Diagnosing Life and Death Through Observation

The following passage describes Zhang Zhongjing’s clinical method of assessing a patient’s prognosis through observation of facial color, voice, and breathing patterns. It is dense with fundamental TCM diagnostic principles and merits careful memorization.

A student asked: “When a patient’s complexion reveals itself on the face, I wish to hear your explanation.”

The Master replied: “If the tip of the nose is bluish-green, there is abdominal pain; if the patient also suffers from severe cold, the case is fatal. A slight darkening of the nose tip indicates fluid retention. A yellowish hue indicates cold in the chest. A pale white color indicates blood loss. A faint redness appearing out of season is a sign of death. Eyes that stare rigidly and round indicate convulsion — this is incurable. Furthermore, a bluish-green complexion indicates pain, a dark complexion indicates exhaustion, a red complexion indicates wind, a yellow complexion indicates difficult defecation, and a bright, lustrous complexion indicates retained fluid.”

The Master said: “When a patient’s voice is quiet but punctuated by sudden cries of alarm, the disease lies in the joints. When the voice is muffled and fails to carry, the disease lies in the heart and diaphragm. When the voice is thin, drawn-out, and chirping, there is pain in the head.”

The Master said: “When breathing causes the shoulders to heave, the center is hard and blocked. When breathing pulls at the chest and there is upward qi, there is coughing. When the patient breathes through an open mouth, there is shortness of breath and lung atrophy with frothy saliva.”

The Master said: “When inhalation is slightly rapid, the disease is in the middle jiao. If it is an excess condition, purging will bring immediate recovery; if it is a deficiency condition, it is incurable. If the problem is in the upper jiao, inhalation is rushed and urgent; if in the lower jiao, inhalation is long and drawn out — both are difficult to treat. When breathing causes the whole body to tremble and shake, the condition is incurable.”

The Master said: “When the pulse at the Cunkou beats strongly, it does so according to the season of its prosperity. For instance, when the Liver is flourishing, the complexion should be green. Each of the four seasons has its corresponding color. If the Liver’s color should be green but appears white instead — a color and pulse that do not match the season — illness is inevitable.”

Reflections

These passages are once again extraordinarily rich in content, embedding many fundamental principles of Chinese medicine that must be thoroughly memorized.

Much of later physiognomic tradition drew upon these very principles, and the two can be cross-referenced for predicting illness and misfortune — even, in skilled hands, for making definitive prognostic judgments.

The medical content here traces directly to the Huangdi Neijing (Yellow Emperor’s Inner Canon), with nearly every statement having a clear textual source. It speaks plainly about the intrinsic relationship between symptoms and disease but does not provide specific formulas. Professor Liu Duzhou’s commentary on this section is exceptionally insightful and well worth studying.

The line about “a thin, drawn-out, chirping voice indicating head pain” resonates deeply with me. During my second year of doctoral studies, I went through a period of intense pressure, spending long hours processing data on the computer. I suspect my intraocular pressure had risen, and the headaches were severe. My speech became abnormal — I couldn’t bring myself to speak loudly at all. I had to speak in a soft, drawn-out manner just to manage; otherwise, the headache would split my skull and bring on waves of nausea.

The statement “rapid inhalation indicates disease in the middle jiao — if excess, purging brings immediate recovery” is even more common in clinical practice. Many patients with acute abdominal episodes display exactly this vivid presentation: the epigastric discomfort is so severe they cannot catch their breath, and they must curl up to find any relief. Someone unfamiliar with this passage might be quite alarmed to witness such a scene, but in reality there is no great danger. Most cases are excess conditions, and within ten minutes or so they generally resolve on their own. If it were a deficiency condition, the problem would not be in the middle jiao — one would expect the typical presentation of myocardial infarction instead.

I remember the winter of 2012, when Teacher Jiang Yifa came to Beijing for a conference and we had dinner together. He mentioned at the time that the essence of Zhang Zhongjing’s scholarship lies in the ability to distinguish life from death — to see at a glance the trajectory of a disease and determine whether it is treatable or not. This is a profound test of a physician’s skill. These passages are therefore critically important: they must be memorized and reflected upon again and again.

中文原文 / Chinese Original