《黃帝內經素問補註釋文》Vol. 15

The chapter “Treatise on the Jade Mechanism and the True Viscera” says:

The Yellow Emperor asked, “The pulse in spring is like a bowstring. What makes a pulse a bowstring pulse?”

Qibo replied, “The spring pulse corresponds to the Liver, and the Liver belongs to Wood in the east. Spring is the season when all things begin to grow. Thus, when the spring pulse comes, it is gentle, faint, light, empty, and smooth; its movement is straight and long. This is what is called a bowstring pulse. ‘Bowstring’ means that the pulse moves straight and long, shaped like a bowstring.”

The New Corrected Edition says: According to the account in the Yue Ren, the spring pulse is bowstring-like because spring belongs to Wood in the east, when all things are just beginning to grow and have not yet put forth branches and leaves. Therefore, the pulse is gentle, faint, and long. The Treatise on the Four Seasons writes “broad” where this text has “light.” If the spring pulse differs from this normal pattern, it indicates illness.

The Yellow Emperor asked, “What counts as a departure from the normal pattern?”

Qibo replied, “If the pulse Qi comes full and forceful, this is called excess, and the illness is mostly in the body’s exterior. If the pulse Qi comes lacking and faint, this is called deficiency, and the illness is mostly in the body’s interior.”

The commentary says: When pulse Qi is abundant, illness manifests on the outside; when pulse Qi is insufficient, illness arises within. The New Corrected Edition cites Lü Guang’s explanation: A full, forceful pulse indicates flourishing Yang Qi. The Qi of Lesser Yang should normally be faint, but here it is instead full and forceful, so this is called excess. Yang Qi is located on the outside, so the illness is external. Jueyin Qi nourishes the sinews and vessels, and its pulse should normally be bowstring-like. Here, however, it is weak and faint, so this is called deficiency. Yin Qi is located within, so the illness is internal.

The Yellow Emperor asked, “What illnesses arise when the spring pulse is in excess or deficient?”

Qibo replied, “Excess makes a person prone to forgetfulness, mental disorientation, dizziness, and blurred vision; it may even cause illness at the crown of the head. Deficiency causes chest pain that draws through to the back, with distension and fullness below along both flanks and beneath the armpits.”

The commentary says: “Huhuang” means a mind that is unclear; “xuan” means that the vision blurs, as if things were spinning; “mao” means a dull, heavy feeling in the head; and “qu” refers to the armpits and flanks. Here, “forgetfulness” should be a mistaken form of the character for “anger.” The Ling Shu Jing says that an excess of Liver Qi makes a person angry. The Liver’s Jueyin channel rises from the foot, passes along the inner thigh, crosses the diaphragm, and spreads through the flanks. It then travels behind the throat up to the nasopharynx, reaches the forehead, and joins the Governor Vessel at the crown of the head. This explains the symptoms described above. The New Corrected Edition also points out that the Treatise on the Interaction of Qi and Transformation records that excess Wood Qi makes a person mentally disoriented and prone to anger, with dizziness, blurred vision, and illness at the crown. Therefore, “forgetfulness” here should be changed to “anger.”

The Yellow Emperor said, “Good. The pulse in summer is like a hook. What does it mean for it to be like a hook?”

Qibo replied, “Summer corresponds to the heart and belongs to Fire among the Five Phases. It is the season when all things flourish and grow. So the pulse Qi arrives full and strong, then fades as it recedes. This is why it is called ‘hook-shaped.’ The pulse is full and strong as it arrives, then gradually weakens as it departs, curving like a hook.”

The Supplementary Notes to the Newly Corrected Edition add: Yue Ren (Bian Que) says that the summer pulse is called ‘hook-shaped’ because the south belongs to Fire and all things flourish there. Branches droop and leaves spread out, their shapes curving downward like hooks. For this reason, the pulse arrives quickly and departs slowly. Lü Guang explains that Yang Qi is strong, so the pulse arrives quickly; Yin Qi is weak, so it departs slowly. In other words, the pulse moves quickly from below up to the cun position (the wrist pulse-taking point), then returns more slowly to the chi position (the pulse-taking area on the inner side of the cun position).

The Yellow Emperor asked, “What does a pulse that is the opposite of normal look like?”

Qibo replied, “If the pulse Qi arrives full and strong and departs just as full and strong, this is called excess, and the illness is on the body’s exterior. When the pulse is full and strong both as it arrives and as it departs, Yang Qi is excessive. If heart Qi is in excess, this is an excess pattern.

“If the pulse Qi does not arrive full and strong but becomes full and strong as it departs, this is called deficiency, and the illness is within the body.”

The Supplementary Notes to the Newly Corrected Edition point out that Yue Ren says the pulses of the four organs—the liver, heart, lungs, and kidneys—are in excess when forceful and strong, and deficient when weak and faint. This differs from the account in the Suwen.

The Yellow Emperor asked, “What illnesses arise when the summer pulse is in excess or deficient?”

Qibo replied, “Excess causes bodily heat and pain in the skin, and the pain may spread. Deficiency causes distress in the heart, coughing and spitting in the upper body, and the release of Qi from below.”

The Shaoyin pulse of the heart (the Hand Shaoyin Heart Channel) begins in the heart, connects with the heart system, passes downward through the diaphragm to link with the small intestine, then turns back from the heart system and travels upward to the lungs. Thus, excess heart Qi causes bodily heat and pain in the skin, with the pain spreading throughout the body. Deficient heart Qi causes distress in the heart, coughing and spitting in the upper body, and the release of Qi from below.

The Yellow Emperor said, “Good. The pulse in autumn is like a floating pulse. What does it mean for it to be like a floating pulse?”

Qibo replied, “Autumn corresponds to the lungs and belongs to Metal among the Five Phases. It is the season when all things mature and draw inward. So the pulse Qi arrives light, empty, and floating; it arrives quickly and disperses as it recedes. This is why it is called ‘floating.’”

Because the pulse arrives light and empty, it is called floating. It arrives quickly because Yang Qi has not yet descended. It disperses as it recedes because Yin Qi is rising.

The Supplementary Notes to the Newly Corrected Edition add that Yue Ren calls the autumn pulse ‘hair-like.’ The west belongs to Metal. In autumn, all things move toward decline: flowers and leaves wither and fall, leaving only the branches, which resemble fine hairs. The autumn pulse is therefore light, empty, and floating, and is called ‘hair-like.’

The opposite of a normal pulse is a sign of illness. The Yellow Emperor asked, “What counts as the opposite?” Qibo replied, “When the pulse qi arrives, it feels light and floating, like a feather. This is excess, and the illness lies on the exterior. When the pulse qi arrives, it feels faint and weak. This is insufficiency, and the illness lies within.”

The Yellow Emperor asked, “What illnesses can result from an excessive or insufficient autumn pulse?” Qibo replied, “Excess can make qi surge upward, cause back pain, and leave the heart feeling restless and oppressed. Insufficiency can cause panting, shortness of breath and scant qi, coughing, and qi rushing upward. The person may even cough up blood, and a sound can be heard in the lungs as they pant.”

The lungs correspond to the Hand Taiyin meridian, one of the body’s channels. This meridian begins in the Middle Burner, the area of the abdomen where the spleen and stomach are located. It descends to connect with the large intestine, then follows the opening of the stomach upward, passes through the diaphragm, and enters the lungs. From the lung system, the area connecting the lungs to the throat, it extends laterally toward the armpit. If the movement of lung qi is obstructed or deficient, it may cause coughing and panting. Thus, excessive lung qi can cause pain in the shoulders and back; disordered or deficient lung qi can cause panting, difficulty breathing, scant qi, coughing, qi surging upward, and coughing up blood. “A sound can be heard below” means that a sound from within the lungs can be heard while the person pants.

The Yellow Emperor said, “Well explained. The pulse in winter is said to be like ying. What kind of pulse is considered like ying?”

The pulse is deep and forceful, like ying qi moving through the vessels. In the original text, the character “deep” is thought by textual scholars to be a mistake for “soft.” On this reading, a deep and gentle pulse is the balanced pulse of winter; a deep pulse that strikes forcefully is excessive.

Qibo said, “The pulse in winter corresponds to the kidneys, which belong to Water in the north. In winter, all things draw inward and lie hidden, so the pulse qi arrives deep and forceful. This is called ‘ying.’”

Here, “ying” describes the characteristic of the winter pulse. Textual scholars also point out that the Difficult Classic calls the winter pulse “stone”: the north belongs to Water, and in winter all things are stored away; water congeals like stone. Thus the pulse is deep, gentle, and slippery, and is called “stone.”

The opposite of a normal winter pulse is a sign of illness. The Yellow Emperor asked, “What counts as the opposite?” Qibo replied, “When the pulse qi arrives, it is hard like a stone being struck. This is excess, and the illness lies on the exterior. When the pulse qi departs, it is rapid and hurried. This is insufficiency, and the illness lies within.”

The Yellow Emperor asked, “What illnesses can result from an excessive or insufficient winter pulse?” Qibo replied, “Excess can leave a person weary, drowsy, and dispirited.”

The New Collation’s note says: For the meaning of “jieyi,” see the commentary in Volume Five.

Pain in the channels of the back, accompanied by scant Qi and reluctance to speak, may result from a deficiency of channel Qi. This leaves the person feeling uneasy, as though something were suspended within.

There may also be a sensation like hunger, coldness within the navel, pain along the spine, fullness in the lower abdomen, and abnormal urination.

The Foot Shaoyin Kidney Channel, which runs from the foot to the kidneys, ascends along the back edge of the inner thigh, passes through the spine, connects with the kidneys, and links to the bladder. Its direct branch rises from the kidneys, passes through the liver and diaphragm, enters the lungs, ascends along the throat, and reaches both sides of the root of the tongue. Another branch leaves the lungs, connects with the heart, and flows into the chest. Thus, when the Kidney Channel is diseased, the symptoms described above may occur.

“Miao” refers to the soft, hollow areas below the lower ribs, on either side of the spine. The kidneys lie on either side of the lower abdomen and back, opposite these areas, so a patient may feel coldness there.

The Yellow Emperor said, “Well explained.”

The Yellow Emperor then asked, “The sequence of the four seasons may be followed or reversed, and the pulse likewise changes in different ways. In spring the pulse is wiry, in summer it is hooked, in autumn it is floating, and in winter it is ying. These are the different pulse patterns that appear in accord with, or in opposition to, the seasons. What, then, does the Spleen pulse alone govern?”

Here, “govern” means to ask which season or month is governed by the Spleen pulse.

Qibo replied, “The Spleen belongs to Earth and is the solitary organ. It transforms food and drink into fluids and sends them forth to nourish the Liver, Heart, Lungs, and Kidneys. The Spleen does not govern a season by itself; it helps nourish the four organs, and so is called the ‘solitary organ.’”

The Yellow Emperor said, “Then how can one tell whether the Spleen pulse is normal or abnormal?”

Qibo replied, “A normal Spleen pulse is not easy to distinguish on its own, but an abnormal one can be detected.”

The Spleen does not govern a season by itself. Instead, it takes part in governing at the end of each season. For this reason, when it is normal, its pulse is difficult to distinguish on its own; only when it becomes abnormal is it readily detected.

The Yellow Emperor asked, “What does an abnormal Spleen pulse feel like?”

Qibo replied, “If the pulse comes like flowing water, this is excess, and the disease is external. If it comes like a bird’s beak pecking, this is insufficiency, and the disease is internal.”

The New Collation notes: The Treatise on the Qi of the Ordinary Person’s Pulse records “like a crow’s beak”; another version reads “pecking.”

The Yellow Emperor asked, “You have said that the Spleen is the solitary organ, belongs to Earth at the center, and nourishes the four directions. What illnesses result when Spleen Qi is excessive or insufficient?”

Qibo replied, “Excessive Spleen Qi prevents a person from raising the limbs, because the Spleen governs the limbs. Insufficient Spleen Qi causes the person’s nine orifices to become obstructed; this is called ‘heavy and rigid.’”

As the solitary organ, the Spleen nourishes the four directions. When it is diseased, the five organs may fall out of harmony, potentially causing the nine orifices to become obstructed. The Classic of Difficulties says that when the five organs are out of harmony, the nine orifices become obstructed. “Heavy” means that the Qi of the organs overlaps and stagnates; “rigid” means that the movement of Qi is not smooth.

The Yellow Emperor rose in astonishment, bowed, and touched his forehead to the ground again. “Excellent! I have grasped the essentials of pulse signs. The deepest principles under Heaven—whether the variations in the five colors or in pulse signs, whether the methods of estimation and measurement or the discernment of the extraordinary and the ordinary—all converge on one fundamental truth.”

“Spirit turns without reversing; if it reverses, it cannot turn, and so loses its opportunity” means that the Qi of the Five Phases circulates in accordance with the seasons without error. This is called the flow of Shen without reversal. If Qi’s waxing and waning become abnormal and violate the natural order, it reverses and can no longer function properly, thereby losing the vital pivot through which life arises and develops. Here, “Shen” refers to the force that sustains the activities of life and keeps Qi in constant motion.

The key to mastering the deepest principles lies in grasping what is subtle. Those who truly understand these principles can assess a condition closely in diagnosis and treatment, and perceive its slightest changes. “Closely” here means drawing near to something.

Write these teachings on a jade tablet and store it away. Reciting it each morning is called the Jade Pivot. It takes its name from being written on a jade tablet, and it explains the pivotal workings of life.

The Five Zang organs receive pathogenic Qi from the organ that nourishes them, then transmit it to the organ they overcome. The pathogenic Qi temporarily lodges in the organ that nourishes them; in the end, it reaches the organ that they cannot overcome—that is, the organ that overcomes them. When an illness is about to prove fatal, it must first pass to the organ that the affected organ cannot overcome, and only then does death follow.

“Receiving Qi from what it engenders” means receiving pathogenic Qi from the organ engendered by that organ. “Transmitting it to what it overcomes” means passing pathogenic Qi to the organ that it overcomes. “Qi lodging in what engenders it” means that pathogenic Qi lodges in the organ that nourishes it. “Dying in what it cannot overcome” means that the illness progresses to the organ that overcomes the affected organ. When pathogenic Qi moves in this reverse course, it may cause death. The sequence given below illustrates this reversal:

The Liver receives pathogenic Qi from the Heart and transmits it to the Spleen. The Qi lodges in the Kidney; when it reaches the Lung, death follows.

The Heart receives pathogenic Qi from the Spleen and transmits it to the Lung. The Qi lodges in the Liver; when it reaches the Kidney, death follows.

The Spleen receives pathogenic Qi from the Lung and transmits it to the Kidney. The Qi lodges in the Heart; when it reaches the Liver, death follows.

The Lung receives pathogenic Qi from the Kidney and transmits it to the Liver. The Qi lodges in the Spleen; when it reaches the Heart, death follows.

The Kidney receives pathogenic Qi from the Liver and transmits it to the Heart. The Qi lodges in the Lung; when it reaches the Spleen, death follows.

All these are cases in which reversed Qi leads to death. By dividing the day and night into five periods for observation, one can use this sequence to estimate how soon a patient may die.

If liver disease spreads to the lungs, the lungs are governed by autumn, and the illness is likely to become severe on Geng and Xin days. The same principle applies to the other four organs: dawn is governed by Jia and Yi days, daytime by Bing and Ding days, the end of each season by Wu and Ji days, evening by Geng and Xin days, and night by Ren and Gui days. From this, one can infer when an illness is likely to become critical and when death may occur.

The New Collation says: According to the Jia Yi Jing, the character “sheng” here is written “gu.”

When the disease spreads to the kidneys, if these symptoms appear, treatment may be given through massage, medicine, or acupuncture. If left untreated, kidney disease will spread to the heart. The patient’s sinews and vessels will pull and contract; this condition is called chi (convulsions and twitching of the sinews).

When Kidney Qi is deficient, fluids cannot nourish the sinews and vessels. The sinews therefore become dry and contracted, pulling against one another. Yin Qi is deficient within, while Yang heat blazes outside; heated by this, the sinews and vessels twitch and convulse on their own. This is why the condition is called chi.

At this stage, the illness can be treated with moxibustion or medicine. If left untreated, the patient will, by the usual reckoning, die after ten days. This occurs when the disease spreads to the heart and Heart Qi becomes severely depleted. If the pathogenic influence continues to spread, the course is as described below.

When kidney disease spreads to the heart, and the heart in turn passes it back to the lungs, the patient will develop alternating chills and fever and, by the usual reckoning, die after three years.

This means that kidney disease spreads to the heart, but the heart is not itself afflicted; the disease then shifts to the lungs. The lungs belong to Metal and have now been damaged again, so chills and fever appear. The “three years” are counted according to the sequence by which disease passes among the Five Organs: the lungs pass it to the kidneys in one year, the kidneys to the liver in one year, and the liver to the heart in one year. The Fire of the heart then overcomes the Metal of the lungs, hence the prediction of death after three years.

This is the sequence in which disease passes from one organ to another: the pathogenic influence moves according to the cycle of mutual overcoming.

Sudden-onset illnesses, however, do not necessarily need to be treated according to this sequence, nor should one be bound by the usual rules of transmission. Some illnesses spread out of sequence. Emotions such as worry, fear, grief, joy, and anger arise without fixed timing; a stimulus may bring them on, causing the illness to develop out of sequence and become severe.

If excessive joy causes Qi to become deficient, Kidney Qi will take advantage of the resulting weakness. Joy shifts Heart Qi to the lungs, so Heart Qi cannot remain in its proper place; Kidney Qi then takes advantage of the deficiency.

The Treatise on the Five Qi in the Xuanming says: “When the essence Qi gathers in the heart, joy arises.”

When anger arises, Liver Qi takes advantage of the deficiency. Anger makes Qi flow counter to its proper course, so Liver Qi attacks the spleen.

When grief arises, Lung Qi takes advantage of the deficiency. Grief shifts Lung Qi to the liver, leaving the liver vulnerable to pathogenic influence; Lung Qi then takes advantage of the deficiency.

The Treatise on the Five Qi in the Xuanming says: “When the essence Qi gathers in the lungs, grief arises.”

When fear arises, Spleen Qi takes advantage of the deficiency. Fear shifts Kidney Qi to the heart, so Kidney Qi cannot remain in its proper place; Spleen Qi then takes advantage of the deficiency.

The Treatise on Clarifying the Five Qi says, “When Jing and Qi gather in the kidneys, fear arises.”

When a person is distressed, Heart Qi takes advantage of the weakness and rises. Distress causes Liver Qi to shift to the Spleen. Unable to remain in its proper place, Liver Qi leaves an opening for Heart Qi to rise.

The Treatise on Clarifying the Five Qi also says, “When Jing and Qi gather in the liver, distress arises.”

This is the principle behind the change, and it is a common effect when the Qi of the five zang organs becomes disordered.

There are five basic patterns of illness, each with five variations, making twenty-five in all. The five zang organs can each combine with one another in five ways; when these are further worked out according to the relations of overacting, there are twenty-five variations. These changes also transform from one organ to another according to the relations of mutual overcoming, and do not necessarily follow a set sequence. This is why illness can change in so many ways. The New Commentary says that the phrase in the Treatise on Yin-Yang Discrimination, “In all, Yang has five forms; five times five makes twenty-five,” conveys the same idea.

What is the relationship between “transmission” and “overacting”? “Transmission” is simply another term for “overacting.”

If the large bones are withered, the major muscles wasted and sunken, the chest distended, and breathing labored, and the body sways from weakened breath, the shoulders and back will rise as though searching afar for a response to the breath. These signs indicate that the zang organ governing the body’s form has failed, and that the zang organ storing the spirit has also been damaged. When this pattern appears, death is expected within 180 days. Only after the true-organ pulse is detected—the pulse that appears when the Qi of an organ is failing—can the specific date of death be determined. The method for diagnosing the true-organ pulse is described in detail in the lower classic. This is a pattern of lung disease.

If the large bones are withered, the major muscles sunken, the chest distended, and breathing labored, with internal pain extending to the shoulders and neck, death is expected within thirty days. The specific date can be determined only after the true-organ pulse appears. This is a pattern of heart disease. The Heart belongs to Fire. When Fire Qi manifests outwardly and Yang Qi burns upward, Metal is overcome by Fire. This gives rise to pain within the chest that extends to the shoulders and neck.

If the large bones are withered, the major muscles sunken, the chest distended, and breathing labored, with internal pain extending to the shoulders and neck, and the body is also hot, the muscles are wasted, and the flesh has atrophied, death will follow within ten months after the true-organ pulse appears. Yin Qi is weak, while Yang Qi burns fiercely within the body, causing the body to become hot. “Jiong” refers to muscle.

The Spleen governs the muscles. When the muscles waste away as though they were coming loose, and the flesh behind the elbows and knees appears damaged and worn, this is a sign of disease in the Spleen. In such cases, death usually follows within three hundred days. The term qun refers to the fleshy bulges behind the elbows and knees; it is pronounced “qun,” with the reading indicated by the fanqie spelling qu yun qie.

When the large bones are wasted, the muscles deeply sunken, and the vital energy in the shoulders and bone marrow seems gradually depleted, with movement growing weaker, this shows that the true Qi of the organs has begun to display signs of decline and foretells death within a year. “The shoulders and marrow wasting inward” refers to a deep hollowing at the supraclavicular hollow above the collarbone. The commentators hold that this passage discusses only how to judge the time of death when Qi moves in reverse; it does not discuss when the patient might recover. Wang Bing changed “death” to “recovery,” but this reading is less convincing than the original wording of the Suwen as preserved in the Jiayi jing.

The Yellow Emperor said, “The five organs are interconnected. Pathogenic Qi shifts among the organs and bowels according to a fixed sequence. When one of the five organs is diseased, the illness is transmitted to the organ it restrains.”

This describes pathogenic Qi transmitting in reverse, reaching the organ that restrains the affected organ and causing death. The New Collation argues that in the phrase “transmitted in reverse according to the sequence of what it restrains,” the word “reverse” should read “in due order.” The preceding passage has already discussed transmission in reverse, while the following passage describes transmission in accordance with the restraining sequence.

When an illness cannot be cured, pathogenic Qi may spread through the five organs over three months, six months, three days, or six days, ultimately causing death. This describes transmission according to the restraining sequence. Three months refers to pathogenic Qi moving gradually from one organ to another. Six months refers to its reaching the organ it restrains. The three days are counted according to the number of the Three Yang; the six days include the Three Yin as well. The Treatise on Heat Diseases explains the principle: on the first day of cold damage, the illness is in Taiyang; on the second, it passes to Yangming; on the third, to Shaoyang; on the fourth, to Taiyin; on the fifth, to Shaoyin; and on the sixth, to Jueyin.

The New Collation points out that the seven characters meaning “this is transmission in due order according to the sequence of what is restrained” originally belonged to the preceding commentary and were mistakenly placed beneath the canonical text. Neither the Suwen in the Quan Yuanqi edition nor the Jiayi jing contains these seven characters, so they should be deleted. They are retained here in the commentary, however, to explain the reason.

Thus, distinguishing changes in the Yang channels makes it possible to know where an illness originated; distinguishing changes in the Yin channels makes it possible to judge its course and the time of death. By understanding the signs of the Three Yin and Three Yang, one can know which organ pathogenic Wind will reach after entering the body, and which organ will be unable to resist it. At this point, the original text continues with the following passage.

The commentary explains that “distinguishing the Yang” means identifying where the pathogenic influence lies and thus knowing where the illness will arise; “distinguishing the Yin” means assessing the condition of the Yin aspect and thus judging when life and death will be determined. Another passage says that “distinguishing the Yang” can reveal the days when the illness is likely to flare, while “distinguishing the Yin” can determine the time of death. The two passages mean the same thing.

To know where a patient will die means to know when the illness has progressed to a stage the patient cannot withstand. Here, “overwhelmed” means that the illness has advanced to the point where it overcomes and damages a particular organ. The passage above says that a patient will die at the point where the illness can no longer be overcome.

Thus it is said that Wind is the forerunner of the hundred illnesses. In other words, many illnesses are often preceded by an invasion of Wind. The new collation notes that the “Treatise on the Vital Qi Communicating with Heaven” says, “Wind is the beginning of the hundred illnesses,” which has a similar meaning.

When Wind and Cold invade the body, all the body hair stands on end and the skin closes, causing heat to build up inside. Here, “lodges” means that pathogenic Qi remains in the body. Wind invades the skin, while Cold congeals in the Couli—the spaces between the skin and muscles—so the body hair stands up, the pores close, and heat arises.

At this point, sweating can be induced to disperse the pathogenic influence from the body’s surface. Since it is still between the skin and body hair, it can be expelled through sweating. The “Treatise on the Correspondence of Yin and Yang” says, “Those skilled in treatment first treat the skin and hair.” This is the principle being described.

If treatment is delayed and the illness changes, numbness, swelling, and pain may develop. Heat trapped in the Blood and Qi causes numbness; Cold damages the body’s form, causing swelling and pain. The “Treatise on the Correspondence of Yin and Yang” says, “Cold injures form, while heat injures Qi; when Qi is injured, there is pain, and when form is injured, there is swelling.”

At this point, treatment may use medicinal decoctions, hot compresses, moxibustion, or acupuncture to dispel Cold and unblock upright Qi.

If treatment is still not given, the pathogenic influence enters the Lungs. This is called “Lung impediment,” and its symptoms include coughing and Qi surging upward. When a pathogenic influence enters the Yin aspect, an impediment disorder develops; once it enters the Lungs, it is called Lung impediment. The “Treatise on the Five Qi Manifestations” says, “When a pathogenic influence enters the Yang, there is mania; when it enters the Yin, there is impediment.” Lung disorders manifest as coughing, so during a cough, Qi counterflows upward.

If Lung impediment remains untreated, the pathogenic influence continues to the Liver, forming “Liver impediment,” also called “reversal.” Symptoms include pain along the ribs and flanks, and food being vomited back up after eating. The Lungs belong to Metal and the Liver to Wood. When illness passes from the Lungs to the Liver, it is like Metal overcoming Wood; hence the saying that the pathogenic influence has passed from the Lungs to the Liver. Liver Qi connects with the Gallbladder. When Liver Qi is disordered, anger arises; when a person becomes angry, Qi surges upward, which is why this condition is also called “reversal.” The Liver channel begins in the lower abdomen, connects with the Liver and links to the Gallbladder, then passes upward through the diaphragm and spreads along the ribs and flanks before ascending behind the throat. This explains the pain along the ribs and flanks. Food enters the abdomen and is then vomited back up, which is why this is called “bringing food back out.”

At this stage of the illness, massage, acupuncture, and similar methods can be used for treatment. If it is left untreated, the liver disease will pass to the spleen. This condition is called pifeng (spleen wind) and may cause jaundice, heat in the abdomen, agitation, and yellow urine.

Liver Qi corresponds to wind and Wood. When Wood Qi is excessive, it restrains Spleen Earth. Since the spleen is affected by wind, the condition is called pifeng. The name comes from the connection between wind and the liver. Spleen disease often causes jaundice, hence the phrase “fa dan” (“developing jaundice”; dan refers to illnesses of the jaundice type). The Spleen channel (the Foot Taiyin Spleen channel) enters the abdomen, connects with the spleen and stomach, passes upward through the diaphragm, runs alongside the throat to the root of the tongue, and then spreads beneath the tongue. A branch also leaves the stomach, passes upward through the diaphragm, and flows into the heart. This explains the heat in the abdomen, agitation, and yellow urine.

At this stage, the illness can be treated with massage, medicines, or medicinal baths. If it is left untreated, the spleen disease will pass to the kidneys. This condition is called shanjia (abdominal masses and accumulations) and may cause dull heat and pain in the lower abdomen, along with the discharge of a white fluid. Another account calls it gu (parasitic illness).

The Kidney channel (the Foot Shaoyin Kidney channel) ascends along the back of the inner thigh, passes through the spine, and connects with the kidneys and bladder. This explains the dull heat and pain in the lower abdomen, as well as the discharge of white fluid in the urine. Heat that accumulates internally consumes the body’s fat and flesh, gradually damaging the body as though worms were gnawing at it. Thus, the patient grows weaker after each sexual encounter. Since the other organs have not yet all been damaged, death is expected within the following three hundred and sixty-five days. This describes a disorder of the kidneys.

The Xin jiaozheng (“Newly Collated Corrections”) says: A comparison with the version by Quan Yuanqi and the Jia Yi Jing shows that in the phrase “the true-organ pulse appears,” the character lai (“comes”) should be wei (“not yet”); lai is a scribal error.

If the large bones become withered and thin, the major muscles sink away, the chest becomes distended, the abdomen hurts, the heart feels unsettled, the neck and shoulders become hot, the flesh breaks down and wastes away, and the eye sockets become hollow, these are signs that the true-organ pulse has appeared. If the patient can no longer see people, death will follow immediately. If the patient can still see, death will come when the season arrives that overcomes the affected organ.

Wood generates Fire, and Liver Qi connects with the Heart pulse. The Liver channel reaches the lower abdomen, spreads upward across the ribs, ascends behind the throat, and enters the upper part of the nasal cavity, known as the hangsang. This accounts for the abdominal pain, the unsettled feeling in the heart, the heat in the shoulders and neck, and the breakdown and wasting of the flesh. The liver governs the eyes, which explains the hollow eye sockets. If the patient can no longer see people, death will follow immediately. “The time that cannot be overcome” refers here to the months of Geng and Xin, when, according to the Five Phases, Metal overcomes Liver Wood. This describes a disorder of the liver.

If the body is suddenly struck by a fierce attack of deficient pathogenic influence, the Qi of the five organs becomes blocked, the channels of the pulses fail to flow, and the breath cannot move back and forth. The condition resembles falling or drowning, and the time of death cannot be predicted.

The point here is that when diseases pass from one of the five organs to another, reaching an organ that overcomes the affected one, the appearance of the true-organ pulse can usually be used to estimate the date of death. But if deficient pathogenic influence suddenly and violently enters the body and blocks the Qi of the five organs, the time of death cannot be determined this way.

When the Qi of the organs and bowels is cut off, the pulse pathways are blocked, and the breath no longer comes and goes, the condition is like a person falling into water and drowning, on the verge of death. The precise time of death cannot be determined from this alone.

If the pulse stops and does not return, or beats five or six times in the span of one breath, and yet the body and muscles have not withered away, death will still follow, even if no true visceral pulse has appeared—that is, a pulse that emerges when the Qi of the organs has lost the Stomach Qi that harmonizes it. This is the pulse seen when Qi and blood suddenly collapse.

The Newly Collated Corrected Edition says: If the pulse beats five or six times in the span of one breath, how can this be a death pulse? The word “breath” is probably an error; it should read “exhalation.” That would make sense.

When the true Liver pulse appears, it is tense both at the surface and deep within, hard like the edge of a blade and like a string under the fingers. The complexion is blue-white and dull, and the body hair falls out; death follows. When the true Heart pulse appears, it is hard and forceful, with distinct, beadlike bumps under the fingers, like touching grains of coix seed. The complexion is red-black and dull, and the body hair falls out; death follows. When the true Lung pulse appears, it is broad and hollow, like a feather brushing the skin. The complexion is white tinged with red and dull, and the body hair falls out; death follows. When the true Kidney pulse appears, its beat suddenly stops, with a “pak-pak” sensation like a finger tapping stone. The complexion is black-yellow and dull, and the body hair falls out; death follows. When the true Spleen pulse appears, it is faint and alternates between fast and slow. The complexion is yellow tinged with blue and dull, and the body hair falls out; death follows. The appearance of any true visceral pulse indicates a critical, incurable condition.

The Newly Collated Corrected Edition says: Yang Shangshan explains that these pulses are called “true” because no other Qi is mixed with and harmonizing them in the pulse. The Qi of the Five Organs must all be harmonized by Stomach Qi; none can appear alone. It is like a hard object that cannot be used on its own: used alone, it is easily broken, but when softened and harmonized, it becomes firm. The Qi of the Five Organs can sustain life only when harmonized by Stomach Qi. If a true visceral pulse appears by itself, death is inevitable.

To distinguish the true visceral pulses of the Five Organs, which signify death, from pulse Qi harmonized with Stomach Qi, which signifies life, examine the pulse at the cun position, the pulse-taking point at the wrist. For example, a pulse with a wiry quality is a Liver pulse. A slight wiriness is a harmonious pulse: this means the pulse contains two parts Stomach Qi and one part wiry Qi, beating together. If all three parts are wiry Qi, with no Stomach Qi, the true Liver pulse has appeared. The same applies to the other four organs.

The Yellow Emperor asked, “Why does the appearance of a true visceral pulse signify death?” Qibo replied, “The Five Organs all receive their Qi from the Stomach. The Stomach is the root of the Five Organs.”

The Stomach is where food and drink gather, so all the Five Organs receive nourishment from it.

The Qi of the organs and bowels cannot reach the Hand Taiyin channel—the Lung channel—on its own. It must rely on Stomach Qi to reach the Hand Taiyin channel.

In a healthy person, Qi is nourished by the Stomach. Stomach Qi is the fundamental Qi shared by all healthy people. Therefore, the Qi of the organs and bowels must rely on Stomach Qi to reach the Hand Taiyin channel.

Wang Bing, a Tang-dynasty physician, quoted this passage while explaining “The Treatise on the Pulse of the Healthy Person” (Pingren Qixiang Lun). In a commentary, he wrote: “The Jia Yi Jing records that people ordinarily rely on Stomach Qi to nourish the pulse Qi, and that Stomach Qi is the foundation. This differs slightly from what is said here. The account in the Jia Yi Jing is more appropriate.”

The Qi of the five zang organs each manifests its pulse at the season when that organ is in command, and then all must reach the pulse opening of the Hand Taiyin Lung channel. When pathogenic Qi is strong, the body’s upright Qi weakens. In severe illness, Stomach Qi can no longer accompany the Qi of the five zang organs to the Hand Taiyin; only the organs’ original pulse Qi appears in the pulse. This is called “true-organ Qi.” It shows that pathogenic forces have overwhelmed the Qi of the organs, so the illness is grave and may be fatal. This is what it means for the pulse to lack Stomach Qi. “The Treatise on the Pulse of the Healthy Person” also says: “When a person lacks Stomach Qi, this is called counterflow; counterflow leads to death.”

The Yellow Emperor said: “When diagnosing and treating illness, observe the patient’s build, breathing, the luster of the complexion, the strength of the pulse, and how long the illness has lasted. Then decide on the treatment; do not miss the right moment. Strive to intervene in time, before the illness takes hold.”

When a person’s build and breathing are in keeping with one another, the illness is easy to treat. For example, abundant Qi together with a strong build, or deficient Qi together with a frail build, are both considered in keeping. If the complexion is lustrous and bright, the illness is easy to recover from, because a moist, radiant complexion shows that Qi and Blood are harmonized and nourishing one another.

When the pulse accords with the changes of the four seasons, the illness is easy to treat: the spring pulse is wiry, the summer pulse hook-shaped, the autumn pulse floating, and the winter pulse deep (the original text reads “ying”). This is called following the seasons. A pulse that is gentle and smooth shows that Stomach Qi is still present, and the illness is easy to treat. Treating at the proper time improves the results; treatment should also take account of how Qi and Blood move in each season. The New Textual Correction notes that the Jia Yi Jing has “treat and direct it” where this passage has “take it up at the right time”; both readings make sense.

When a person’s build and breathing are not in keeping with one another, the illness is difficult to treat. For example, a strong build with deficient Qi, or abundant Qi with a frail build, are both considered out of keeping. If the complexion is dark and dull, without luster, the illness is difficult to recover from. “Yao” means a dark, unhealthy-looking complexion; “without luster” means dry and lacking moisture. A pulse that is forceful and hard shows that pathogenic Qi is flourishing, and the illness will worsen.

When the pulse is out of step with the four seasons, it is difficult to treat, because the movement of Qi has become disordered. The four statements above describe four conditions that are difficult to treat. That is why the text goes on to say, “These four difficult conditions must be examined and clearly explained to people.” They are conditions that practitioners with shallow medical skills can readily identify, but that even skilled practitioners find hard to manage.

A pulse that goes against the four seasons means that a Lung pulse appears in spring, a Kidney pulse in summer, a Heart pulse in autumn, or a Spleen pulse in winter, and that the pulse feels as though it hangs in space and breaks off, or is sunken, hidden, and sluggish. This is called “going against the four seasons.”

A Lung pulse in spring is the pulse expected in autumn; a Kidney pulse in summer is the pulse expected in winter; a Heart pulse in autumn is the pulse expected in summer; and a Spleen pulse in winter is the pulse expected in spring. “Hanging and severed” means that the pulse feels like something suspended that has broken apart and drifted away.

In spring and summer, the pulse should not be sunken, hidden, and sluggish; in autumn and winter, it should not be floating and forceful. All of this is called going against the four seasons. The phrase “not present” here means that the pulse should not normally take this form. The New Collation notes that the Treatise on the Pulse and Qi of the Ordinary Person says “a thin pulse,” which has the same meaning here.

When there is fever but the pulse is calm, diarrhea but the pulse is forceful, or blood loss but the pulse is firm; when illness is internal but the pulse is firm, or illness is external but the pulse is not firm—these conditions are all difficult to treat. They are difficult because the pulse does not correspond to the illness.

The New Collation notes that the Treatise on the Pulse and Qi of the Ordinary Person says, “When illness is internal, the pulse is deficient; when illness is external, the pulse is rough and firm,” which is the opposite of what is said here. In the collator’s view, the text here is in error, and the account in the Treatise on the Pulse and Qi of the Ordinary Person is correct. The passage beginning “There has not yet been a manifestation of the Zang in spring and summer” and continuing to this point repeats material from that treatise; the related commentary can be consulted there.

The Yellow Emperor said, “I have heard that life and death can be judged from deficiency and excess. I would like to hear the reasoning behind this.” Qi Bo replied, “Excess in the five Zang organs can lead to death, and deficiency in the five Zang organs can also lead to death.”

“Five excesses” means that pathogenic Qi is abundant in the five Zang organs; “five deficiencies” means that the true Qi of the five Zang organs is weak.

The Yellow Emperor said, “Please tell me what the five excesses and five deficiencies are.” Qi Bo replied, “A forceful pulse, hot skin, abdominal distension, difficulty passing urine and stool, and agitation and confusion in the chest—these are called the five excesses.”

“Excess” here means that pathogenic Qi is strong: a forceful pulse corresponds to the Heart, hot skin to the Lung, abdominal distension to the Spleen, difficulty passing urine and stool to the Kidney, and agitation and confusion in the chest to the Liver.

“A faint, weak pulse, cold skin, diminished strength, loose passage of urine and stool, and inability to swallow food—these are called the five deficiencies.”

“Deficiency” here means that true Qi is insufficient: a faint pulse corresponds to the Heart, cold skin to the Lung, diminished Qi to the Liver, loose passage of urine and stool to the Kidney, and inability to take in food to the Spleen.

The Yellow Emperor asked, “When these conditions occur, people sometimes survive. Why is that?” Qi Bo replied, “If thin rice water and gruel can enter the stomach, and excretion…”

Signs that the condition is improving are these: when diarrhea stops, a weak person regains vitality; after the body sweats and the bowels move freely, a person with an excess pattern can also improve.

The whole commentary means that being able to drink gruel and keep it in the stomach shows that the Stomach Qi is gradually coming into harmony. The diarrhea will slowly stop, the Stomach Qi will grow stronger, and a weak person will recover. “Those with excess” refers to people who are able to sweat, allowing pathogenic Qi to move outward. Once the bowels move freely, the body will naturally come into harmony over time.