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Disordered pulse indicates the scattering of spirit. These are all signs of the extinction of life. From this, we can deduce that although the pulse may appear floating and surging (Hong), it must be rootless; this is the diagnostic sign of the isolated Yang of the Zang organs flying away (Zhen Zang Gu Yang Fei Yue).

[Collected Notes] Wang Kentang said: When fire is about to extinguish, it must shine brightly. A pulse that comes floating, surging, and vigorous is a sign that the body is about to depart. However, one or two of the following symptoms must also be present before concluding that life has ended.

Yang remains alone while Yin is exhausted; the body appears dark like smoke, with fixed staring eyes and shaking head—this indicates the exhaustion of Heart Qi.

[Note] When Heart Qi exhausts, Yin fluids are depleted, leaving only Yang alone. Thus, the body becomes extremely hot, and the form appears dark like smoke, transforming from Fire. The Heart stores Spirit; fixed staring eyes indicate the departure of Spirit. The Head belongs to Yang; when Yang has no foundation, the head shakes.

[Collected Notes] Cheng Wuji said: The Heart meridian runs along the throat and connects to the eyes. Fixed staring eyes indicate the exhaustion of the Heart meridian. The Head is the meeting point of all Yang meridians; shaking head indicates the exhaustion of Yin and the lack of a root for Yang.

The lips and corners of the mouth turn cyan, and the four limbs twitch and tremble—this indicates the exhaustion of Liver Qi.

[Note] The color of the lips and mouth should be red with yellow undertones. If cyan appears instead, it indicates Wood (Liver) overcoming Earth (Spleen). Continuous sweating from the four limbs indicates the exhaustion of Liver Qi.

[Collected Notes] Cheng Wuji said: The lips and mouth are the external manifestations of the Spleen. The color of the Liver is cyan; when Liver Qi exhausts, its true color appears in the area it overcomes (the Spleen governs the lips and mouth). The four limbs are governed by the Spleen, while the Liver governs the sinews. When Liver Qi exhausts, the sinews and vessels become tense and contracted, manifesting in the area it overcomes.

Fang Youzhi said: The edges of the lips are called "Wen". The four limbs refer to the hands and feet. "Xi" describes the appearance of sweating; "Xi" also means birds flying frequently, implying that the hands and feet tremble as if birds are practicing flight, flapping continuously without stopping.

The area around the mouth turns dark black, with soft cold sweat and yellowish sweat—this indicates the exhaustion of Spleen Qi.

[Note] The Spleen's brilliance manifests in the skin around the lips. Dark blackening around the mouth indicates the withering of its brilliance. Cold sweat and Yin jaundice are both signs of Spleen Qi exhaustion.

[Collected Notes] Fang Youzhi said: The mouth is the orifice of the Spleen. "Li hei" refers to a smoky yellow turning dark, which is the color of failing Earth. "Rou han" is commonly known as cold sweat.

Zhang Xiju said: The Spleen governs the four whites (skin around the lips). Dark blackening around the mouth indicates failing Earth being insulted by Water. "Rou han" is soft and sticky, representing the true fluid of the Spleen; yellow is the true color of the Spleen. When true fluid leaks out and true color appears, it is called Spleen Qi exhaustion.

Incontinence of urine and feces, delirious speech, and eyes rolling upward with fixed staring—this indicates the exhaustion of Kidney Qi.

[Note] The Kidney controls the two lower orifices. Incontinence indicates Kidney Qi exhaustion. The Kidney stores Essence and Will; delirious speech and fixed staring indicate the failure of both Essence and Will.

[Collected Notes] Fang Youzhi said: "Sou bian" refers to urinary incontinence. The Kidney controls opening and closing; when these functions fail, both urine and feces cannot be controlled. The Classic states: The Kidney stores Will. Delirious speech indicates loss of Will; those who lose their Will will die. The Kidney governs bones, and the essence of bones manifests in the pupils. Eyes rolling upward with fixed staring indicate that the bone essence fails to nourish the pupils, resulting in an inability to move them.

Question: An excellent physician knows through observation, a mediocre physician through inquiry, and a poor physician through pulse diagnosis. I wish to hear the explanation. Master said: The patient's family says, "The patient suffers from fever and body pain." The patient lies down on their own. When the physician arrives and palpates the pulse, finding it deep and slow, they know the illness will recover. Why do they know this? If there were a exterior pathology, the pulse should be floating and large. Now that the pulse is deep and slow, recovery is indicated.

[Note] The following details methods of knowing through observation and inquiry. Observation involves examining the prosperity or decline of the form and the depth or shallowness of the color. Inquiry involves asking about the patient's suffering and desires, and the root cause of the disease. Pulse diagnosis involves examining the Yin and Yang of the pulse, ensuring it aligns with the form and color. Suppose the patient's family comes requesting help, stating the patient suffers from fever and body pain. Upon arrival, seeing the patient lying down, and palpating a deep and slow pulse, recovery is predicted. Why? Exterior diseases typically present with a floating and large pulse. The current deep and slow pulse, lacking exterior pulse characteristics and symptoms, indicates recovery.

[Collected Notes] Zhang Xiju said: There is a question regarding fever and body pain with a deep and slow pulse, which is a Yang disease presenting with a Yin pulse. Why is recovery stated? The answer is: One must observe signs of peacefulness and drowsiness, and inquire about the cessation of heat and lightness of the body, before combining these with the pulse to conclude recovery.

Suppose the patient says, "There was sudden abdominal pain." The patient sits on their own. When the physician arrives and palpates the pulse, finding it floating and large, recovery is indicated. Why? If there were an interior pathology, the pulse should be deep and fine. Now that the pulse is floating and large, recovery is indicated.

[Note] The patient's family requests help, stating sudden abdominal pain. Upon arrival, seeing the patient sitting comfortably without signs of distress, and palpating a floating and large pulse, recovery is predicted. Why? Interior diseases typically present with a deep and fine pulse. The current floating and large pulse, lacking interior pulse characteristics and symptoms, indicates recovery.

Master said: The patient's family requests help, stating the patient suffers from extreme fever and irritability. The next day, when the physician arrives, the patient lies facing the wall quietly, indicating the heat has gone. Even if the pulse is not harmonious, recovery may be declared.

[Commentary] "Not harmonious" should likely be "naturally harmonious"; how can recovery be declared if the pulse is not harmonious?

[Note] This elaborates on the previous two points. The family reports extreme fever and irritability. Before the physician leaves, upon returning the next day, seeing the patient lying quietly facing the wall indicates the heat has subsided, thus predicting recovery. If the pulse is not harmonious, recovery cannot yet be declared; it must be harmonious and slow to confirm recovery. This logic applies similarly to abdominal pain. As stated at the beginning of this chapter: "If circumstances do not match, carefully consider and examine." "Carefully consider" means today's observation differs from yesterday's inquiry.

Suppose the patient lies facing the wall. Upon hearing the physician arrive, they do not startle up but glance sideways. If they speak three words then pause three times, and swallow saliva during pulse diagnosis, this is feigned illness. Even if the pulse is naturally harmonious, the physician should declare the illness severe, requiring emetic and purgative medicines, and dozens or hundreds of acupuncture points to achieve recovery.

[Note] This sets forth a method for treating feigned illness. Zhang Zhongjing did not wish for people to deceive him, nor did he wish for physicians to be deceived into treating falsely. Physicians who study and ponder this will find that patients dare not deceive, and physicians will not treat recklessly.

[Collected Notes] Cheng Zhi said: Responding to feigned illness with feigned treatment requires skill that only an excellent physician possesses.

When the physician holds the pulse, if the patient yawns, there is no disease. If the patient groans during pulse diagnosis, there is disease. If speech is slow, it indicates Wind. If the head shakes while speaking, it indicates interior pain. If walking is slow, it indicates exterior stiffness. If sitting and leaning forward, it indicates shortness of breath. If sitting with one leg hanging down, it indicates waist pain. If the abdomen feels full and the patient protects it as if holding an egg, it indicates heart pain.

[Note] Yawning occurs due to the mutual attraction of Yin and Yang; air is drawn in first, then exhaled with a sigh, hence "yawning". Lack of mutual attraction between Yin and Yang indicates disease; mutual attraction indicates harmony. Thus, yawning signifies health. Groaning during pulse diagnosis indicates the sound of suffering from illness. Slow speech indicates language impediment, hence "slow speech indicates Wind". Shaking the head while speaking indicates pain so severe that vocalization is difficult; the head shake signals an attempt to alleviate pain, hence "shaking head while speaking indicates interior pain". Slow walking indicates Wind disease causing poor circulation in sinews and collaterals, hence "slow walking indicates exterior stiffness". Sitting and leaning forward indicates inability to connect Qi, hence "sitting and leaning forward indicates shortness of breath". Those with waist pain cannot sit steadily; even slight sitting requires extending the legs for support, hence "sitting with one leg hanging down indicates waist pain". Those with heart pain hunch over to protect the painful area, hence "full abdomen protecting the belly as if holding an egg indicates heart pain".

[Collected Notes] Fang Youzhi said: Tongue stiffness causes slow speech; tendon contraction causes stiff collaterals. The Liver belongs to Wood, governs sinews, and rules Wind. The Head belongs to Yang, the interior to Yin; head shaking indicates Yin does not harmonize with Yang. Shortness of breath indicates interior deficiency. These eight items are matters of knowing through observation.

Zhang Zhicong said: "Physician holding the pulse" implies the physician only palpates without asking questions. These eight items involve observing spirit and obtaining disease mechanisms, which is what is meant by "knowing through observation".

Question: What is the pulse condition of a person experiencing terror? Master said: The pulse feels like tracing beads on a thread, and the face is pale and loses color.

[Note] Fear in illness indicates insufficiency of Yang Spirit. Insufficiency of Yang leads to fear; insufficiency of Spirit leads to terror. Fear causes blood to follow Qi downward, resulting in a pale, lusterless face. Terror causes Qi to follow chaotic Spirit, resulting in a pulse that feels like tracing beads on a thread and is disordered.

[Collected Notes] Fang Youzhi said: "Kong bu" means panic and fear. "Xun" means to smooth or manage; "Si" means thin. "Lei lei" means connected. "Tuo se" means losing color. Generally, internal Qi deficiency leads to external loss of complexion, causing sudden changes.

Cheng Yingmao said: This demonstrates the method of observing color and combining it with pulse. Fear causes Qi to sink and Spirit to be deprived, resulting in a thin and unstable pulse, and a white, pallid face.

Question: What is the pulse condition of a person who does not drink water? Master said: The pulse is naturally choppy, and the lips and mouth are dry.

[Note] Scanty fluids lead to a choppy pulse, causing dry lips and mouth. This results from not drinking, not the other way around.

[Collected Notes] Cheng Yingmao said: Not drinking may resemble holding a grudge against others, where even after two or three days, no soup or water touches the lips. The Lung loses its ability to circulate essential Qi and fluids, resulting in a choppy pulse and dry lips and mouth.

Question: What is the pulse condition of a person feeling ashamed? Master said: The pulse is floating, and the face alternates between white and red.

[Note] "Kui" means shame. Shame causes spirit and color to fluctuate, resulting in a floating pulse and alternating white and red facial color. These are examples of observing color and combining it with pulse, using judgment to determine the condition.

[Collected Notes] Cheng Yingmao said: The above cases apply regardless of whether there is disease; any internal emotional burden manifests in color and pulse. From this, one can infer that by careful consideration, the nature of various diseases can be verified internally through external signs.

Question: What is meant by "disaster and strangeness" in pulses? Master said: Suppose a person is ill, presenting with a Taiyang pulse corresponding to their symptoms, and a decoction is prepared accordingly. Upon returning with the medicine, after about the time it takes to eat a meal, the patient suddenly vomits severely or experiences diarrhea with abdominal pain. The physician says: "I did not see these symptoms earlier; now they have changed strangely. This is called 'disaster and strangeness'." Asked again: "What causes this vomiting and diarrhea?" Answered: "Perhaps the patient took medication previously, which is now taking effect. Hence it is called 'disaster and strangeness'."

[Note] "Disaster and strangeness in pulse" refers to adverse reactions caused by medication. Suppose a person has a Taiyang disease, presents with a Taiyang pulse, and the pulse matches the symptoms, so a Taiyang decoction is administered. Upon returning with the medicine, after about a meal's time, the patient suffers severe vomiting and diarrhea with abdominal pain. The physician asks: "I did not see these symptoms before; why this strange change causing vomiting and diarrhea?" The patient answers: "Perhaps I took medication previously, which is now acting up, causing this disaster and strangeness!" Observation and inquiry are duties of the physician, but the patient must also be completely honest to allow the physician to perform their best. Zhang Zhongjing included this clause because patients often failed to inform doctors of prior medication use, serving as a warning!

[Collected Notes] Cheng Wuji said: When the physician matches the pulse and symptoms with the appropriate medicine, but a strange variation occurs, it is named "disaster and strangeness".

Zhang Zhicong said: When the pulse corresponds to Taiyang and the physical symptoms match, such as Taiyang disease with a floating pulse, stiff neck, headache, and aversion to cold, the pulse and symptoms correspond. If old medication taken previously now acts up, it means that within the time it takes to eat a meal, the newly administered medicine has not yet circulated fully through the meridians; this is necessarily due to the effects of the old medication.