Shang Han Lun · Treatise on Cold Damage

1. Distinguishing Pulse Methods

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Question: What is meant by yin and yang in the pulse? Answer: Large, floating, rapid, stirring and slippery pulses are called yang. Deep, rough, weak, wiry and faint pulses are called yin. If a yin illness shows a yang pulse, the person lives; if a yang illness shows a yin pulse, the person dies. Question: How are yang binding and yin binding in the pulse distinguished? Answer: A floating, rapid pulse, with an ability to eat but no bowel movement, indicates repletion and is called yang binding. It is expected to become severe on the seventeenth day. A deep, slow pulse, inability to eat, heaviness of the body and unexpectedly hard stool are called yin binding. It is expected to become severe on the fourteenth day. Question: Why can an illness produce shivering aversion to cold and then also fever? Answer: When the yin pulse is insufficient, yang goes to join it; when the yang pulse is insufficient, yin goes to overtake it. Question: What is meant by insufficient yang? Answer: For example, a faint pulse at the cunkou is called insufficient yang. Yin qi rises into yang, producing shivering aversion to cold. Question: What is meant by insufficient yin? Answer: For example, a weak pulse at the chi position is called insufficient yin. Yang qi sinks into yin, producing fever. A floating yang pulse and a weak yin pulse indicate blood deficiency. Blood deficiency makes the sinews tense. A deep pulse indicates that nutritive qi is faint. A floating pulse with sweat flowing like a stream of pearls indicates decline of defensive qi. If fire-needling is added when nutritive qi is faint, the flow of blood is obstructed, and fever, restlessness and agitation develop as well. A pulse spread out like a carriage canopy is called yang binding. A pulse extending in a continuous line, as though the fingers were following a long pole, is called yin binding. A pulse flickering like fat on the surface of soup indicates faint yang qi. A pulse trailing like a spider's thread indicates declining yang qi. A pulse drawn into a fine thread like the last stream of poured lacquer indicates loss of blood. Yin and yang striking against each other is called stirring. Stirring of yang produces sweating; stirring of yin produces fever. A cold body with aversion to cold indicates injury to the triple burner. If both the yang and yin pulses are floating, large and yielding, with the yin pulse equal to the yang pulse, this is called relaxed. A pulse that is floating and tight is called wiry. A wiry pulse resembles a bowstring and does not shift under pressure. A tight pulse resembles a twisting rope and changes without constancy. When the pulse is wiry and large, the wiriness signifies diminution and the largeness signifies a hollow pulse. Diminution indicates cold; hollowness indicates deficiency. Cold and deficiency striking together are called a drumskin pulse. In women this means miscarriage and persistent uterine bleeding; in men it means loss of blood and loss of essence. If the pulse is floating and rapid but does not feel hollow under pressure, the person was not originally deficient. If the illness is about to resolve spontaneously, there will only be sweating, without a shaking chill. Question: Why do some illnesses resolve without shaking chills or sweating? Answer: The pulse is naturally faint because sweating, vomiting, purging or blood loss has already occurred, leaving no fluids within. Yin and yang now harmonize by themselves, and recovery must follow spontaneously. Thus the illness resolves without shaking chills or sweating. Question: In a pulse disorder, how can one distinguish whether recovery is approaching? Answer: When the three sites—cunkou, above the guan, and within the chi—are equal in size, floating or depth, slowness or rapidity, the pulse's yin and yang are harmonious. Even if chills and fever have not yet resolved, and even if the illness is severe, recovery should follow. Question: For any illness, how can one know from the time of onset when recovery will occur? Answer: If illness begins at midnight, recovery comes at noon the next day; if it begins at noon, recovery comes at midnight. Why say this? Illness beginning at noon resolves at midnight because yang meets yin. Illness beginning at midnight resolves at noon the next day because yin meets yang. If the Fuyang pulse is floating and rough while the Shaoyin pulse is normal, the illness is in the Spleen and diarrhea should occur. How is this known? A floating, large pulse would indicate replete qi and deficient blood. Since the Fuyang pulse is now floating and rough, we know that Spleen qi is insufficient and Stomach qi deficient. A Shaoyin pulse that is wiry and floating, appearing only slightly, is a regulated pulse; hence it is called normal. If instead it is slippery and rapid, we know that pus should be passed in the stool. A Fuyang pulse that is slow and relaxed indicates normal Stomach qi. When it is floating and rapid, floating signifies injury to the Stomach and rapidity signifies disturbance of the Spleen. This is not the original illness but a result of the physician's purging. Nutritive and defensive qi sink inward, and the rapid quality first becomes faint. If the pulse then remains only floating, the stool must be hard, and qi is relieved by belching. Why say this? Originally, the rapid pulse disturbed the Spleen. Since its rapidity first became faint, we know that Spleen qi is not functioning properly, the stool is hard, and qi is relieved by belching. Now the pulse is instead floating and its rapidity has become faint: harmful qi alone remains. There is hunger in the Heart region, but harmful heat cannot digest grain; tidal fever and thirst arise. The rapid pulse should become slow and relaxed. If its rhythm and rate before and afterward follow the proper pattern, the patient feels hunger. If the rapid pulse is irregular in timing, severe sores arise. When the pulse is floating and large but the region below the Heart is hard, heat belonging to the viscera should be attacked, without inducing sweating. If it belongs to the bowels, do not cause frequent urination. Frequent urination makes the stool hard; abundant sweating resolves the heat, whereas scant sweating leaves difficult defecation. If the pulse is slow, an attacking treatment is still not permissible. A floating, surging pulse, sweat on the body like oil, unceasing panting, inability to take water or gruel, numbness of the body, and alternation between quiet and agitation indicate the ending of life. It remains to determine which viscus first receives the disaster. Sweat moistening the hair with unceasing panting indicates that the Lung is the first to expire. Yang remaining alone, a body looking smoke-darkened, fixed staring and shaking of the head indicate expiration of the Heart. Blue-green lips and corners of the mouth with repeated damp sweating of the limbs indicate expiration of the Liver. Dark discoloration around the mouth and gentle sweating with yellowing indicate expiration of the Spleen. Incontinence of urine and stool, delirious speech, and upturned or fixed staring eyes indicate expiration of the Kidney. One must also determine whether yin or yang expires first. If yang qi expires first and yin qi is exhausted afterward, the body must be blue-green at death. If yin qi expires first and yang qi is exhausted afterward, the body must be red at death, with warmth beneath the armpits and heat below the Heart. A floating Fuyang pulse indicates deficiency. Floating and deficiency combine to produce qi obstruction or choking—the supplied graph is ye—signifying that Stomach qi is deficient and exhausted. A slippery pulse produces hiccups. This is the physician's fault: treating deficiency as though seeking repletion, guarding an empty place and forcing the blood. A floating pulse with dryness inside the nose means that nosebleeding must occur. With a floating, slow pulse, a hot red face, and trembling with apprehension, sweating should occur on the sixth or seventh day and bring resolution. If fever develops instead, recovery is delayed. Slowness means absence of yang, which cannot produce sweat; the body must itch. When both yin and yang at the cunkou pulse are tight, clear harmful influence should have struck the upper burner and turbid harmful influence the lower burner. Clear influence striking above is called clear; turbid influence striking below is called muddy. When harmful influence strikes yin, internal trembling must occur. The exterior qi is somewhat deficient and the interior qi fails to guard, allowing harmful influence to strike yin. When harmful influence strikes yang, fever, headache, stiff nape, neck contraction, lower-back pain and aching shins must occur: yang has been struck by the qi of mist and dew. Hence it is said that clear influence strikes above and turbid influence below. Yin qi produces trembling, reversal cold of the feet and knees, and uncontrolled passage of stool and urine. Exterior qi is slightly deficient and interior qi somewhat tense. The three burners mingle in confusion, and communication between inside and outside is blocked. The upper burner is constrained; visceral qi fumes against itself, producing ulceration of the mouth and erosion of the gums. The middle burner is disordered: Stomach qi surges upward, Spleen qi fails to turn, and the Stomach becomes turbid. Nutritive and defensive qi fail to communicate; blood congeals and does not flow. If defensive qi opens through first, urine is red-yellow. It contends with heat, which acts as its agent, traveling through channels and networks and entering and leaving viscera and bowels. Wherever the hot qi passes, abscesses and pus form. If yin qi opens through first, yang qi is reversely faint and yin has nothing to employ. Guest qi enters within; sneezing expels it, with a muffled voice and blocked throat. Cold and reversal chase each other and are hemmed in by heat. Congealed blood discharges downward, resembling pig's liver. Yin and yang both reverse; Spleen qi is isolated and weak, and the five fluids pour downward. The lower burner does not close; there is downward heaviness during evacuation, making passage frequent and difficult, with pounding, deep pain at the navel. Life will be difficult to preserve. If the yin and yang pulses are both tight and vomiting and diarrhea occur, but the pulse alone does not ease, the departure of tightness and arrival of calm indicate approaching resolution. If the pulse is slow and, by the sixth or seventh day, the person still does not wish to eat, this is a late development due to retained water and remains unresolved. If eating becomes naturally possible, resolution is approaching. After six or seven days of illness, if the pulses at all three regions of the hands and feet arrive, with great agitation, a clenched mouth preventing speech and restless disturbance, resolution must be approaching. If the pulse is harmonious, the person is greatly agitated, the eyelids feel heavy and the inner corners of the eyelids are yellow, this also indicates approaching resolution. A floating, slippery pulse: floating signifies yang and slipperiness repletion. Yang and repletion strike together, making the pulse rapid and swift. Defensive qi loses its proper measure. If a floating, slippery pulse is rapid and swift, with fever and sweating, the condition is not treatable. In cold damage with cough, counterflow and upward qi, a dispersed pulse means death, because the bodily form has been damaged.

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