The diagnostic significance of pulse patterns may seem straightforward at first glance: floating pulse indicates exterior conditions, deep pulse indicates interior conditions, slow pulse indicates cold, rapid pulse indicates heat, weak pulse indicates deficiency, and full pulse indicates excess. Historical texts and textbooks on pulse diagnosis generally agree on these points, suggesting little need for further analysis. However, a close reading of the “Shang Han Lun” (Treatise on Cold Damage) and “Jin Gui Yao Lue” (Essential Prescriptions from the Golden Cabinet) reveals that the diagnostic significance of pulse diagnosis is related to various factors, including the progression of the disease, changes in syndromes, the patient’s constitution, and the nature of the pathogenic factors. The diagnostic significance of a pulse pattern is often multifaceted and should be clarified through comprehensive analysis of various related factors. Here, we provide a thorough analysis of the significance of various pulse patterns as described in the “Shang Han Lun” and “Jin Gui Yao Lue,” aiming to shift the perspective of pulse diagnosis from a one-pulse-one-syndrome approach to enhance its clinical diagnostic value.
1
Floating Pulse
In the “Shang Han Lun,” the floating pulse is recorded 64 times. It suggests exterior syndrome 43 times (67%), of which 6 instances are not typical exterior syndromes but indicate the presence of external pathogens. It suggests heat syndrome 15 times (23%), mostly in the context of Yangming disease, indicating that the heat of Yangming syndrome has an outward manifestation. It suggests deficiency syndrome 4 times (6%). The distinction between deficiency and excess is significant, as the treatment methods differ greatly. Additionally, 2 instances refer to the vomiting method, indicating the mechanism of the pathogen rising. In the “Jin Gui Yao Lue,” the floating pulse is recorded 44 times. (In the section on wind and cold of the five organs, the terms for floating in deficiency, floating in weakness, floating in excess, and floating in firmness refer to light pressure during pulse diagnosis, not floating pulse, and are not included.) It suggests wind pathogen invasion 15 times (34%), which is significantly lower than in the “Shang Han Lun.” It suggests heat syndrome 14 times (32%). It suggests deficiency syndrome 13 times (30%), which is notably higher than in the “Shang Han Lun,” indicating that floating pulse in various diseases should highly consider the possibility of deficiency syndrome. There are also 2 instances referring to conditions suitable for vomiting.2
Deep Pulse
In the “Shang Han Lun,” the deep pulse is recorded 24 times, all indicating interior conditions. Among these, there are 12 instances of interior excess syndrome, 9 instances of interior deficiency syndrome, 2 instances of interior cold excess syndrome, and 1 instance of mixed deficiency and excess. This indicates that the reliability of floating pulse indicating exterior conditions is less than 70%, while the reliability of deep pulse indicating interior conditions is very high. However, the presence of a deep pulse does not negate the existence of exterior syndrome, as seen in the case of Shaoyin disease, where both exterior and interior conditions are present with a deep pulse. In the “Jin Gui Yao Lue,” the deep pulse is recorded 33 times (including 2 instances of hidden pulse), with 30 instances indicating interior conditions (13 instances of deep pulse due to water retention causing edema), suggesting interior cold excess syndrome 13 times, interior deficiency cold 8 times, and interior excess heat 8 times, distributed among conditions such as diarrhea, jaundice, yellow sweat, phlegm fluid, water retention, and syncope, which should be given special attention. Additionally, in the section on cough, the deep pulse in the Zexi Decoction case elucidates the mechanism of the disease, belonging to interior conditions, but the complexity of cold-heat deficiency-excess mixed conditions is significant.3
Rapid Pulse (Accompanying Disease Pulse)
In the “Shang Han Lun,” the rapid pulse is recorded 21 times. It indicates heat syndrome 14 times, including 2 instances of deficiency heat, 9 instances of excess heat, and 3 instances where the pathogenic factor belongs to excess heat but the righteous qi is slightly insufficient. There are 5 instances of rapid pulse indicating exterior cold syndrome, suitable for warming and releasing the exterior, using Mahuang Decoction or Guizhi Decoction. Although it belongs to cold pathogens, the body temperature rises, resulting in a rapid pulse; one should not deny the cold condition due to the rapid pulse and should avoid using warming herbs. There are also 2 instances of rapid pulse indicating deficiency cold. Deficiency cold and excess heat are opposite in nature, but both can present with a rapid pulse, which requires careful consideration. There is 1 instance of disease pulse, in the Yangming disease section, where the pulse is slippery and rapid, indicating the use of Xiao Chengqi Decoction. The slippery pulse indicates interior excess, and one can use Da Chengqi Decoction, but the rapid pulse suggests that the righteous qi is slightly insufficient, hence the use of Xiao Chengqi Decoction.4
Slow Pulse
In the “Shang Han Lun,” the slow pulse is recorded 13 times, with 5 instances truly belonging to deficiency cold syndrome (38%), and 6 instances indicating excess syndrome (including 2 instances of Yangming excess heat, 1 instance of chest obstruction due to excess heat, 1 instance of cold excess accumulation, and 2 instances of dampness obstructing the interior). There is also 1 instance of heat retreating with body cooling, resulting in a slow pulse. The sample size of the above data is too small to have statistical significance. However, among the diseases presenting with a slow pulse, excess conditions are more common than deficiency conditions, and the proximity of excess heat and deficiency cold is noteworthy.5
Tight Pulse
In the “Shang Han Lun,” the tight pulse appears 23 times, mostly indicating cold pathogens in the exterior, with 11 instances. It indicates cold excess pathogenic factors in the interior 6 times, indicates pathogens in the Shaoyang 2 times, and indicates interior excess heat accumulation 3 times. In the “Jin Gui Yao Lue,” the tight pulse appears 24 times. There are 14 instances indicating cold excess pathogenic factors in the interior, indicating deficiency cold 5 times, indicating exterior cold 2 times, and indicating interior excess heat 3 times (due to food retention and intestinal abscess). It appears that the tight pulse primarily indicates cold pathogens (81%), mostly of cold excess, with a few instances of deficiency cold. The instances indicating excess heat account for 18%, which should be given clinical attention.6
Slippery Pulse
In the “Shang Han Lun,” the slippery pulse appears 7 times, reflecting heat syndrome, with cases such as Baihu Decoction, Xiaoxianxiong Decoction, and heat excess leading to blood loss. In the “Jin Gui Yao Lue,” the slippery pulse is recorded 9 times, with 8 instances indicating heat syndrome, including Chengqi Decoction, lung abscess, gastrointestinal excess heat, wind water transforming heat, and lower jiao damp-heat. Only one instance in the phlegm fluid disease section states “pulse floating and fine slippery due to phlegm fluid,” which cannot be definitively classified as heat syndrome.7
Choppy Pulse
In the “Shang Han Lun,” the choppy pulse appears 11 times. 10 instances indicate deficiency syndrome (including 6 instances of qi and blood insufficiency, 2 instances of yang deficiency heart, and 2 instances of insufficient yin fluids). The severity of deficiency syndrome varies greatly, with the lightest being spleen deficiency syndrome, where heat retreats and fluids are damaged; the heaviest being the critical case of Da Chengqi Decoction, where “a choppy pulse indicates death.” Only 1 instance of choppy pulse indicates exterior syndrome without sweating, “How do we know that sweating does not fully occur? It is known by the choppy pulse.” In the “Jin Gui Yao Lue,” the choppy pulse appears 10 times. 9 instances indicate deficiency syndrome (including 6 instances of deficiency cold, 2 instances of deficiency heat, and 1 instance of bleeding). Only one instance of choppy pulse refers to food retention and accumulation, suitable for Da Chengqi Decoction to purge.8
Large Pulse and Flooding Pulse
In the “Shang Han Lun,” the large pulse appears 8 times, all indicating disease progression, consistent with the “Nei Jing” (Inner Canon) stating “a large pulse indicates disease advancement.” However, the severity of the disease varies. In the upper section of Taiyang disease, it states: “After taking Guizhi Decoction, if there is a large sweat and the pulse appears large for a time, but the exterior syndrome has not resolved, one can still use Guizhi Decoction.” This case is the lightest, but there is also the possibility of developing into an interior heat syndrome. In the lower section of Taiyang disease, it states: “In the case of chest obstruction, if the pulse is large, one must not purge; purging will lead to death.” This case indicates a critical condition of deficiency and excess. Among the 8 instances of large pulse, 6 instances are essentially excess conditions, and 2 instances are accompanied by flooding pulse, and both appear simultaneously, hence no separate discussion.9
Small Pulse and Fine Pulse
Small pulse and fine pulse have similar forms and characteristics, thus discussed together. In the “Shang Han Lun,” the fine pulse appears 11 times, while the small pulse appears only once, with another instance being a small, fine, deep, and tight composite pulse, indicating a complex pathogenesis. Both small and fine pulses reflect insufficient righteous qi, but the severity varies greatly. For example, “If the Shaoyang pulse is small, it indicates recovery” suggests that the pathogen has receded and the righteous qi is deficient, indicating that the disease has entered the recovery phase. In contrast, the fine pulse in Shaoyin disease and Jueyin disease indicates severe deficiency of righteous qi.10
Weak Pulse
In the “Shang Han Lun,” the weak pulse appears 13 times. All weak pulses indicate insufficient righteous qi, but the severity varies significantly. There are 5 instances indicating severe insufficiency of righteous qi, among which 3 instances show weak and fine pulses together, 1 instance shows weak and choppy pulses together, and 1 instance shows weak pulse with counterflow. There are 8 instances of weak pulse indicating only slight insufficiency of righteous qi. Among these, 2 instances indicate that the pathogen has receded and the righteous qi is deficient, suggesting recovery is hopeful. There are 4 instances of floating weak pulse together, such as in the case of Taiyang disease, where it states: “In Taiyang disease, if the exterior syndrome has not resolved and the pulse is floating and weak, one should resolve it with sweating, using Guizhi Decoction.” Although the righteous qi is slightly sufficient, it still belongs to exterior syndrome and can still be resolved with sweating, but one should not use Mahuang Decoction for severe sweating; in the case of Xiao Chaihu Decoction; in the Yangming disease section, it states that the use of Da Chengqi Decoction should be modified to Xiao Chengqi Decoction due to the weak pulse; in the case of Taiyang disease, it states that due to the weak pulse, the nature or dosage of the expelling pathogen medicine should be reduced. There are also 2 instances of floating weak pulse together indicating that the pathogen has receded and the righteous qi is deficient, suggesting recovery is hopeful.11
Deficient Pulse
In the “Shang Han Lun,” the deficient pulse appears only 3 times, all indicating insufficient righteous qi. The deficiency and floating pulse together indicate a lighter condition, while the deficient pulse and counterflow together indicate a heavier condition.12
Excess Pulse
In the “Shang Han Lun,” the excess pulse is recorded only 4 times, and its diagnostic significance is very important. In the 245th case, “Yang pulse is excess, due to sweating,” indicates an exterior excess condition. In the 240th and 394th cases, the pulse is deep and excess, indicating interior excess heat syndrome, suitable for purging. In the 369th case, “If diarrhea occurs more than ten times, and the pulse is still excess, it indicates death,” indicates deficiency of righteous qi and excess of pathogenic factors. Although all excess pulses indicate the presence of excess pathogenic factors, the specific conditions vary greatly and must be carefully analyzed.13
Leather Pulse (Accompanying Leather Pulse)
In the “Shang Han Lun,” there is only 1 instance of leather pulse. In the Yangming disease case, “the pulse is floating and leather,” indicating excess heat in Yangming, damaging both fluids and qi. In the “Jin Gui Yao Lue,” there are 6 instances of leather pulse. In the section on Taiyang, the pulse “is stringy, fine, leather, and slow,” indicating both qi and blood deficiency. The “extreme deficiency leather and slow” and “leather pulse with fine tightness” both indicate loss of blood and essence. There are also 3 instances that are essentially repetitions, explaining that leather pulse is a type of leather pulse combined with stringy pulse, indicating deficiency cold. In the section on deficiency syndrome, it states: “If the pulse is stringy and large, stringy indicates reduction, large indicates leather, reduction indicates cold, leather indicates deficiency, and deficiency and cold are in conflict; this is called leather.” In the sections on bleeding and women’s diseases, there are instances with similar content.14
Slow Pulse
In the “Shang Han Lun,” there are 7 instances of slow pulse. There are 2 instances of slow pulse reflecting three different conditions: one indicates dampness, such as in Taiyin disease or jaundice; the second indicates the reception of external pathogens but with low fever, such as in the case of Taiyang wind with Guizhi Decoction or Daqinglong Decoction combined with dampness; the third indicates slight insufficiency of righteous qi, such as in the recovery phase of an external pathogen with heat retreat and a slow pulse, or in the case of wind disease with slight insufficiency of qi and blood.15
Moving Pulse
In both the “Shang Han Lun” and “Jin Gui Yao Lue,” there is one instance of moving pulse each. In the lower section of Taiyang disease, it states, “Movement indicates pain,” and in the section on palpitations, it states, “Movement indicates fright,” both caused by disturbance of qi mechanism. In the section on viscera, it states, “If the pulse at the cun position moves, it is due to its vigorous time and movement,” where the first “movement” refers to the pulse beat, and the second “movement” refers to the change in pulse pattern, neither of which refers to arteries.16
Long Pulse and Short Pulse
In the “Shang Han Lun,” there is one instance of long pulse. In the case of Taiyin disease, “If the yang is weak and the yin is choppy and long, it indicates recovery,” where long indicates recovery of righteous qi. There is also one instance of short pulse, stating, “If the pulse is short and the patient is delirious, it indicates death,” where short indicates that the yang qi is about to deplete.17
Rapid Pulse, Knotted Pulse, and Intermittent Pulse
In the “Shang Han Lun,” both types of pulse are referred to as rapid pulse. One is a rapid pulse without interruption, such as in exterior syndrome with fever presenting rapid pulse (34th and 140th cases); the other is a rapid pulse with interruption, such as in chest yang not vibrating (21st case) or yang deficiency with counterflow (349th case). In the “Shang Han Lun,” there are 3 instances of knotted pulse. One is “In cold damage, if the pulse is knotted and intermittent, it indicates heart yin and yang qi deficiency;” another is “If the pulse is deep and knotted, with hardness in the lower abdomen, use the Resisting Decoction to purge the stagnant heat,” indicating a significant difference in the nature of the conditions; the last is a description of the knotted pulse without a specific condition. In the “Shang Han Lun,” there are 2 instances of intermittent pulse. One is in the case of Resisting Decoction, as mentioned above; the other is a description of the intermittent pulse.18
Other Pulse Descriptions
In Zhang Zhongjing’s works, in addition to the 26 pulse patterns mentioned above, there are many descriptions of pulse patterns, such as flat pulse, harmonious pulse, self-harmonizing pulse, low pulse, absent pulse, non-pulsating pulse, returning pulse, non-returning pulse, violent pulse, micro pulse, yin and yang both stagnant pulse, non-supporting pulse, falling pulse, quiet pulse, and pulse that has resolved, etc. Some of these descriptions are self-evident and do not require detailed explanation; others are difficult to interpret and have varying understandings. Here, we briefly elaborate on “flat pulse” and “returning pulse.” In both the “Shang Han Lun” and “Jin Gui Yao Lue,” there is a record of “flat pulse.” A flat pulse does not indicate no disease; some can be treated with Da Chengqi Decoction to purge food retention, some are warm malaria treated with Baihu Decoction plus Guizhi Decoction, and some are phlegm fluid diseases causing shortness of breath. Of course, there are also cases where the disease is about to resolve. It can be seen that not all diseases will present corresponding abnormal pulse patterns, and TCM diagnosis is not solely based on pulse patterns. Zhang Zhongjing recorded instances of disease with a flat pulse based on actual conditions.
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