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The *Ling Shu* (Spiritual Pivot) states: Whenever one is about to use acupuncture, one must first diagnose the pulse. Although pulse methods are numerous, acupuncturists can summarize them in six characters: slow (Huan), rapid/tense (Ji), large (Da), small (Xiao), slippery (Hua), and choppy (Se). (1) A tense pulse indicates mostly cold; a slow/relaxed pulse indicates mostly heat; a large pulse indicates excess Qi and deficient Blood; a small pulse indicates deficiency of both Qi and Blood; a slippery pulse indicates abundant Yang Qi with slight heat; a choppy pulse indicates abundant Blood but deficient Qi with slight cold. These six pulses primarily correspond to various diseases of the five Zang organs, as detailed in the classic texts, which will not be repeated here. Only when the pulse is small should needling be avoided. In cases of small pulses, both Yin and Yang, as well as form and Qi, are insufficient. One should not use needles for regulation but instead employ sweet (Gan) herbs.

Since Yin and Yang, deficiency and excess, often influence each other with fluctuations in abundance and decline, treatment may require tonification or sedation. The Renying point (located at the carotid artery on the neck) mainly reflects the three Yang meridians, while the Cunkou pulse (located at the radial artery of the wrist) mainly reflects the three Yin meridians. If the Renying pulse is one, two, or three times larger than the Cunkou pulse, it indicates excess Qi in the three Yang meridians; one should sedate the three Yang meridians and tonify the three Yin meridians. Conversely, if the Cunkou pulse is one, two, or three times larger than the Renying pulse, it indicates excess Qi in the three Yin meridians; one should sedate the three Yin meridians and tonify the three Yang meridians. Excess is treated by sedation, deficiency by tonification, heat by quick needling (rapid insertion and withdrawal), and cold by retention needling (long retention time). This is the correct method for handling tonification, sedation, heat, and cold. When there is neither excess nor deficiency, one should treat the affected meridian directly; this is the standard method for harmonizing Ying (Nutritive) and Wei (Defensive) Qi. In cases of chronic illness where both Yin and Yang, as well as Qi and Blood, are insufficient, and both Renying and Cunkou pulses are small, only sweet and bland herbs should be used for regulation, and acupuncture should be used with extreme caution.

Furthermore, the exhaustion of Zang organ Qi can occur internally or externally. Exhaustion occurring externally is characterized by a pulse that departs and does not return. The *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet) states: "If the pulse departs and does not return, or if it winds like a snake, death ensues." Or, if the pulse arrives but does not depart, and there is no pulse at the Chi position (distal part of the radial pulse), this is the pulse manifestation of impending exhaustion of Zang organ Qi. If one needles without diagnosing the pulse, the patient will die immediately upon needle insertion. Such deaths manifest as either restlessness or stillness. Restlessness indicates that the true Qi of the five Zang organs has first exhausted externally; the pulse departs and does not return. When the physician presses the Chi pulse, the Cun (proximal) and Guan (middle) pulses are completely absent. The limbs are cold (Jue Ni), and the Jing-Well points at the extremities, along with the Twelve Yuan-Source points which serve as pathways for the transmission of seasonal Qi and grain Qi from 365 acupoints, are cut off. The true Qi of the Zang organs cannot combine with Heaven's Qi and Grain Qi, causing Zang Qi to be exposed externally. Consequently, the pulse departs and does not return. Even without needling, this is a sign of impending death; needling causes immediate death. The death process is marked by restless agitation because the true Qi of the Zang organs is fully depleted externally. This is called "Nijue" (Rebellious Jue).

Stillness indicates that the true Qi of the five Zang organs has first exhausted internally; the pulse arrives but does not depart. When the physician presses the Cun pulse, the Chi and Guan pulses are completely absent. The patient opens their mouth and suffers from shortness of breath, finding inhalation difficult. This is because the true Qi of the Zang organs is about to exhaust; although Heaven's Qi and Grain Qi wish to replenish it, they are powerless to do so. Even without needling, this is a sign of impending death; needling causes immediate death. This is because the true Qi of the Zang organs was already exhausted, and reckless needling further depletes the incoming Qi. The death process is marked by stillness, which is called "Chongjie" (Double Exhaustion).

Puncturing the Wuli point leads to death, for two reasons:
(1) The pulse at the Wuli point. The Chi pulse at the Wuli point is one of the five prohibitions against needling. The true Qi of the five Zang organs relies on the water and grain Qi of the six Fu organs for nourishment. Wuli is an important point of the Hand-Yangming Large Intestine Meridian. If Zang Qi is already damaged and one recklessly needles it, the crucial pathway for the Fu organs' water and grain Qi to supplement the Zang organs is severed. "Those who obtain grain prosper; those deprived of grain perish"—this is the meaning behind this principle.
(2) The exhaustion of Qi in the five Zang organs presents with specific pulse forms: String-like (Xian) in Spring, Hook-like (Gou) in Summer, Hair-like (Mao) in Autumn, Stone-like (Shi) in Winter, and Intermitting (Dai) during the transition seasons (2). However, if there is only a String-like pulse without Stomach Qi (Wei Qi), death ensues; the pulse feels stiff like pressing a zither string. If there is only a Hook-like pulse without Stomach Qi, death ensues; the pulse bends forward and stays back, like holding a hooked belt. If there is only a Hair-like pulse without Stomach Qi, death ensues; it feels desolate when pressed, like wind blowing through hair. If there is only a Stone-like pulse without Stomach Qi, death ensues; it comes like untying a rope and goes like flicking a stone. If there is only an Intermitting pulse without Stomach Qi, death ensues; the pulse movement stops and cannot recover itself. None of these five pulses should be treated with acupuncture. Zhang Zhongjing stated: "Intermitting and knotted pulse, palpitations—Zhi Gancao Tang (Honey-Fried Licorice Decoction) governs this." This aligns with the righteous principle of regulating with sweet herbs. However, in his explanation of pulse methods, he added: "It is named Dai Yin (Intermitting Yin); those who obtain this pulse will certainly find it difficult to treat." The *Mai Jing* (Classic of Pulse Diagnosis) classifies this as a death pulse. Even the wise Master Zhang, in his judgment of this pulse, added the word "certainly" (Bi) to "difficult to treat," bringing it very close to untreatable death syndromes. How could one possibly use acupuncture?