《黃帝內經素問補註釋文》Vol. 13

The Supplementary Annotations and Explanatory Text to the Basic Questions of the Yellow Emperor’s Inner Classic, Volume Thirteen, Careful Examination, Part Eleven

Commentary by Wang Bing, also known as Qixuanzi, Director of the Imperial Stables in the Tang dynasty. Collated and revised by Lin Yi and others, including a Court Gentleman of Guanglu and a Director of the Palace Library, in the Song dynasty. Errors further corrected by Sun Zhao, a Supervising Secretary in the Ministry of Works, in the Song dynasty.

“Essentials and Subtleties of the Pulse” Chapter

The Yellow Emperor asked, “What is the method for examining the pulse?”

Qibo replied, “Pulse examination should usually be carried out at dawn. At this time, Yin Qi has not yet stirred, Yang Qi has not yet dispersed, the person has not yet eaten, and the Qi and blood in the channels are not yet abundant. The collateral vessels are also relatively harmonious, and the Qi and blood have not been disturbed. Only then can abnormal pulse signs be discerned.

“‘Stirred’ refers to the pulse Qi moving and gradually declining; ‘dispersed’ refers to Qi spreading outward. ‘Deviation’ means that the pulse differs from what is usual. The New Collation notes that the Pulse Classic and the Essential Prescriptions Worth a Thousand Gold Pieces record ‘a pulse with a deviation’ as ‘deviating from this,’ and considers the latter wording incorrect. Wang Bing’s commentary explains ‘Yin Qi has not yet stirred’ as meaning that it moves and gradually declines. But according to the ‘Discourse on the True Words of the Golden Cabinet,’ Yang Qi is at its strongest from dawn until midday. Dawn, then, is the time of day when Yang Qi is purely abundant and Yin Qi has not yet stirred. How could this mean ‘gradually declining’?

“Feel the pulse with the fingers, observe the brightness of the eyes, examine the five colors of the face, determine whether the five zang organs are in excess or deficiency and whether the six fu organs are strong or weak, and assess the condition of the body. Compare all these findings together to judge the course of life and death.

“‘Feel’ means to examine the pulse by placing the fingers against it. ‘Jingming’ is the name of an acupuncture point, located near the inner corners of the eyes, at the blue-green areas on either side of the Mingtang, the central region of the face. It is called ‘Jingming’ because of its proximity to the eyes. The meaning here is to consider the condition of the body and complexion together with changes in the pulse, observe the color around the Jingming points, distinguish whether the zang-fu organs are in excess or deficiency, and compare the signs from each area to judge the course of life and death.

“The pulse is where blood gathers. The amount of blood is therefore revealed in the channels. Thus the ‘Discourse on Acupuncture Methods’ says that when the pulse is full, the blood is full; when the pulse is deficient, the blood is deficient. This is the ordinary pattern. If the signs are reversed, it indicates illness.

“A long pulse indicates that the Qi mechanism is harmonious; a short pulse indicates that Qi is insufficient and there is illness; a rapid pulse makes a person restless; a large pulse indicates that the illness is worsening. Here, a long pulse means that the pulse travels a greater distance as it comes and goes; a short pulse travels a shorter distance; a rapid pulse comes quickly; and a large pulse feels full and broad as it comes and goes.

“When the pulse in the upper region is predominant, Qi rises counterflowing and appears forceful.”

A full, forceful pulse in the lower position indicates distension of Qi (vital energy); an intermittent pulse, which pauses and does not resume on its own, indicates depleted Qi; a fine pulse indicates diminished Qi; and a rough, sluggish pulse indicates heart pain.

Here, “upper” refers to the cun position, the pulse-taking site at the wrist; “lower” refers to the chi position, the part of the pulse just below the cun toward the elbow. “Full” describes a pulse that feels abundant and forceful. “Fine” means a small, delicate pulse, like a slender grass head stirring in the breeze. “Rough” describes a pulse that moves with difficulty, its flow uneven and impeded.

A turbid, disordered pulse that arrives like a drum-skin pulse—taut, large, firm, and long—and surges like a spring, flowing out without returning, indicates that the illness is worsening and the complexion will also deteriorate. A pulse that is faint and threadlike, barely perceptible, or one that suddenly breaks off like a snapped bowstring, foretells death when the illness grows worse and the complexion deteriorates.

“Hunhun” describes turbid, disordered pulse-Qi. “Ge zhi” means a pulse that is taut and large, firm and long. “Like a surging spring” describes a pulse that wells up continuously but does not return. “Mianmian” describes a faint pulse that seems to be present but is barely perceptible. “Like a snapped bowstring” means the pulse suddenly ceases, as if a bowstring had broken. The New Textual Correction cites the Jia Yi Jing and Mai Jing, which give this passage as: “Turbid and disordered, taut and forceful, arriving like a surging spring: as the illness advances and becomes critical, feeble and faint, its departure like a snapped bowstring—death.”

A person’s spiritual vitality and the Five Colors are outward expressions of Qi. The refined Qi of the Five Zang organs appears in changes in the colors of the face. The “Treatise on the Six Sections and Manifestations of the Zang Organs” says that Heaven nourishes people with the Five Qi; the Five Qi enter through the nose and are stored in the heart and lungs, making the complexion bright and lustrous. This is what is meant by observing the Five Colors to assess a person’s condition.

A red complexion should be bright and lustrous, like cinnabar wrapped in white silk, not dull and dark like red ochre. A white complexion should be pure and bright like a goose feather, not dry and lifeless like salt. The New Textual Correction cites the Jia Yi Jing, which says white should be like a lustrous white jade disc, not like white earth; the Taishu includes both versions.

A blue-green complexion should be moist and lustrous like a dark green jade disc, not dull like indigo dye. A yellow complexion should be bright and lustrous, like realgar wrapped in fine silk, not dry and dull like yellow earth. A black complexion should be deep and lustrous, like layers of lacquer, not ashen like dark earth. The New Textual Correction notes that the Jia Yi Jing reads “the color of charcoal” where this text has “dark earth.”

If the complexion shows the dry, dull colors of red ochre, salt, indigo dye, yellow earth, or dark earth, this is a sign that the refined Qi is failing, and life will not be long.

Only with bright eyes can one see all things clearly, distinguish black from white, and tell long from short. If one sees long as short and white as black, it means the refined Qi has already weakened.

This passage warns people against misjudgment: these conditions are all signs that Jing and Qi are declining.

The five viscera are the body’s inner guardians. Within the human form, they are where the five spirits dwell and are kept safe. These statements all explain the importance of the five viscera. ○ The New Collation says: A comparison with the Jiayi Jing and the Taisu shows that both texts read “storehouse” here instead of “guard.”

A distended, full abdomen with abundant Qi, and a voice that, when one is startled, sounds as though it is coming from inside a room—these are signs of dampness in the abdomen.

“Within” here means inside the abdomen; “abundant” means that Qi is exuberant; “viscera” refers to the Lung; and “Qi exceeding” describes a state in which the force of the breath surpasses normal levels and alters respiration. When Qi is abundant in the abdomen and Lung Qi is full, breathing becomes rapid. If one is startled and cannot produce a clear voice, so that it sounds as though it is coming from behind a wall, these are all signs of dampness in the abdomen.

If the voice carries when speaking but one can speak only briefly before losing the ability to speak, this is a sign that Qi has been depleted.

If the voice is faint and broken, it indicates severe depletion of Qi.

Being unable to put one’s clothes and bedding in order, speaking without regard for what is appropriate, and showing no regard for closeness or distance in one’s relationships are signs that the spirit and consciousness are disordered. “The granaries and storehouses do not hold” means that the Spleen and Stomach cannot contain and secure their contents.

“Granaries and storehouses” refers to the Spleen and Stomach; “gate” refers to the po gate, or anus. The Discourse on the Secret Documents of the Numinous Orchid says that the Spleen and Stomach govern the granaries and storehouses. The Treatise on the Separate Functions of the Five Viscera says that the po gate, too, is governed by the five viscera, preventing food and drink from remaining in the body too long. Here, “secure” means to close and contain.

Inability to control urination means that the Bladder cannot contain and secure it.

“Water spring” refers to urine flowing from the anterior opening.

When the body can maintain its containment and the functions of the organs and viscera are normal, a person can live; when containment is lost, the person dies.

The signs described above—the granaries and storehouses failing to contain, abundant Qi accompanied by a startled response, inability to put clothes and bedding in order, and uncontrollable urination—all show whether the spirit and Qi can be maintained. If they can be maintained, a person can live; if they cannot, the person dies. How can we tell that the spirit and Qi are no longer being maintained? Inability to put clothes and bedding in order, speaking without regard for what is appropriate, and showing no regard for closeness or distance are signs of disorder. When the disorder becomes severe, the spirit and Qi can no longer dwell securely in the five viscera.

The five viscera are the foundation of bodily strength.

When the five viscera are settled, the spirit and Qi can be maintained; when the spirit and Qi are maintained, the body is strong. That is why the five viscera are called the foundation of bodily strength.

The head is where clarity of spirit and the senses reside. A drooping head and sunken gaze indicate that the spirit is about to decline. The back is where the Qi of the chest resides. A hunched back and drooping shoulders indicate that the Qi of the chest is about to decline. The waist is where the Kidneys reside. Weak, swaying movements indicate that Kidney Qi is about to be exhausted. The knees are where the sinews reside. When the knee joints cannot bend or straighten, the body bends forward while walking and relies on something for support.

When the sinews and channels are about to decline, the bones—the storehouse of marrow—can no longer support a person standing for long; while walking, the body begins to sway.

The bones are about to decline.

These parts are called the “storehouse” (fu) of something because they are named for what they contain or for the source from which they arise.

When the inner Qi is strong and healthy, a person can live; when it loses its strength, a person dies. Here, “strong” means that the central Qi—the Qi that sustains the body’s vital activities—is firm and stable, able to guard the body.

Qibo says—

[New Editorial Correction: No question precedes Qibo’s statement, so the passage seems to be missing something.]

When the pulse departs from the patterns of the four seasons, excess in the vessels is called “essence,” and deficiency is called “wasting.” When the pulse accords with the season but is excessive, or instead deficient, it is called “essence”; when it should be deficient but appears excessive, it is called “wasting.” When Yin and Yang cannot harmonize with one another, the condition is called “closure and separation” (guange), in which the Qi of Yin and Yang cannot communicate.

Here the text explains in detail how the pulse corresponds to the four seasons. To say that the pulse departs from the seasonal patterns means that every form of deficiency indicates depletion of Blood and Qi, while every form of excess indicates that pathogenic Qi has overwhelmed the vital essence. The Qi of Yin and Yang cannot respond to or nourish one another, so the condition is called “closure and separation.”

The Yellow Emperor said, “How does the pulse change with the four seasons? How can we tell where an illness is located? How can we tell whether an illness has suddenly arisen inside or outside the body? May I ask you to explain these five matters?”

Here the Yellow Emperor is asking about the signs of the pulse as it follows the four seasons and corresponds with Yin and Yang.

Qibo says—

[New Editorial Correction: Qibo’s reply does not fully match the Yellow Emperor’s question. The earlier discussion of how the pulse changes with the seasons, where an illness is located, and how an illness changes has some connection with whether it is inside or outside. The material that follows, however, is clearly unrelated.]

Allow me to explain the broad relationship between the pulse and the movement of the seasons.

The observable movements of Yin and Yang are used here to explain changes in Yin and Yang that are not easily seen directly.

Beyond the myriad things and within the Six Directions—the four cardinal points and above and below—Heaven and Earth undergo change, and Yin and Yang respond in turn. The warmth of spring develops into the heat of summer; the desolation of autumn develops into the severe cold of winter. As the seasons change, the pulse rises and falls accordingly.

“Six Directions” refers to the four cardinal points, above, and below. The change from spring warmth to summer heat describes Yang Qi moving from growth into abundance. The change from autumn’s desolation to winter’s severe cold describes Yin Qi gradually increasing from a lesser state. Another version reads “urgent” instead of “fierce,” referring to the forceful, urgent quality of autumn Qi. [New Editorial Correction: In the commentary in the Quan Yuanqi edition, “warm” is written as “mild.”]

The pulse in spring should resemble the circular shape drawn with a compass.

The spring pulse is soft, light, and slippery, like the shape drawn by a compass. These qualities appear both within and at the surface of the pulse, so the spring pulse is said to “conform to the compass.”

The pulse in summer should resemble the square shape made with a carpenter’s square.

The summer pulse is expansive and large, and also slippery and rapid. Like a shape made with a carpenter’s square, it is regular and straight.

Thus, the pulse in summer corresponds to the carpenter’s square, while the pulse in autumn corresponds to the balance scale. The autumn pulse is light as a feather, rough and scattered, like a scale beam held in balance: its two sides are level. This is why autumn is said to correspond to the balance.

The pulse in winter corresponds to the weight. The winter pulse is heavy as a stone, yet also has a smooth, flowing quality, like a scale weight pulling downward below the beam. This is why winter is said to correspond to the weight. Saying that autumn corresponds to the balance and winter to the weight refers to the different heights at which these pulses are felt. Pulses change with the movement of Yin and Yang Qi, so each season has its own characteristic pulse.

For forty-five days after the winter solstice, Yang Qi gradually rises and Yin Qi gradually declines. For forty-five days after the summer solstice, Yin Qi gradually rises and Yang Qi gradually declines. The movement of Yin and Yang follows a set sequence, and this is also reflected in the pulse. Pulse changes each have their season, so they can be used to infer roughly when a person’s life will end.

Observe carefully the patterns by which Yin and Yang rise and fall, and you can understand how the channels change with the seasons. Examine whether changes in the weather correspond to changes in the pulse, and you can determine when Qi and Blood separate and come together. If these seasonal timings are judged accurately, you can infer roughly the season in which a person will die.

The subtle changes in the pulse are all contained in these patterns, and they must be observed with care. Pulse diagnosis requires a guiding principle, and the first step is to begin with Yin and Yang. To investigate the subtle shifts as Yin and Yang rise and fall, observe how the Qi in the channels changes with the seasons. Careful examination is essential, with Yin and Yang serving as the guiding principle.

Pulse diagnosis also requires standards. These standards arise from the generative transformations of the Five Phases and take the four seasons as their basis. To establish standards from the transformations of the Five Phases means to assess whether a pulse is excessive or deficient according to the waxing and waning of the Qi of the Five Phases. In making this judgment, consider whether the pulse accords with what is appropriate for the season and whether it reflects the presence of life-giving Qi. The New Collation notes: “Here, ‘appropriate’ should be read as ‘sequence.’”

In treatment, drain what is excessive and replenish what is deficient; do not make a mistake. This accords with the patterns governing the movement of Heaven and Earth. The Dao of Heaven and Earth is to diminish what is excessive and augment what is deficient. Drainage and replenishment must be undertaken with care; regulating the Qi of the body should follow the same principle.

Once you understand the principles governing the movement of Heaven and Earth and can perform drainage and replenishment without error, you have grasped the key and can use it to judge life and death.

Thus, sound corresponds to the Five Tones, complexion to the Five Phases, and the pulse to Yin and Yang. Sound is expressed through the five tones—Gong, Shang, Jue, Zhi, and Yu—while complexion appears as blue-green, yellow, red …

White and black correspond to the Five Phases, and the pulse also changes with cold and heat, becoming strong or weak. Thus, the pulse corresponds to the Qi of Yin and Yang.

When Yin Qi is predominant, one dreams of wading through deep water and feels afraid. Yin belongs to water, so the dream involves crossing water and feeling fear. The “Treatise on the Correspondences of Yin and Yang” says, “Water is Yin.”

When Yang Qi is predominant, one dreams of being scorched by a great fire. Yang belongs to fire, so the dream involves a blazing fire burning oneself. The “Treatise on the Correspondences of Yin and Yang” says, “Fire is Yang.”

When both Yin and Yang Qi are predominant, one dreams of people fighting and wounding one another. This, too, symbolizes the contention between Yin and Yang Qi.

When Qi in the upper body is predominant, one dreams of flying; when Qi in the lower body is predominant, one dreams of falling. When Qi rises, one flies upward in the dream; when Qi descends, one falls downward.

When one has eaten too much, one dreams of giving things to others, because there is an excess within. When one is very hungry, one dreams of asking others for things, because there is a deficiency within.

When Liver Qi is predominant, one dreams of becoming angry, since the Liver corresponds to anger among the emotions. When Lung Qi is predominant, one dreams of weeping, since the Lung corresponds to the sound of grief.

The commentator responsible for the new collation points out that the passage beginning “When Yin Qi is predominant, one dreams of wading through water and feeling afraid” originally comes from the Lingshu and was mistakenly placed here. It also omits what one dreams of when the Qi of the Heart, Spleen, and Kidneys is predominant; the relevant material can be found in the Jiayi Jing.

When there are many short worms in the body, one dreams that a crowd has gathered; when there are many long worms, one dreams of people fighting and wounding one another. The activity of long worms makes the body unsettled, and this unrest disturbs the mind and spirit, giving rise to such dreams.

The new collator also points out that these two sentences seem out of place here and may have been displaced from another classic and mistakenly inserted.

Thus, pulse diagnosis has its own method: one must keep the mind empty and still in order to judge the pulse’s strength and weakness reliably and avoid error. This passage first explains how the pulse changes with the seasons and then describes the state of mind needed for pulse diagnosis. The new collator notes that the Jiayi Jing has the character “treasure,” meaning that emptiness and stillness should be regarded as the key to diagnosing the pulse.

In spring, the pulse rises, like a fish swimming among the ripples. Though it has surfaced, it is not yet fully apparent.

In summer, the pulse appears at the surface of the skin, broad and full, like the abundant growth of all things. Here, “broad and full” describes a pulse that is even and replete. When Yang Qi is flourishing, the pulse is as abundant as the growth of all things: it is easy to detect and relatively strong.

In autumn, the pulse recedes beneath the skin, like an insect about to hide away in its burrow. As Yang Qi gradually declines, the pulse sinks with it. The insect preparing to hibernate aptly illustrates Yang Qi’s gradual descent.

In winter, the pulse lies deep among the bones, like insects concealed securely in hibernation, while the noble person rests indoors.

“Within the bones” means that the pulse is deep and sunken. “Hibernating creatures lie close and hidden” means that Yang Qi is concealed. “The gentleman stays indoors” refers to a person’s daily life.

Thus, those who know how to observe the body’s interior use palpation to grasp the essential features of the pulse. Those who know how to observe the body’s exterior watch for changes in complexion, following the changes in the Five Colors through a cycle from end to beginning.

Grasping these six aspects is the basic method for examining the pulse. Only by discerning all six can one understand how the pulse changes.

The New Collation says: A close reading of the preceding passage shows that this section follows on from the Yellow Emperor’s question, “How does the pulse change with the four seasons?”

When the Heart pulse beats with force, feels firm, and is long, the patient should have a condition in which the tongue curls up and the person cannot speak. Here, “beats” means that the pulse strikes forcefully against the fingers. When any pulse feels firm and long, it indicates that excessive mental exertion has made the pulse Qi stored in the Heart extremely weak. The Hand Shaoyin Heart channel connects the Heart to both sides of the throat, so the tongue curls up and becomes contracted, making speech impossible.

When the Heart pulse is soft and scattered, the illness should resolve on its own. A pulse that is soft and scattered indicates abundant Qi but deficient blood. “Dissipate” means to disperse; “cycle” means to revolve continuously. Here, the channel Qi is said to flow in a continuous circuit, like a ring, and when Heart Fire becomes strong, the illness will dissipate on its own. The New Collation says: In the Jia Yi Jing, “cycle” is written as “thirst.”

When the Lung pulse beats with force, feels firm, and is long, the patient should cough up blood. Extreme weakness of Lung Qi disrupts the flow of Qi and blood in the Lung network vessels, leading to bleeding and thus the coughing up of blood.

When the Lung pulse is soft and scattered, the patient should have a condition called “soaked sweat”: after sweating, the person can no longer sweat normally. Sweat leaks out through the skin’s pores, called the Mysterious Palaces, and the body’s fluids gather as a result. If the person is then washed with cold water, the skin tightens and the sweat becomes trapped inside the body. In ancient usage, this condition—when sweat has been washed off, sealed in, and can no longer be released—was called “soaked sweat.” “Soaked” means to wash or rinse. This condition is more common in the height of summer.

The New Collation says: A close reading of the passage below shows that each of the other organs is associated with a corresponding color, while the Heart and Lung alone are not. It is suspected that words have been omitted here.

When the Liver pulse beats with force, feels firm, and is long, but the complexion is not blue-green, the patient should have fallen ill after a fall or a blow. If blood accumulates below the ribs, the person will breathe heavily and suffer counterflow of Qi. When the pulse displays the Qi of its own channel but the complexion does not correspond to it, the illness has not arisen within the body; an external pathogenic influence has entered and overcome the organ. The Liver pulse is straight and long, so the scripture says that if the complexion is not blue-green, the illness may have resulted from a fall or a blow. The Liver governs both sides of the ribs, hence the statement that blood accumulates below the ribs. The Foot Jueyin Liver channel runs between the ribs…

A branch running upward behind the throat also arises from the liver and passes upward through the diaphragm.

When the Lung descends: blood has now accumulated beneath the ribs, and the Blood-Qi rises and steams into the Lung, causing panting and rebellious Qi.

If the pulse is soft and scattered and the complexion is lustrous, the person is likely to develop “overflowing fluid.” This refers to a sudden thirst followed by drinking large amounts of water, after which fluids readily flow into the spaces between the skin and beyond the stomach and intestines, where they collect and fail to disperse. A lustrous, swollen-looking complexion indicates an abundance of dampness within the body and deficient blood. Dampness prevents fluids from circulating normally, which is why this condition is called overflowing fluid. When fluids overflow, they readily seep into the spaces between the skin and beyond the stomach and intestines. The New Collation notes that in the Jiayi Jing, the character here meaning “readily” is written as “overflow.”

If the Stomach pulse is firm and long and the complexion is flushed, the person is likely to have pain in the thigh, as though it were broken. When Stomach Qi is weak and the complexion is flushed, Fire Qi is coming to assist Stomach Qi. The Heart belongs to Fire, which is why the complexion is flushed. The Foot Yangming Stomach channel descends from Qichong, passes through the thigh to the Futu point, and so illness causes pain in the thigh as though it were broken.

If the pulse is soft and scattered, the person is likely to develop food impediment. Here, “impediment” means pain. A branch of the Foot Yangming Stomach channel descends from the area in front of Daying, passes through Renying, follows the throat into the supraclavicular fossa, then descends through the diaphragm, connecting with the Stomach and linking to the Spleen. Thus, eating brings pain and fullness, and the movement of Qi cannot flow freely. The New Collation notes that interpreting “impediment” as pain seems not to make the passage’s meaning sufficiently coherent.

If the Spleen pulse is firm and long and the complexion is yellow, the person is likely to have shortness of breath. When the Spleen is deficient, it cannot nourish the Lung. The Lung governs Qi, so this results in scant Qi and shortness of breath.

If the pulse is soft and scattered and the complexion lacks luster, the person is likely to develop swelling in the feet and lower legs, resembling edema. A lustrous, swollen-looking complexion indicates dampness and water accumulation; since the complexion here is said to lack luster, the text describes the swelling only as resembling edema. The Foot Taiyin Spleen channel ascends from in front of the inner ankle, follows the inner side of the lower leg behind the tibia, then crosses in front of the Foot Jueyin Liver channel. It continues upward along the front of the inner knee and thigh and enters the abdomen. Therefore, illness causes swelling of the feet and lower legs.

If the Kidney pulse is firm and long and the complexion is yellow tinged with red, the person is likely to have pain in the lower back, as though it were broken. A yellow-red complexion indicates that the Qi of the Heart and Spleen is disturbing the Kidney. The Kidney is affected by this external Yang Qi, so the lower back feels as though it is about to break. The lower back is the residence of the Kidney, so the illness arises from within the Kidney.

If the pulse is soft and scattered, the person is likely to have a deficiency of blood that persists without recovery. The Kidney governs water and transforms it to produce fluids. Now the Kidney Qi cannot transform fluids normally, so blood becomes deficient and remains so for a long time.

The Emperor said:

The New Collation notes that in the Quan Yuanqi edition, the passage from “The Emperor said” through “It is cured by treating according to what overcomes it” appears in the “Decoctions and Liquids” chapter.

If the heart pulse is rapid and urgent, what illness is this, and what symptoms will it produce? Qibo replied:

The illness is called “heart hernia,” a hernia caused by cold affecting the heart pulse. There should be a lump or some abnormality of shape in the lower abdomen.

The heart is a Yang organ, and its Qi corresponds to Yang Qi. But the pulse now shows signs of cold, so a hernia develops. Pulses that are tense and forceful are generally caused by Cold pathogens. Here, “shape” means the visible signs of the illness.

The Yellow Emperor asked, “Why do you say this?” Qibo replied, “The heart is a Yang organ, and the small intestine is governed by the heart. That is why there should be an abnormality of shape in the lower abdomen. Here, ‘lower abdomen’ refers to the area where the small intestine is located. The Treatise on the Inner Canon’s Secret Treasury says that the small intestine receives and holds food and drink. Because it takes in and contains them, its disorders show themselves inside the abdomen.”

The Yellow Emperor asked, “When the stomach pulse is examined, what symptoms will the illness produce?” Qibo replied, “If the stomach pulse is replete, there will be abdominal distension; if it is deficient, there will be diarrhea. A replete pulse means Qi is in excess, so there will be fullness and distension. A deficient pulse means Qi is insufficient, so there will be diarrhea.”

The Yellow Emperor asked, “What does it mean for an illness to change after it has formed?” Qibo replied:

An invasion by Wind pathogen may produce an illness with alternating chills and fever. The Treatise on the Generation of Qi and Its Communication with Heaven says that exposure to Wind brings on chills and fever. Thus Wind pathogen can cause chills and fever.

Accumulated damp heat may produce “wasting-thirst in the middle,” a pattern marked by voracious appetite and emaciation. Here, “dan” refers to damp heat. When damp heat accumulates inside the body, the illness may develop into wasting-thirst in the middle. The original commentary describes this as being able to eat while growing thin. Editors point out that, according to this classic, wasting-thirst in the middle should involve eating and urinating excessively; being able to eat while growing thin more closely matches “food wasting,” a pattern in which the body grows thin despite normal or abundant eating.

Qi rising counter to its proper direction may produce an illness affecting the crown of the head. Here, “jue” means Qi counterflow. If Qi continues to surge upward, it may develop into a disorder affecting the crown of the head.

Wind pathogen lingering for a long time may cause diarrhea in which undigested food passes through. If someone is exposed to Wind pathogen for a prolonged period, the pathogen may remain in the stomach, preventing food from being fully digested and causing diarrhea. This is because Liver Qi affects the stomach. The Treatise on the Correspondences of Yin and Yang and Their Manifestations says that Wind Qi is associated with the Liver; Wind pathogen therefore resonates internally with the Liver.

Wind pathogen entering the channels may develop into “li feng,” an ancient term for certain skin diseases. The Treatise on Wind Disorders says that when Wind-Cold enters the channels and remains there for a long time without dispersing, the condition is called li feng. It also says that in people with li feng, nutritive Qi is heated and Qi becomes impure, which may lead to damage to the bridge of the nose, changes in complexion, and ulceration of the skin. Commentators identify this with leprosy and consider it the result of Wind pathogen becoming constrained and transforming within the channels.

The transformations of illness are too numerous to count.

The revised edition adds: For details, compare the earlier passage in which the Yellow Emperor asks how diseases change.

The Yellow Emperor asked, “How do various swellings and abscesses, muscular and vascular spasms, and bone pain arise?”

Qibo replied, “These are swellings caused by Cold Qi, and they also result from the changes brought about by the Eight Winds—the winds from the eight directions. Swellings and abscesses arise through the influence of the southeast and southwest winds; muscular and vascular spasms and bone pain arise through the influence of the east and north winds. The Ling Shu Jing says: the east wind is called the ‘Infant Wind’; when it injures people, the pathogenic influence lodges in the sinews. The southeast wind is called the ‘Weak Wind’; when it injures people, the pathogenic influence lodges in the outer layers of the flesh. The southwest wind is called the ‘Scheming Wind’; when it injures people, the pathogenic influence lodges in the flesh. The north wind is called the ‘Great Firm Wind’; when it injures people, the pathogenic influence lodges in the bones. Changes brought about by these four winds produce the three kinds of illness just described. That is why the Yellow Emperor next asks how they should be treated.”

The Yellow Emperor asked, “How should they be treated?”

Qibo replied, “These are illnesses of the four seasons. Treat them according to the principle of mutual restraint among the Five Phases, and the illness will be cured.”

“Mutual restraint” refers to the relationships by which the Five Phases control one another: Metal overcomes Wood, Wood overcomes Earth, Earth overcomes Water, Water overcomes Fire, and Fire overcomes Metal.

The Yellow Emperor then asked, “Some longstanding illnesses cause the Qi of the five viscera to move abnormally; in other cases, an injury affects the pulse and complexion. How can we tell whether an illness is longstanding or a recent acute condition?”

Qibo replied, “That is a carefully considered question. Observe the pulse and complexion. If the pulse has changed but the complexion shows no clear change, the illness is recent. At this stage, although the body’s vital energy is weak, the spirit can still hold up.

“If the pulse shows no clear change but the complexion has changed, the illness is longstanding. The spirit can still hold up, but pathogenic influences have already damaged the body’s vital energy.

“If both the pulse and complexion have changed clearly, the illness is longstanding, showing that both the spirit and the body’s vital energy have weakened.

“If neither the pulse nor the complexion shows a clear change, the illness is recent, showing that both the spirit and the body’s vital energy remain strong.

“If the liver and kidney pulses appear together while the complexion is green and red, there must have been an injury, but no bleeding. If bleeding has occurred, dampness or Water Qi may have entered the body.”

Note: The final passage of the original uses correspondences between the pulses and colors of the five viscera to assess the condition. The liver is associated with green, and the heart with red; according to the Five Phases correspondences, the kidney pulse would normally be associated with black. Since a red complexion appears instead when the kidney pulse is present, the commentators explain this as an injury in which blood has not escaped from the body. If bleeding has occurred, it suggests the presence of dampness or Water Qi within the body.

On both sides of the cubit section—the part of the wrist pulse closest to the wrist—correspond to the flank areas beside the lower ribs, near the kidneys.

“Within the cubit” here means the inner side of the cubit section; “on both sides” means its two flanks. The flank areas lie near the kidneys, and the cubit section is used to assess the kidneys, so its two sides correspond to those flank areas.

The outer side of the cubit section is used to assess the kidneys, and the inner side to assess the abdomen. The outer side is the face turned outward; the inner side is the face turned inward. The areas below the cubit section on both sides correspond to the flank areas; above those areas corresponds to the kidneys; and inward from them corresponds to the abdomen.

At the bar section—the part of the wrist pulse near the thenar eminence—the outer side on the left is used to assess the liver, and the inner side to assess the diaphragm. The liver governs the area around the diaphragm; the diaphragm is the transverse partition in the torso.

On the right, the outer side is used to assess the stomach, and the inner side to assess the spleen. The spleen lies at the center of the body, so it is assessed from the inner side. The stomach is like a place where food and drink gather, so it is assessed from the outer side.

Above the bar section, on the right, the outer side is used to assess the lungs, and the inner side to assess the chest. The lobes of the lungs hang outward and downward, so they are assessed from the outer side. The chest governs the movement of Qi, so it is assessed from the inner side.

On the left, the outer side is used to assess the heart, and the inner side to assess the chest center, where the movement of Qi gathers. The heart governs the area around the diaphragm; the chest center is the sea of Qi. An earlier commentary says that “chest center” refers to the throat, but the later editorial correction notes that Wang Bing’s interpretation is probably mistaken.

The front of the pulse position is used to assess the front of the body, and the back to assess the back of the body. At the upper level, “front” means the cun position on the left wrist; at the lower level, it means the front of the chest, the breast region, and the sea of Qi. At the upper level, “back” means the cun position on the right wrist; at the lower level, it means the chest and back, as well as the area where the windpipe lies.

The uppermost end of the pulse positions can reveal the condition of the chest and throat; the lowermost end can reveal that of the lower abdomen, lower back, legs, knees, shins, and feet. The “uppermost end” means the extension toward the thenar eminence; the “lowermost end” means the end of the pulse range in the cubit section. The movement of Qi in the lower abdomen, womb, sea of Qi, lower back, legs, knees, and feet should all be assessed according to the distance between their locations and their relationships to one another, in order to judge their condition.

A broad, forceful pulse indicates insufficient Yin and excessive Yang, and is associated with internal heat. “Broad” means a surging pulse; a surging pulse indicates heat, hence the term “internal heat.”

A pulse that arrives rapidly and departs slowly, with strength above and weakness below, indicates counterflow reversal and disorders at the crown of the head. A pulse that arrives slowly and departs rapidly, with weakness above and strength below, indicates susceptibility to attacks by harsh wind. These descriptions all refer to pulse qualities.

Susceptibility to harsh wind arises because the upper region is weak, leaving Yang Qi vulnerable to invasion.

If the pulse as a whole is deep, fine, and rapid—that is, if it beats quickly—it indicates reversal in the lesser Yin channel.

If the pulse at the cubit position—the part of the wrist nearer the elbow, corresponding to the kidneys—is deep, fine, and rapid, with hurried beats, this indicates that the Qi of the Kidney Shaoyin is in disorder. A rapid pulse should not normally appear at the cubit position; when it does, the condition is called Jue, meaning that the movement of Qi is in disorder.

Here, “deep, fine, and rapid” describes the pulses at the cubit positions on both the left and right sides.

A pulse that is deep, fine, rapid, and irregular indicates alternating cold and heat. Yang Qi disrupts Yin Qi, and Yin Qi is insufficient, so cold and heat occur. The Zhengli Lun says, “A rapid pulse belongs to Yang.”

A floating, scattered pulse may indicate sudden fainting. A floating pulse shows deficiency, and a scattered pulse shows insufficiency. Qi is deficient, and Blood is also insufficient, so the person becomes dizzy and collapses. (“Xiong” is pronounced like “shun.”)

All floating pulses, if not agitated, indicate illness in the Yang channels, presenting as heat. If the pulse is agitated, the illness is in the Yang channels of the hands. This is a general summary: when the pulse is floating but not agitated, the illness is in the Yang channels of the feet; when it is agitated, the illness is in the Yang channels of the hands. Hence the saying, “When agitated, the illness is in the hands.” Yang belongs to Fire, so there is fever.

All fine, deep pulses belong to Yin and present as bone pain. If the pulse is calm, the illness is in the Yin channels of the feet. If the pulse is fine and deep but also agitated, the illness arises in the Yin channels of the hands; if it is calm, the illness is in the Yin channels of the feet. Hence the saying, “When calm, the illness is in the feet.” Yin governs the bones, so there is bone pain.

A rapid pulse with a single pause between beats indicates illness in a Yang channel. The pulse may also appear this way when there is diarrhea or an emission of pus and blood. “Intermittent” means that the pulse pauses. This pulse, rapid and agitated with one pause, reflects a disorder of Yang Qi; hence the illness is said to be in a Yang channel.

When examining the pulse, an excess on either side is indicated as follows: a rough pulse shows an excess of Yang Qi, while a slippery pulse shows an excess of Yin Qi. When Yang Qi is in excess, Blood is scant, so the pulse is rough; when Yin Qi is in excess, Qi is abundant, so the pulse is slippery. (The New Collation says: “Abundant Qi” may be an error; it should read “abundant Blood.”)

When Yang Qi is in excess, the body becomes hot without sweating; when Yin Qi is in excess, there is profuse sweating and the body becomes cold. These signs reveal the condition of scant Blood and abundant Qi.

If both Yin and Yang are in excess, there will be no sweating and the body will feel cold: excess Yang Qi accounts for the lack of sweating, and excess Yin Qi accounts for the cold. When both Yin and Yang are in excess, there should be both no sweating and coldness.

When pressing outward during pulse examination, if the pulse can be felt only on the inner side and does not meet the finger on the outer side, this indicates a mass in the chest or abdomen. The pulse runs alongside the tendons of the arm. If it is difficult to distinguish while taking the pulse, the tendons can be moved slightly aside so the pulse can be felt on the outer side. If it still remains only on the inner side and cannot be felt outwardly, this indicates a mass in the chest or abdomen.

When palpating the pulse, push it outward. If it remains inside and cannot be pushed outward, this indicates heat in the body.

If you push a pulse vessel from farther up the arm toward the hand, but it remains far away and cannot be brought closer, Yang Qi is excessive, and the body is therefore feverish.

Push the pulse upward. If it reaches the upper position but does not move downward, this indicates coldness in the lower back and feet. Press and trace the pulse vessel: if the pulse rises upward with force, Yang Qi is excessive, and the lower back and feet are therefore cold.

The New Collation says: On checking the Jiayi Jing, the phrase here, “upward but not downward,” reads “downward but not upward.”

Push the pulse downward. If it reaches the lower position but does not move upward, this indicates pain in the head and neck. Press and trace the pulse vessel: if the pulse sinks downward and pulls taut, Yang Qi is excessive, and the head and neck are therefore painful.

The New Collation says: On checking the Jiayi Jing, the phrase here, “downward but not upward,” reads “upward but not downward.”

If, when pressing beside the bone, the pulse Qi remains very faint, the lower back and spine will ache, and the body will feel numb and uncomfortable. This is caused by excessive Yin Qi.