparatory training for pulse diagnosis, increasing focus, awareness and sensitivity.
     Dr. Lad heartily recommends meditation for all his students, but adds another exercise for increasing sensitivity in the fingertips while taking the pulse:  Hold your hands out in front of you with the palms facing each other, and the fingertips touching.  Then, start to concentrate on feeling the blood pulsating through the capillaries at the tips of the fingers.  How many fingertips can you feel pulsations at?
     Hakim G. M. Chishti, in his book The Traditional Healer's Handbook, talks about training for pulse diagnosis with his teacher by feeling grains of sand through successive sheets of paper.  Everyone can open a book, place a grain of sand on one of its pages, and feel its presence through one or two overlying sheets of paper, but how many can increase that number to 10, 20, 30 sheets or more and still feel that grain of sand?
     Of course, the best and most specific training for pulse diagnosis is taking as many pulses as you can.  Start by taking the pulses of friends and acquaintances and seeing what you can detect in their pulse, starting with the basic qualities and parameters.  This will build up your skill and confidence, not to mention your clinical experience. 
     The basic degree of normality or abnormality of a pulse is always measured against one's expectations, either consciously or subconsciously.  For example, you would expect to find a full, forceful, hefty pulse on a big, musclebound bodybuilder.  If, on the contrary, you find his pulse to be thready and weak, the big question is:  What is making his pulse that way?
     Or, take another case: A patient walks in, and you can tell by his feisty demeanor and his ruddy complexion that he probably has a Choleric temperament.  These expectations are more than confirmed by his pulse, which is so tense, bounding, forceful and high pressured that it feels like it's almost ready to explode!  The pulse findings really drive home the fact that, above all, there is a supremely urgent need to cool this guy off and mellow him out, letting off steam and tension.

Books and Internet Resources on Pulse Diagnosis

     I received my initial training in pulse diagnosis in the Chinese system.  And so, in this article, I have used it as the basis for my approach, especially since I have the most clinical experience and training in it; therefore, it seems to me to be the most easily accessible and understandable.  I have mainly translated the underlying principles and clinical significances of the various pulse types into Greek medical terms.
     As a supplementary perspective and approach, I have used Ayurvedic pulse diagnosis, as I studied it and learned it from Dr. Lad, who has raised Nadi Pariksha, or Ayurvedic pulse diagnosis, to its highest level.  Since many pathophysiological concepts of Ayurveda relate quite closely to those of Greek Medicine, I feel that this is helpful and appropriate.
     My main source on Unani pulse diagnosis is what I have read in Hakim G. M. Chishti's book, The Traditional Healer's Handbook, published by Healing Arts Press in Rochester, Vermont, USA.  Most of this material is also available on Hakim Chishti's website, www.unani.com, on its Pulse Diagnosis page.  I have also observed some Unani pulse diagnosis firsthand while I was in India.
     Graeme Tobyn, in his excellent book on Culpeper and Greek Medicine entitled Culpeper's Medicine, discusses and touches on various aspects of pulse diagnosis throughout the book.
     My main textual source and reference for Chinese pulse diagnosis in preparing this page has been Ted Kaptchuk's excellent introduction to Chinese medicine, The Web That Has No Weaver, published by Contemporary Books of Chicago, Illinois, USA.
     For the serious student of Ayurvedic pulse diagnosis, I would like to recommend Dr. Vasant Lad's excellent book, Secrets of the Pulse, published by the Ayurvedic Press in Albuquerque, New Mexico, USA.  Please contact their website, www.ayurveda.com, to obtain a copy.  Dr. Lad also holds intensive workshops on pulse diagnosis every summer at the Ayurvedic Institute in Albuquerque.
     Just from doing a Google search on pulse diagnosis, the vast majority of results concern Chinese pulse diagnosis, including the seemingly universal site, www.pulsediagnosis.com.  Click on their Traditions tab, and you get only various lineages and traditions within the Chinese system.  I think that Unani, Greek and Ayurvedic pulse diagnosis traditions should also be represented there, don't you? 
     The California College of Ayurveda in Grass Valley has an excellent page on their website about Ayurvedic pulse diagnosis.  Just visit their website at www.ayurvedacollege.com
     When it comes to Galen and information on ancent Greek pulse diagnosis, all I could find on the internet were a few charming anecdotes and passing references to Galen's pulse diagnosis treatise, De Pulsibus.  One of these anecdotes about Galen relates how he diagnosed lovesickness in a woman patient by noticing how her pulse got excited and irregular whenever a certain dancer's name, on whom she had a crush, was mentioned.
     I personally would like to see a lot more quality, detailed information on ancient Greek, Galenic and Unani pulse diagnosis up on the internet.  Create or refer me to such a page or site, and I will immediately put up a link to it on my own site.  Just email me at: davido@greekmedicine.net
     And, it goes without question that I would love to see a copy of Galen's  De Pulsibus translated into English.  Or, I would love to see a serious, in-depth discussion of this treatise and its particulars up on the internet.