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(Ling Shu, Chapter: Pathogenic Factors and Diseases of the Zang-Fu Organs and Meridians)

Huangdi asked: I would like to ask about the pathological manifestations reflected by the six pulse qualities: slow (Huan), rapid/tight (Ji), small (Xiao), large (Da), slippery (Hua), and choppy (Se). Qibo replied: Please allow me to explain the pathological changes of the five Zang organs. (These six are the outlines of pulse diagnosis, which is why the Emperor specifically raised them for inquiry.)

When the Heart pulse is extremely tight (Ji), it manifests as convulsions (Chi-Zhong); when slightly tight, it manifests as heart pain radiating to the back and difficulty in swallowing food. ("Tight" belongs to the category of wiry (Xian) pulses. A tight pulse indicates wind-cold; the Heart governs blood vessels. Therefore, an extremely tight Heart pulse leads to convulsions. Tendon and vessel contraction is called "Chi", and relaxation/extension is called "Zhong". Wiry and tight pulses generally indicate pain; thus, a slightly tight pulse manifests as heart pain radiating to the back. If there is pathogenic factor in the chest and heart, food should be difficult to swallow. Generally, wiry and tight pulses should present with these conditions; therefore, extreme tightness may also cause heart pain, and slight tightness may cause convulsions. Practitioners should apply flexibility based on medical principles. The same logic applies to other organs. "Chi" is pronounced chi, ji, or xi. "Zhong" is pronounced zong.)

When the Heart pulse is extremely slow (Huan), it manifests as manic laughter; when slightly slow, it manifests as Fuliang (a mass disease), located below the heart, moving up and down, accompanied by occasional spitting of blood. (Heart Qi heat causes the pulse to become loose and slow, leading to scattered spirit and manic laughter; the Heart's vocalization is laughter. If the pulse is slightly slow, it indicates Fuliang below the heart that can ascend and descend, with occasional hemoptysis, all indicating impurity in the Heart organ. The meaning of Fuliang is detailed in Disease Category 73.)

When the Heart pulse is extremely large (Da), it manifests as a gurgling sound in the throat; when slightly large, it manifests as Xinbi (heart obstruction) radiating to the back and excessive tearing. (Extreme largeness of the Heart pulse indicates Heart fire flaring upward, causing a gurgling sound in the throat. Slight largeness leading to Xinbi radiating to the back and tearing occurs because the Hand Shaoyin Heart meridian connects the throat and the eye system. The meaning of Xinbi is detailed in Disease Category 67. "Jie" is pronounced jie. "Bi" is pronounced mi.)

When the Heart pulse is extremely small (Xiao), it manifests as frequent hiccups (Yue); when minute, it manifests as Xiaodan (wasting-thirst). (Extreme smallness of the Heart pulse indicates deficiency of Yang Qi and cold in the Stomach Earth, leading to frequent hiccups. Minute size also indicates depletion of blood vessels, leading to Xiaodan. Xiaodan refers to emaciation of the skin and muscles. "Yue" is pronounced jue. "Dan" is pronounced dan, or shang/qu sounds.)

When the Heart pulse is extremely slippery (Hua), it manifests as excessive thirst; when slightly slippery, it manifests as Xinshe (heart hernia) radiating to the umbilicus and borborygmus in the lower abdomen. Extreme slipperiness of the Heart pulse indicates blood heat; blood heat causes dryness, leading to thirst. Slight slipperiness indicates heat in the lower jiao, leading to Xinshe radiating to the umbilicus and abdomen. The *Mai Yao Jing Wei Lun* states: The disease is named Xinshe. Because the Heart is a Yang organ (Mu Zang) and the Small Intestine acts as its envoy, it is said that there should be a palpable mass in the lower abdomen.)

When the Heart pulse is extremely choppy (Se), it manifests as aphonia; when slightly choppy, it manifests as hemorrhage, limb coldness (Wei Jue), tinnitus, and epilepsy. (Extreme choppy Heart pulse indicates stagnation of Qi and blood in the upper body. Voice is generated by Yang Qi; stagnation leads to aphonia. Slight choppy pulse causes hemorrhage, as choppy pulses injure blood. "Wei Jue" refers to reversal of Qi in the four limbs, because the limbs are the root of all Yang meridians, but blood is deficient and Qi is stagnant. Tinnitus and epilepsy occur because the Heart opens into the ears, and Heart deficiency leads to mental confusion. "Yin" is pronounced yin, meaning hoarseness.)

When the Lung pulse is extremely tight, it manifests as epilepsy; when slightly tight, it manifests in Lung cold-heat syndrome, lethargy, coughing up blood, pain radiating to the waist, back, and chest, or nasal polyps causing obstruction. (Extreme tightness of the Lung pulse indicates prevailing wind pathogen; Wood counter-attacks Metal, leading to epilepsy. Slight tightness also results from excess wind-cold transforming into heat, causing cold-heat and lethargy.)

When the Lung pulse is extremely slow, it manifests as profuse sweating; when slightly slow, it manifests as Wei Bi (paralysis) and hemiplegic wind, with unstoppable sweating below the head. (Extreme slowness of the Lung pulse indicates insecure exterior and hair/skin, leading to deficiency of the exterior and profuse sweating. Slight slowness leading to Wei Bi and hemiplegic wind with head sweating occurs because Yang pathogen enters Yin.)

When the Lung pulse is extremely large, it manifests as swelling of the calves; when slightly large, it manifests as Feibi (lung obstruction) radiating to the chest and back, and aversion to sunlight upon rising. Extreme largeness of the Lung pulse indicates Heart fire scorching Lung Metal, depleting true Yin, leading to calf swelling. Slight largeness also results from Lung heat, causing Feibi radiating to the chest and back. Feibi is characterized by irritability, fullness, wheezing, and vomiting. Aversion to sunlight occurs because Fire is excessive in the Qi level while Yin essence is depleted.)

When the Lung pulse is extremely small, it manifests as diarrhea; when minute, it manifests as Xiaodan. (Extreme smallness of the Lung pulse indicates deficiency of Yang Qi and insecurity of the Fu organs, leading to diarrhea. Minute size also indicates decline of Metal; Metal decline leads to Water weakness, causing Xiaodan.)

When the Lung pulse is extremely slippery, it manifests as Xiben (asthma) and rebellious Qi; when slightly slippery, it manifests as bleeding from the upper and lower orifices. Extreme slipperiness of the Lung pulse indicates excess heat in both Qi and Blood, causing Xiben (rapid breathing). Slight slipperiness also causes bleeding from the upper (mouth/nose) and lower (two yin) orifices. "Ben" is pronounced ben.)

When the Lung pulse is extremely choppy, it manifests as hematemesis; when slightly choppy, it manifests as Shulou (scrofula) in the neck and axilla, inability of the lower body to support the upper, and soft/weak knees. Choppy pulses result from blood injury. Since the Lung is in the Upper Jiao, extreme choppy pulse leads to hematemesis. Slight choppy pulse indicates Qi stagnation, leading to Shulou in the neck and axilla. Qi stagnation causes Yang pathology, and blood injury causes Yin deficiency, so the lower body cannot support the upper, resulting in weak knees. "Suan" is pronounced suan.)

When the Liver pulse is extremely tight, it manifests as aversion to speech (or irritable speech); when slightly tight, it manifests as Feiqi (a mass), located under the hypochondrium like an inverted cup. (Extreme tightness of the Liver pulse indicates strong Liver Qi. Strong Liver Qi leads to anger and lack of joy, resulting in irritable speech. Slight tightness also results from Wood pathogen injuring Earth, causing Feiqi under the hypochondrium. The hypochondrium is the pathway of the Liver meridian. Note: *Nan Jing* Chapter 56 states: The accumulation of the Liver is named Feiqi, located in the left hypochondrium. This section derives from that meaning. However, *Nan Jing* associates Wood with the East, hence specifying the left side, whereas this text does not specify "left".)

When the Liver pulse is extremely slow, it manifests as frequent vomiting; when slightly slow, it manifests as Shuijia Bi (water retention obstruction). Slow pulse is characteristic of the Spleen. When the Liver pulse becomes extremely slow, it indicates Wood overcoming Earth, leading to frequent vomiting. Slight slowness leading to water retention and obstruction occurs because Earth is controlled by Wood and fails to transport and transform. Shuijia refers to water accumulation. "Jia" is pronounced jia or jia.)

When the Liver pulse is extremely large, it manifests as internal abscess and frequent epistaxis; when slightly large, it manifests as Ganbi (liver obstruction), retraction of the genitals, and cough radiating to the lower abdomen. (Extreme largeness of the Liver pulse indicates vigorous Liver Fire. Wood and Fire blazing together cause internal abscess. Heat in the blood prevents it from being contained, causing epistaxis. Slight largeness leading to Ganbi, genital retraction, and cough radiating to the lower abdomen occurs because Fire is in the Yin aspect. The meaning of Ganbi is seen in Disease Category 67. "Nu" is pronounced ni, referring to nosebleed.)

When the Liver pulse is extremely small, it manifests as polydipsia; when minute, it manifests as Xiaodan. (The Liver stores blood. Extreme smallness of the Liver pulse indicates blood deficiency and thirst, leading to polydipsia. Minute size also indicates Yin deficiency and blood dryness, causing Xiaodan.)

When the Liver pulse is extremely slippery, it manifests as Kuihan (ulcerated hernia); when slightly slippery, it manifests as enuresis. (Extreme slipperiness of the Liver pulse indicates heat obstructing the meridians, causing ulcerated hernia. Slight slipperiness leading to enuresis occurs because Liver Fire is in the lower jiao, causing uncontrolled discharge. "Kui" is the same as "Kui". "Niao" is the same as "Niao".)

When the Liver pulse is extremely choppy, it manifests as Yi Yin (overflowing drink/water retention); when slightly choppy, it manifests as convulsions, tendon cramps, and tendon bi. (Extreme choppy Liver pulse indicates decline and stagnation of Qi and blood. Insufficient Liver Wood allows Spleen Earth to overact, causing dampness to overflow into the limbs, known as Yi Yin. Slight choppy pulse leading to convulsions, cramps, and tendon bi occurs because blood is insufficient to nourish the tendons. "Chi" is pronounced chi or xi. "Luan" is pronounced luan, meaning tendon contraction.)

When the Spleen pulse is extremely tight, it manifests as convulsions; when slightly tight, it manifests as Ge Zhong (obstruction in the diaphragm/chest), where food and drink enter and immediately return out, and stool contains saliva/phlegm. (Extreme tightness of the Spleen pulse indicates Wood attacking Earth. The Spleen governs the limbs, and wind pathogen invades, causing convulsions. Slight tightness also results from Liver pathogen insulting the Spleen, preventing Spleen transportation, causing food regurgitation. Earth failing to control Water leads to excessive saliva. "Wo" is pronounced wu, describing water pooling.)

When the Spleen pulse is extremely slow, it manifests as Wei Jue (paralysis and cold limbs); when slightly slow, it manifests as Feng Wei (wind paralysis), inability to use the four limbs, but the mind remains clear as if healthy. (The Spleen pulse should be slow. Extreme slowness generates heat. The Spleen governs muscles and limbs, so Spleen heat causes muscle atrophy and reversal cold. Slight slowness leading to wind paralysis and limb immobility occurs because weak Earth generates wind. Although the tendons/muscles are weak in the meridians, the Zang organs are intact, so the mind remains clear.)

When the Spleen pulse is extremely large, it manifests as sudden collapse as if struck; when slightly large, it manifests as Hernia Qi, abdominal distension, and pus/blood outside the intestines and stomach. (The Spleen governs Middle Qi. Extreme largeness of the Spleen pulse indicates extreme Yang, leading to Yin collapse, causing collapse as if struck. Slight largeness leading to Hernia Qi occurs because damp-heat is in the meridians, and the anterior yin is the convergence of Taiyin and Yangming. Abdominal distension is due to pus/blood outside the intestines/stomach, caused by Spleen Qi stagnation.)

When the Spleen pulse is extremely small, it manifests in alternating chills and fever; when minute, it manifests as Xiaodan. (Small Spleen pulse indicates deficiency of Middle Jiao Yang Qi. Extreme smallness leads to chills and fever, while minute size leads to Xiaodan.)

When the Spleen pulse is extremely slippery, it manifests in Long Han (strangury and hernia); when slightly slippery, it manifests in worm toxicity causing abdominal heat. (Extreme slipperiness of the Spleen pulse indicates Taiyin excess heat. Taiyin combines with the sinews, causing strangury and hernia. Slight slipperiness indicates damp-heat in the Spleen. Damp-heat steaming generates worms and causes abdominal heat. "Long" is the same as "Long". "Long" is pronounced long. "Hui" is the same as "Hui", pronounced hui. "Xie" is pronounced xie.)

When the Spleen pulse is extremely choppy, it manifests in Chang Pi (dysentery); when slightly choppy, it manifests in Ne Shi (internal hemorrhoids) and frequent passage of pus and blood. (Extreme choppy Spleen pulse leads to Chang Pi; slight choppy pulse leads to Ne Shi and pus/blood stool. Choppy indicates Qi stagnation and blood injury. The collateral of the Foot Taiyin Spleen enters and connects to the intestines and stomach. Chang Pi and Ne Shi differ only in location. Another view calls it a lower swelling disease, belonging to hernia fistula.)

When the Kidney pulse is extremely tight, it manifests as Gu Dian Ji (bone epilepsy); when slightly tight, it manifests as Chen Jue (deep reversal cold), Ben Tun (running piglet), inability to move the feet, and inability to urinate or defecate. (Extreme tightness of the Kidney pulse indicates wind-cold in the Kidney. The Kidney governs bone, leading to bone epilepsy. Slight tightness leading to deep reversal cold and immobile feet indicates cold pathogen in the meridians. Ben Tun indicates cold pathogen in the Zang organs. Inability to pass urine/stool indicates cold pathogen in the Yin aspects. Note: *Nan Jing* Chapter 56 states: The accumulation of the Kidney is named Ben Tun, originating in the lower abdomen, rising to the epigastrium like a pig, moving up and down without fixed time. This section derives from that meaning. The meaning of Gu Dian Ji is detailed in Acupuncture Category 37.)

When the Kidney pulse is extremely slow, it manifests as broken spine sensation; when slightly slow, it manifests as Dong Xie (hole diarrhea), where food is not digested and comes back up after swallowing. (Extreme slowness of the Kidney pulse indicates Yin deficiency, leading to spinal pain, as the Foot Shaoyin Kidney meridian passes through the spine. Slight slowness indicates Kidney Qi deficiency. Kidney deficiency leads to衰竭 of Mingmen Qi, failure of Lower Jiao transformation, and reflux of undigested food, causing Dong Xie.)

When the Kidney pulse is extremely large, it manifests as impotence; when slightly large, it manifests as Shi Shui (stone water/ascites), heavy swelling from below the navel to the lower abdomen, extending up to the epigastrium, which is a fatal untreatable condition. (Extreme largeness of the Kidney pulse indicates Water deficiency and Fire hyperactivity, causing impotence. Slight largeness indicates Kidney Yin deficiency. Yin deficiency leads to failure of transformation, causing Qi stagnation and water accumulation forming Shi Shui. If water rises to the epigastrium, Water pathogen is extreme, counter-attacking Earth, overflowing uncontrollably, leading to death. The meaning of Shi Shui is seen later in Section 24. "Chui" is pronounced chui, meaning heavy/dropping. "Wan" should be "Wan" (epigastrium).)

When the Kidney pulse is extremely small, it manifests as Dong Xie (profuse diarrhea); when minute, it manifests as Xiaodan. (Extreme smallness of the Kidney pulse indicates decline of Yuan Yang in the lower jiao, causing Dong Xie. Minute size indicates deficiency of True Qi, causing Xiaodan.)

When the Kidney pulse is extremely slippery, it manifests in Long Bi (urinary retention); when slightly slippery, it manifests as Gu Wei (bone atrophy), difficulty sitting or standing, and blindness upon standing. (Extreme slipperiness of the Kidney pulse indicates flourishing Yin Fire, causing urinary retention. "Shan" refers to hernia. Slight slipperiness also results from Fire hyperactivity. Fire hyperactivity leads to Yin deficiency, causing bone atrophy, inability to rise, and visual impairment upon standing.)

When the Kidney pulse is extremely choppy, it manifests as Da Yong (large abscess); when slightly choppy, it manifests as amenorrhea and Chen Shi (deep hemorrhoids). (Choppy Kidney pulse indicates injury to Essence, blood deficiency, and Qi stagnation. Extreme choppy leads to large abscess; slight choppy leads to amenorrhea and deep hemorrhoids.)

Huangdi asked: Regarding the six variations of disease pulses, how should acupuncture be applied? Qibo answered: All tight (Ji) pulses indicate Cold. (Tight pulse refers to Xian/Jin. Zhang Zhongjing said: Floating and tight pulse is named Xian. Tight indicates Cold. Cheng Wuji said: Tight indicates excess Yin Qi. Thus, tight pulses generally indicate wind-cold, and Qi transformation relates to the Liver.) Slow (Huan) pulses indicate Heat. (Slow pulse refers to a relaxed state, not the slow rate of later generations. Zhang Zhongjing said: Slow indicates growth of Yang Qi. Also: Slow indicates sufficient Stomach Qi. Thus, relaxed pulses generally indicate interior heat, and Qi transformation relates to the Spleen and Stomach.) Large (Da) pulses indicate excess Qi and deficient Blood. (Large pulse indicates excess Yang; Yang excess leads to Yin decline, hence excess Qi and deficient Blood. Zhang Zhongjing said: Floating and large pulse indicates Qi excess and Blood deficiency. Thus, large pulses generally indicate floating Yang, and Qi transformation relates to the Heart.) Small (Xiao) pulses indicate deficiency of both Qi and Blood. (Small pulse is close to micro/fine. In Yang, it indicates Yang deficiency; in Yin, it indicates Yin weakness. Pulse body belongs to Yin and transforms via the Kidney.) Slippery (Hua) pulses indicate abundant Yang Qi with slight heat. (Slippery pulse is Yang, indicating substantial Qi and Blood, hence abundant Yang Qi and slight heat. Zhang Zhongjing said: Slippery indicates solid Stomach Qi. *Yu Ji Zhen Zang Lun* says: Weak and slippery pulse indicates presence of Stomach Qi. Thus, slippery pulse relates to the Stomach.) Choppy (Se) pulses indicate excess Blood and deficient Qi with slight cold. (Choppy indicates Qi stagnation and blood deficiency. Deficiency of both Qi and Blood leads to insufficient Yang Qi, hence slight cold. Zhang Zhongjing said: Choppy indicates deficiency of Ying Qi, i.e., blood deficiency. Here it says "excess blood," which seems erroneous. Observing the instruction not to bleed when treating choppy pulses clarifies this. Choppy pulse is near the skin surface, so Qi transformation relates to the Lung.)

Therefore, when needling tight pulses, insert deeply and retain for a long time. (Tight pulses indicate Cold; Cold comes from Yin and is hard to dispel. "Nei" is the same as "Na".) When needling slow pulses, insert shallowly and withdraw quickly to disperse Heat. (Slow pulses indicate Heat; Heat comes from Yang and is easy to scatter.) When needling large pulses, slightly drain Qi, do not bleed. (Large pulses indicate Yin deficiency, so do not bleed.) When needling slippery pulses, withdraw quickly and insert shallowly to drain Yang Qi and remove Heat. (Similar to needling slow pulses.) When needling choppy pulses, must penetrate the vessel accurately, retain for a long time following the direction of Qi flow, first press and rub the area, after withdrawing the needle, press the puncture site quickly to prevent bleeding and harmonize the pulse. (Choppy pulses indicate Qi and Blood deficiency, making it hard to obtain De Qi. Thus, one must accurately penetrate the vessel, observe direction, retain long, press quickly, and avoid bleeding. This requires more caution than other methods because choppy pulses indicate deficiency, fearing damage to True Qi. "Xun" is pronounced xun, meaning massage/rub. "Can Hen" is pronounced wei/wei, referring to scar/mark.) For all small pulses, where Yin-Yang, Form, and Qi are all deficient, do not use needles; instead, regulate with sweet medicines. (Small pulse indicates deficiency. Not using needles shows that Qi and Blood deficiency should not be needled but regulated with sweet medicine. Note: In this section, regulating Yin-Yang and Form-Qi deficiency with sweet medicine, the character "Sweet" holds profound meaning. Food and medicine must pass through the Spleen and Stomach before nourishing the Five Zang. Strong Stomach Qi strengthens all Zang; weak Stomach Qi weakens all Zang. Stomach belongs to Earth and prefers Sweet. Thus, Middle Qi deficiency requires Sweet-Warm herbs. Strengthening Earth strengthens Metal; strengthening Metal fills Water. This is why Earth is the mother of all things, and Yin-Yang deficiency must be regulated with sweet medicine. Although *Zhi Yao Yao Zheng Lun* lists five flavors with tonifying/draining effects based on Five Element generation/restriction, users should primarily use Sweet with slight combinations of other flavors to tonify the Middle. Just as the Four Seasons require Earth, and the Five Zang require Stomach Qi, Spring pulse is slightly wiry, Summer pulse slightly hook-like. *Yin Yang Ying Xiang Da Lun* states: Tonify form deficiency with Qi; tonify essence deficiency with Flavor. Thus, flavors suitable for the person are called tonics; using bitter/unpalatable flavors to seek tonification is illogical. The study of flavor attack and tonification has great subtleties. If one is not good at harmonizing, mistakes begin immediately. This is the primary principle for physicians.)