On the Life and Death Determination Based on Pulse and Symptoms

On the Life and Death Determination Based on Pulse and Symptoms

Physicians are those who treat people's lives; if they do not know death, how can they know life? If they know that death is incurable, then as long as there is even a trace of vitality, they should try every possible means to revive it. To distinguish between life and death, one must first understand pulse and symptoms. Gao Shizong (1) classified blood coming out of the mouth as "collateral blood" if it is abundant, and "mainstream blood" if it is scarce. He believed that abundant blood indicates a milder illness, while scarce blood indicates a more severe illness. In reality, however, the mainstream blood splits into collateral blood, and the collateral blood splits into smaller branches, much like a dry branch splitting into twigs, and these branches are all ultimately connected to the same trunk. Therefore, dividing blood into "mainstream" and "collateral" based on quantity is meaningless. According to "Medical Principles" (2), external injuries causing blood to come out of the mouth are easier to treat, while internal injuries causing blood to come out of the mouth are harder to treat. According to "Three-Finger Zen" (3), tooth bleeding is the mildest, followed by nosebleeds, then vomiting, and finally coughing, spitting, and hematemesis, which are the most severe. These diseases all originate from the five internal organs, and the blood comes from deep within, unlike vomiting, whose blood comes from the stomach, which is relatively superficial. This aligns with Zhang Zhongjing's distinction between "near blood" and "far blood," and dividing them based on severity is not unreasonable. However, even though nosebleeds and vomiting are relatively mild, if the bleeding does not stop, the blood will carry away the qi, and death can occur in an instant. Although coughing, spitting, and hematemesis are far from the body and more severe, there is still a small amount of blood that can be expelled with a single cough, and even if it is not treated, it can heal on its own. Therefore, we cannot use these symptoms alone to determine life and death. After all, blood carries qi, and qi drives blood. Human life depends entirely on qi; if blood is lost but qi is not, the person is still alive, even if in critical condition. As long as there is a trace of qi, blood can gradually regenerate and return to its original state. If blood is not injured but qi is lost first, the person is doomed to die, regardless of how healthy they appear. If blood is the soul and qi is the spirit, and the soul is not destroyed but the spirit is, there is no way to survive. Therefore, I believe that determining whether blood is dead or alive depends entirely on whether the qi is stable or not. If blood comes out of the mouth without fever, it is easier to heal, because although the body is sick, the defensive system is not, and yang is easy to maintain while yin is easy to protect. If there is fever, it is harder to treat, because the blood disease also heats up the qi, creating a vicious cycle (4). If blood comes out of the mouth without coughing, it is easier to heal, because coughing is caused by qi choking, and blood is injured but qi is not choked, as the water in the kidneys can absorb the qi and bring it back to its roots, making it easier to heal. If coughing does not stop, it means the blood is injured and the fire is burning, the water in the kidneys is exhausted, and there is no way to contain this true qi, so coughing with qi is difficult to treat, and if there is also shortness of breath, the yang has nowhere to cling to. If bowel movements are not loose, there is still a chance, and yin-nourishing medicines can be used to nourish the yang. If bowel movements are loose, the upper body loses the lower body, and there is no hope of survival. Then check the pulse again: if the pulse is not rapid, it is easier to treat, because the qi is still stable; if the pulse is rapid, it is harder to treat, because the qi is too fast. If the pulse is floating and large but has no roots, it is empty yang with no support; if the pulse is fine and tight but not slow, it means true yin is lost, both of which are difficult to treat. If there is even a hint of slowness, there is still a chance to save the situation; if there is no slowness, or if it is scattered, there is no hope of saving the patient. All these cases indicate that yin blood is injured while yang qi has nowhere to go, so the patient cannot be saved. If yin blood is injured but yang qi does not float, even if the pulse is weak and slow, it is still relatively easy to treat. Just use warming and tonifying medicines, and the patient will recover. After all, patients with yang deficiency and weak qi are easier to treat, while those with yin deficiency and qi that does not attach are harder to treat. The so-called "blood injury but no qi injury" means that the qi is not injured, so the blood is not completely damaged, and the qi still has some attachment, making it easier to heal. The origins of qi have been explained in detail in the "Water, Fire, Qi, and Blood" chapter, please refer to it yourself.

[Notes]

(1) Gao Shizong: A physician from the Qing dynasty. He authored books such as "Su Wen Zhi Jie" and "Yi Xue Zhen Chuan."

(2) "Medical Principles": Refers to "Medical Principles Summary," written by Sun Yikui during the Ming dynasty.

(3) "Three-Finger Zen": Written by Zhou Xueting during the Qing dynasty.

(4) Vicious cycle: Mutual promotion that worsens the condition. "Evil" means cruel. 〔Commentary〕The author lists previous scholars' discussions on distinguishing the severity of blood-related conditions, all of which he finds to have certain shortcomings. He argues: "The carrier of qi is blood, and the mover of blood is qi. Human life depends entirely on qi. If blood is depleted but qi remains intact, the patient may still be in critical condition yet survive; as long as there is a trace of qi that has not been exhausted, blood can gradually regenerate and return to its original state. However, if qi is depleted before blood is damaged, even a stable condition will inevitably lead to death." This passage emphasizes that the primary determinant of life or death in blood-related conditions is whether qi is depleted or not—whether qi is balanced or not is the prerequisite for assessing the prognosis of such conditions. Qi depletion is an early sign of yang collapse; from a modern medical perspective, it corresponds to a syndrome resembling peripheral circulatory failure. The author's use of this syndrome to predict the prognosis of patients with blood-related conditions is entirely correct. At the same time, the author also believes that fever, choking cough, and loose stools all have a certain impact on the progression of blood-related conditions. Regarding pulse diagnosis, the author states: "A rapid pulse indicates a difficult-to-treat condition," and "a floating, large, rough, rapid pulse without root" or "a deep, fine, rough, rapid pulse that is not slow" are both difficult to treat. In essence, these pulse patterns reflect either deficiency of true yin or lack of support for deficient yang. From a modern medical standpoint, they often represent disturbances in the compensatory functions of the heart and peripheral vessels. Through long-term clinical experience, the author has arrived at conclusions that broadly align with clinical principles, which is truly commendable. Compared with works like "Yi Zhi," which categorizes the severity of external or internal injuries, or "San Zhi Chan," which classifies the severity based on the site of bleeding, or Gao Shizong's classification based on the amount of bleeding, the author's approach is more comprehensive and reliable. Furthermore, the author believes: "If there is even a slight slowing of the pulse in a blood-related condition, there is still hope for recovery; but if there is no slowing of the pulse, or if the pulse becomes scattered and irregular, then the condition is incurable." Here, he particularly emphasizes the clinical significance of a slow pulse. Modern medicine holds that as the amount of bleeding increases, the heart rate will inevitably accelerate as a compensatory mechanism. For a normally healthy heart, the number of beats often reflects the degree of bleeding. The author's emphasis on using a slow and steady pulse to assess the prognosis of blood-related conditions demonstrates profound insight.