Exploring the Deep Pulse: Insights from Zhang Zhongjing’s Pulse Theory

1. The Deep Pulse Indicates Both Interior and Exterior Conditions (1) In the “Treatise on Cold Damage” (Shang Han Lun), Section 148 states: “The deep pulse is also found in the interior.” 【Note】The deep pulse primarily indicates the interior, but it can also indicate the exterior. The deep pulse may arise due to the winter season when Yang Qi is hidden, leading to a deep pulse, which is a common occurrence in all four seasons, referred to as ‘winter stone’. The pathological deep pulse can be categorized into two types: the strong type, where pathogenic Qi obstructs the flow of Qi and blood, resulting in a strong deep pulse; and the weak type, where the Zheng Qi (upright Qi) is deficient, unable to propel the blood vessels, resulting in a weak deep pulse.Although the deep pulse primarily indicates the interior, it can also indicate the exterior. When cold pathogens invade the exterior, they cause contraction and stagnation, leading to a deep pulse, as stated in the “Four Diagnostic Methods” (Si Zhen Jue Wei): “When there is heavy exterior cold, Yang Qi cannot express outward, and the pulse must first be seen as deep and tight.” It further states: “Is it possible for cold to close the pores, causing both Ying and Wei Qi to stagnate, resulting in a pulse that is not seen as deep?” This deep pulse should be both deep and tight. In the case of a new warm disease, when the pathogen invades the lung’s Wei Qi, the pulse should normally be superficial; however, in clinical practice, it is often found that the pulse is not superficial at the onset of warm disease, but rather deep is more commonly observed. Why is the pulse deep at the onset of warm disease? This is because the warm pathogen first attacks the lung, causing Qi stagnation and a deep pulse. This deep pulse must be deep and rapid or deep and agitated. Of course, this does not mean that a superficial pulse cannot be seen in exterior conditions; when the external pathogen transforms into heat, and the heat stagnates and expands, the pulse will then appear superficial. If the heat further intensifies, the Qi and blood will be forced outward by the heat, resulting in a pulse that is not only superficial but also rapid and surging. At this point, the Wei Qi has transitioned from the Tai Yang to the Yang Ming, or from the Wei level to the Qi level. Ultimately, whether the deep pulse indicates the exterior or the interior must be determined through the four diagnostic methods, as well as by considering the accompanying pulses. (2) In the “Treatise on Cold Damage”, Section 218 it states: “In the case of cold damage for four to five days, if the pulse is deep and there is shortness of breath, the deep pulse indicates the interior, and one should induce sweating; if fluids overflow, there will be difficulty in defecation, indicating exterior deficiency and interior excess, leading to delirium if prolonged.” 【Note】 ① “The deep pulse indicates the interior” refers to the pulse position. The causes of a deep pulse can be categorized into two types: The strong type indicates that pathogenic factors obstruct the flow of Qi and blood, resulting in a deep pulse; these pathogens can include the six excesses, seven emotions, and various factors such as Qi, blood, phlegm, and food that can lead to a deep pulse, which should be strong; The weak type may arise from deficiency of Yin, Yang, Qi, or blood, leading to an inability to propel Qi and blood, resulting in a weak deep pulse. ② “The deep pulse indicates the interior, and one should induce sweating.” The deep pulse indicates the interior, but it can also indicate the exterior. Cold closes the muscle layer, causing Qi and blood to stagnate, resulting in a deep pulse; this deep pulse must be pressed to reveal a strong and tight quality. If cold pathogens directly invade the three Yin organs, the pulse can also be deep and tight, or deep and tight without strength.How can these two types of deep and tight pulses be distinguished?When cold is in the exterior, there will be symptoms of cold and heat, body aches, and no sweating; when cold invades the interior, there will be symptoms related to the organs, such as stomach pain and vomiting due to cold invading the stomach; chest fullness and cough due to cold invading the lungs; chest pain and palpitations due to cold invading the heart, etc. When cold invades the muscle layer and the pulse is deep, one can use warming and dispersing methods; when cold invades the interior and the pulse is deep and tight, one can also use warming and dispersing methods; if the deep and tight pulse decreases, one should warm Yang and induce sweating.Therefore, a deep pulse does not universally contraindicate sweating. (3) In the “Essential Prescriptions from the Golden Chamber: Cough and Shortness of Breath” it states: “For cough with a floating pulse, Hou Po Ma Huang Tang is indicated. For cough with a deep pulse, Ze Qi Tang is indicated.” 【Note】 This is not detailed in terms of symptoms but is determined by the pulse. A floating pulse indicates a strong exterior pathogen; Hou Po Ma Huang Tang is similar to Xiao Qing Long Tang with the addition of gypsum, dispersing pathogens and eliminating phlegm, with a heavy emphasis on Hou Po to regulate Qi. A deep pulse indicates water retention in the interior; the “Shen Nong’s Materia Medica” states that Ze Qi “is indicated for abdominal water retention and swelling of the limbs and face.” It is heavily used to eliminate water retention. In the exterior, one should disperse, while in the interior, one should eliminate, both guided by the situation. Although both cases involve coughing, the differing pulses indicate different conditions, and thus the treatment differs.2. Deficiency with a Deep Pulse (1) In the “Treatise on Cold Damage”, Section 92 it states: “If a patient has fever and headache, and the pulse is deep, if there are no other issues, and there is body pain, one should rescue the interior with Si Ni Tang.” 【Note】 This section is named after “disease”, encompassing both exterior and interior conditions, applicable to all.Headache, fever, and body pain can be seen in exterior conditions, but they can also be seen in deficiency conditions; how can they be distinguished? By the pulse. Zhang Zhongjing states, “the pulse is deep,” which indicates the condition is determined by the pulse. This deep pulse must be pressed to reveal weakness, indicating it is due to Yang deficiency, and thus Si Ni Tang can be used to revive Yang. If the deep pulse is tight and strong, it is due to cold stagnation, and one should warm Yang and disperse cold. A deep pulse alone is not sufficient to diagnose Yang decline; it must be deep and fine to diagnose Yang deficiency, warranting the use of Si Ni Tang. (2) In the “Treatise on Cold Damage”, Section 301 it states: “In the case of Shao Yin disease, if there is a return of fever and the pulse is deep, Ma Huang Xi Xin Fu Zi Tang is indicated.” 【Note】 ① This is a formula for warming Yang and dispersing cold, containing profound meanings. I use it in the following three situations:First, in cases of Tai Shao dual invasion: where there are both exterior symptoms of Tai Yang cold damage and interior symptoms of Shao Yin Yang deficiency. The pulse may be floating and tight, or Yang may be floating and the pulse at the wrist may be deep and weak.Ma Huang Xi Xin Fu Zi Tang can warm Yang, disperse cold, and resolve the exterior, but it must be adjusted to include methods to induce sweating.Second, if there are no Tai Yang exterior symptoms, but cold pathogens directly invade the Shao Yin, primarily with cold as the main factor, leading to symptoms such asYin pain, contraction, lower abdominal cold pain, and difficulty urinating, or chest pain and headache caused by cold pathogens following the meridians, this formula warms Yang, disperses cold, and can be adjusted to include methods to induce sweating. This is a case of both deficiency and excess, with both Yang deficiency and cold invasion; the pulse should be deep, tight, and may be weak or weak at the wrist. This formula warms Yang, disperses cold, and supports the upright Qi while expelling the pathogenic factors. If there is also spleen and stomach Yang deficiency, add Gan Jiang; if there is Qi deficiency, add Ren Shen or Huang Qi; if there is deficiency of essence and blood, add Rou Cong Rong, Ba Ji Tian, Lu Rong, or Zi He Che, which can form many combinations to support the upright Qi and expel pathogenic factors, such as Zai Zao San and others.Third, in cases of Yang deficiency without pathogens: Yang deficiency leads to internal cold, and this internal cold can also cause contraction and stagnation, resulting in a pulse that is deep, tight, and weak, along with symptoms of Shao Yin.In this case, Ma Huang Xi Xin Fu Zi Tang can also be used, but the meaning of the formula changes; Ma Huang and Xi Xin are no longer for inducing sweating, but rather to activate kidney Yang, invigorate Yang Qi, and resolve cold stagnation. In this case, the dosage of Ma Huang and Xi Xin should be small. ② “Return of fever” indicates that if it is a Tai Yang exterior condition, there should be fever and aversion to cold; this only mentions fever, indicating it is not a Tai Yang exterior condition but rather heat. The formula Ma Huang Xi Xin Fu Zi Tang is also not for interior heat and exterior invasion. Therefore, this heat must be due to Yang deficiency, with the virtual Yang floating outward and causing heat. When the virtual Yang is floating outward, the pulse should be floating, weak upon pressure, or floating at the wrist and weak at the deep pulse.Can one still use warming and dispersing herbs if the virtual Yang is already floating?One can use them in small amounts; the purpose is not to disperse but to invigorate Yang Qi, resolve cold stagnation, and should also be combined with Shan Zhu Yu, Long Gu, and Mu Li to restrain and prevent the Yang Qi from dispersing. (3) In the “Treatise on Cold Damage”, Section 305 it states: “In the case of Shao Yin disease, if there is body pain, cold hands and feet, and joint pain, and the pulse is deep, Fu Zi Tang is indicated.” 【Note】 Yang deficiency leads to obstruction and body pain, joint pain, and cold hands and feet. This deep pulse must be deep and weak. (4) In the “Treatise on Cold Damage”, Section 323 it states: “In the case of Shao Yin disease, if the pulse is deep, one should urgently warm it, and Si Ni Tang is appropriate.” 【Note】 A deep pulse in Shao Yin disease, merely stating deep, is not sufficient to explain the pathogenesis; it must be a deep and weak pulse to belong to the Shao Yin pulse. This deep pulse can also be seen as an abbreviated notation, so when reading the “Treatise on Cold Damage”, one must connect the context. Zhang Zhongjing in Section 281 of the Shao Yin disease outline clearly states, “The pulse of Shao Yin disease is fine and weak,” so this deep pulse should also be deep and fine.In the “Treatise on Cold Damage”, the differentiation of pulse patterns does not emphasize the strength or weakness of the deep pulse; in my pulse diagnosis,I emphasize the strength or weakness of the deep pulse, which is the key to pulse diagnosis: a strong deep pulse indicates excess, while a weak deep pulse indicates deficiency. (5) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “In water diseases, the pulse is deep and small, belonging to Shao Yin.” A floating pulse indicates wind, while a water deficiency and distension indicates Qi. If water causes sweating, it is sufficient. If the pulse is deep, Ma Huang Fu Zi Tang is indicated; if it is floating, use Xing Zi Tang. 【Note】 The pulse in water diseases is deep and small, belonging to Shao Yin, and must be deep and small and weak, and Ma Huang Fu Zi Tang is used to treat it, indicating Shao Yin Yang deficiency and water retention. This formula is similar to Ma Huang Fu Zi Gan Cao Tang. In the formula, Fu Zi warms Yang, while Ma Huang invigorates Yang Qi, opens the pathways, and promotes the three Yang levels. 3. Pathogenic Obstruction with a Deep Pulse (1) In the “Essential Prescriptions from the Golden Chamber: Diseases of the Organs and Meridians” it states: “If the pulse at the cun position is deep, large, and slippery, a deep pulse indicates excess, while a slippery pulse indicates Qi; excess Qi collides, and if blood Qi enters the organs, it leads to death; if it enters the bowels, it leads to recovery. This is called sudden collapse; what does it mean?” The teacher said: “If the lips and mouth are blue and the body is cold, it indicates death if it enters the organs; if the body is warm and sweating occurs, it indicates recovery if it enters the bowels.” 【Note】 In the “Plain Questions: Regulation of the Menstrual Cycle” it states: “When blood and Qi run together upward, it leads to great collapse; if Qi returns, one lives; if it does not return, one dies.” A deep, large, and slippery pulse indicates a strong presence of pathogenic Qi. “Slippery indicates Qi,” which indicates a strong presence of Qi. When blood and Qi run together upward, it leads to great collapse. Blue lips indicate blood stasis; cold body indicates Yang closure. This is a case of sudden collapse due to wind, fire, phlegm, and blood stasis, and the treatment should focus on clearing phlegm, invigorating blood, opening the bowels, and calming the wind. Modern renowned doctors such as Ren Jixue and Wang Yongyan treat acute strokes in line with this principle. (2) In the “Essential Prescriptions from the Golden Chamber: Phlegm and Cough” it states: “If there is retained fluid in the chest, the person will have shortness of breath and thirst, with pain in the limbs and joints; if the pulse is deep, there is retained fluid.” 【Note】 Retained fluid refers to phlegm and fluid that remains and does not disperse. Retained fluid obstructs the Yang Qi, leading to a deep pulse. If Yang does not reach, there will be shortness of breath and thirst; if fluid flows into the muscles and bones, there will be pain in the limbs and joints.When the pulse is deep, it must be assessed for strength or weakness; a weak pulse indicates deficiency, while a strong pulse indicates excess, and the treatment methods differ. (3) In the “Essential Prescriptions from the Golden Chamber: Phlegm and Cough” it states: “If there is cough with reverse qi, unable to lie down, Xiao Qing Long Tang is indicated.” This is for cough with phlegm retention, unable to lie down, and I prescribe Xiao Qing Long Tang. However, if after taking Xiao Qing Long Tang, the pulse is deep at the cun position and weak at the chi position, with cold hands and feet, and qi surging from the lower abdomen to the chest and throat, with numbness in the hands and feet, and the face appearing flushed as if intoxicated, due to fluid flowing downwards, leading to difficulty in urination, and intermittent fainting, then Fu Ling Gui Zhi Wu Wei Gan Cao Tang should be used to treat the surging qi. 【Note】 This is primarily for cough with phlegm retention, unable to lie down, and I prescribe Xiao Qing Long Tang. However, if after taking Xiao Qing Long Tang, the pulse is deep at the cun position and weak at the chi position, with cold hands and feet, and qi surging from the lower abdomen to the chest and throat, with numbness in the hands and feet, and the face appearing flushed as if intoxicated, due to fluid flowing downwards, leading to difficulty in urination, and intermittent fainting, then Fu Ling Gui Zhi Wu Wei Gan Cao Tang should be used to treat the surging qi. (4) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “If the pulse is self-deep, and the external symptoms are abdominal fullness without shortness of breath.” 【Note】 The pulse is deep, indicating it must be deep and weak, or deep and tight, indicating water accumulation in the interior, leading to abdominal fullness, but not yet pressing on the lungs, hence no shortness of breath. (5) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “If there is water in the interior, the whole body and face will be swollen, and the pulse will be deep, with difficulty in urination, hence the disease of water.” 【Note】 Water in the interior leads to a deep pulse; water accumulation leads to Qi stagnation, resulting in difficulty in urination; swelling of the whole body and face indicates water overflow, and the yellow color indicates water accumulation obstructing Yang and transforming into heat, leading to yellowing. Therefore, Yue Bi Jia Shu Tang is prescribed, with Ma Huang opening the pathways, Shi Gao clearing heat, and Bai Zhu eliminating dampness. (6) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “If the pulse is floating and slow, a floating pulse indicates heat, while a slow pulse indicates hidden; heat and hidden collide, leading to what is called deep.” A floating pulse indicates Yang is in the exterior, hence a floating pulse indicates exterior heat. A slow pulse indicates Yin, which governs the interior and hidden; water is also Yin, hence the pulse is hidden. When exterior heat penetrates the interior, it collides with water, causing the pulse to transition from floating to deep. Since it is a case of heat and water mutually binding, the deep pulse should be tight, slippery, and strong. When heat and water bind, it obstructs the Qi mechanism, leading to a rapid pulse that eventually stops. This stopping indicates a sense of urgency that cannot be calmed. When heat and water bind, it obstructs the Qi mechanism, leading to a rapid pulse that eventually stops. Water accumulates and overflows the skin, leading to edema. (7) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “If the pulse is deep, it indicates water; if the body is swollen and heavy, it indicates water disease, and if the pulse is out, it indicates death.” 【Note】 ① In water diseases, the pulse must be deep due to water obstructing the Qi mechanism, but a deep pulse is not limited to water diseases. A deep pulse indicates Qi, where the Qi mechanism cannot express outward, leading to a deep pulse. The reasons for Qi mechanism obstruction can be categorized into two types: One is due to pathogenic obstruction leading to a deep pulse; The other is due to deficiency leading to a deep pulse, and there may also be a combination of deficiency and obstruction.Pathogenic obstruction includes the six excesses, seven emotions, Qi, blood, phlegm, and food, not all deep pulses are due to water; water, dampness, and phlegm retention obstruct the Qi mechanism, and this is just one of the reasons. ② “If the pulse is out in water diseases, it indicates death,” this situation primarily refers to those with deficient upright Qi. If a person is ill with water due to deficient upright Qi, and there is no significant improvement in the overall condition, the pulse transitions from deep and fine to weak within a short period, whether half a day or one or two days, suddenly rising, indicating the departure of upright Qi, leading to a separation of Yin and Yang, hence death. If the upright Qi gradually recovers and the pulse gradually rises, it indicates the recovery of upright Qi, which is a good sign. This is true for water diseases and for other diseases as well. If the pulse is deep due to pathogenic obstruction, it does not fall under this category. For example, if cold binds water and causes swelling with a deep pulse, once the cold is released, the pulse can quickly transition from deep to floating; this type of pulse rising is not a sign of death but rather an indication of the expulsion of pathogens and the smooth flow of Qi. (8) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “In cases of water disease, if the pulse is completely deep, it indicates water, and one can use purgative methods.” 【Note】 Pathogenic obstruction leading to a deep pulse can be deep, strong, and powerful. However, in cases of severe obstruction, the pulse can also be deep, fine, small, rough, slow, or even lead to collapse; as long as there is a pulse, among the deep, fine, small, rough, and slow pulses, there must be a sense of urgency that cannot be calmed, indicating excess. This article discusses water diseases with a completely deep pulse, which can be treated with purgative methods, indicating it is a case of excess water or Yang water, hence purgation is appropriate; once the Qi mechanism is smooth, the pulse can emerge. This is true for water diseases and for other diseases with pathogenic obstruction. If the pulse is deep and weak, it indicates deficiency water, and one must not use purgative methods; this is true for other diseases as well. (9) In the “Essential Prescriptions from the Golden Chamber: Water Pathology” it states: “The teacher said: If the pulse at the cun position is deep and rapid, rapid indicates outward, while deep indicates inward; outward indicates Yang excess, while inward indicates Yin stagnation.” 【Note】 ① “A deep and rapid pulse indicates outward, while a deep pulse indicates inward” refers to the classification of the pulse into Yin and Yang, not merely the floating and deep positions of the pulse. This section clearly states that the pulse is deep and rapid, not floating and rapid. ② “Outward indicates Yang excess, while inward indicates Yin stagnation,” a deep and rapid pulse indicates excess heat, while inward indicates Yin stagnation, which is not limited to Yin essence and blood, but rather stagnation in the interior, which is Yin. (10) In the “Essential Prescriptions from the Golden Chamber: Jaundice” it states: “If the pulse is deep, and there is thirst and a desire to drink water, with difficulty in urination, it indicates jaundice.” 【Note】 A deep pulse indicates Qi, and a deep pulse indicates the interior. The Qi mechanism cannot express outward, leading to a deep pulse. Thirst, desire to drink, difficulty in urination, and yellowing indicate damp-heat accumulating in the interior. Damp-heat obstructs the flow of Qi, leading to a deep pulse, which should be deep and moist and rapid.

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• This article is excerpted from “The Complete Medical Works of Li Shimao and Tian Shuxiao, Volume 1”

• Authors: Li Shimao, Tian Shuxiao; Edited and Compiled by Liu Jifang

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