Li Shizhen: Pulse Diagnosis Is "the Last of the Four Diagnoses"
Pulse taking is the hallmark of TCM diagnosis. So just how important is pulse taking? Doctors and patients alike seem to regard TCM pulse diagnosis as very important, but Li Shizhen did not think so.
Li Shizhen's Binhu Pulse Study (Binhu Maixue), Studies on the Eight Extraordinary Meridians (Qijing Baimai Kao), and Textual Research on the Pulse Canon (Maijue Kaogao) are important works in TCM pulse diagnosis teaching. Yet in his writings Li Shizhen said: "The physicians and patients of the world all regard the pulse as the foremost task, not knowing that the pulse is the last of the four diagnoses and is merely a clever technique. A superior physician who wants to grasp the whole must be equipped with all four diagnoses." This means that most doctors and patients in the world regard pulse diagnosis as the most important TCM diagnostic method, but they do not realize that pulse diagnosis is actually the least important of the four TCM diagnoses (inspection, auscultation-olfaction, inquiry, and palpation), and is merely a clever skill. A skilled TCM physician who wants to accurately judge a patient's condition must attach importance to collecting all kinds of clinical data.
Li Shizhen's attitude is very pragmatic and truth-seeking. His pulse studies, like the Compendium of Materia Medica (Bencao Gangmu) he compiled, are all real experiences he summed up from practice. Li Shizhen had rich pulse knowledge; his Binhu Pulse Study, Studies on the Eight Extraordinary Meridians, and Textual Research on the Pulse Canon drew on hundreds of pulse studies and can be called a comprehensive synthesis of pulse lore. Binhu Pulse Study in particular is honored as one of the four small classics of TCM. Since the Ming and Qing dynasties, Binhu Pulse Study has been the introductory textbook for TCM education, and it remains so to this day.
Why did Li Shizhen argue that pulse study is the last of the four diagnoses and the least important? This is mainly because TCM pulse diagnosis is indeed not very accurate. The first to raise this opinion was not Li Shizhen but the author of the Yellow Emperor's Inner Canon (Huangdi Neijing). In the chapter "On Changing the Essence by Transforming Qi, Chapter 13" of the Yellow Emperor's Inner Canon, there is the following exchange between the Yellow Emperor and Qibo: "The Emperor said: I have heard the essentials from you, Sir; you say not to depart from complexion and pulse—this much I know. Qibo said: The treatment's ultimate lies in One. The Emperor said: What is One? Qibo said: One means obtaining it through inquiry. The Emperor said: How so? Qibo said: Close the doors and shut the windows, focus on the patient, and repeatedly ask about their situation so as to follow their will; those who have obtained the spirit will prosper, those who have lost the spirit will perish. The Emperor said: Good."
This means that when the Yellow Emperor asked Qibo about the key to diagnosing disease, after Qibo spoke at length about complexion and pulse, he said the most critical thing was actually to "close the doors and shut the windows, focus on the patient, and repeatedly ask about their situation so as to follow their will." What does this mean? It means that the very key to TCM diagnosis is, on the premise of fully protecting the patient's privacy (hence "close the doors and shut the windows," that is, close the doors and windows so as to prevent the patient's privacy from leaking and let the patient feel safe and at ease), conducting a detailed inquiry and inspection of the patient. One must understand the patient's true signs and observe the patient's spirit and complexion. That is to say, although Qibo himself spoke at length about pulse diagnosis, he also held that pulse diagnosis is less important than inquiry and inspection, which is consistent with Li Shizhen's attitude toward pulse diagnosis.
Treating pulse diagnosis as the most important TCM diagnostic technique is an incorrect historical prejudice accumulated among our folk. This historical prejudice is not only useless but harmful to diagnosing disease. Because when this prejudice develops to the extreme, many people become deliberately mysterious, taking only the pulse and not collecting other detailed information about the patient at all; throughout the consultation they have basically no interaction with the patient, and after taking the pulse they prescribe a formula on their own. Of course the effect of such treatment will not be ideal.
Inquiry and inspection are far more important than pulse taking; in fact, once inquiry and inspection are well done, pulse taking may not even be necessary, and sometimes pulse diagnosis can instead lead the doctor to a wrong judgment. If we do not patiently collect the patient's various symptoms and signs, we cannot prescribe the right medicine for the condition, nor can we grasp the patient's contraindications; the efficacy of the formula prescribed cannot be guaranteed, and safety cannot be avoided. This departs from the principle of safe and effective medical care.
Patients should not, out of superstitious prejudice, entrust their life and death to a pulse diagnosis that even Li Shizhen and Qibo did not dare place high hopes in. When seeing a TCM doctor, do not treat pulse taking as the most important evidence; instead, truthfully and in detail tell the doctor your various symptoms, drug allergy history, and family disease history. Also do not presumptuously diagnose yourself, so that the doctor can understand your situation in greater detail. Even less should you say not a word, merely hold out your hand for the doctor to feel the pulse, and test the doctor's skill. I have encountered such a patient: she refused to tell me what illness she had or what was wrong, merely holding out her hand for me to feel the pulse and let me judge her condition from the pulse alone.
What should a doctor do when encountering such a patient? I say not an extra word, charge no fee, and prescribe a safe, well-balanced formula with as few herbs as possible and absolutely no side effects. I tell the patient to take only one dose; if one dose is ineffective, they should seek another expert. This is how I treat the patient's superstition and obsession. Treating disease is a serious matter of life and death; if the patient is not serious, the doctor should not rashly treat them.