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Chapter 18 of 78
黄帝内经·素问
Overall Paraphrase
This chapter discusses the pulse manifestations of healthy persons (平人) and the diagnostic principles of pulse-taking based on stomach qi as the root.
The Yellow Emperor asked: What is the pulse of a healthy person like? Qi Bo replied: With one exhalation, the pulse beats twice; with one inhalation, the pulse beats twice; during the "pause" (定息) between exhalation and inhalation, the pulse beats once more, so in one breath cycle there are about five beats. Occasionally there is a longer breath (太息), during which one additional beat occurs—this is still normal. This pulse rate is that of a 平人, a person without disease. When a physician examines a patient, he should use his own non-diseased breathing rhythm as the standard, calming his own breath to measure the patient's pulse rate.
If there is only one beat per exhalation and one per inhalation, it indicates 少气 (insufficiency of vital qi). If there are three beats per exhalation and three per inhalation with an agitated pulse, accompanied by warm skin on the forearm (尺肤), it is a warm-heat disease. If the forearm skin is not warm but the pulse is slippery, it is a wind disease. If the pulse is choppy, it indicates bi syndrome (painful obstruction). If there are more than four beats per exhalation, or the pulse is intermittent, or alternately fast and slow, the ancients considered these all critical and fatal signs.
The normal qi of a healthy person derives from stomach qi (the qi produced by the spleen and stomach transforming food and drink into essential nutrients, manifested on the pulse as calm and gentle). Stomach qi is the fundamental qi of a healthy person. If the pulse lacks stomach qi, this is a contrary sign, which the ancients believed could lead to death.
Next, the relationship between the four seasons, five viscera, pulses, and stomach qi: In spring, a pulse with stomach qi and slightly wiry (弦) is normal; more wiry and less stomach qi indicates liver disease; wiry only without stomach qi indicates death; if accompanied by the autumn "fine" (毛) pulse, it prognosticates illness in autumn; if the "fine" quality is pronounced, illness will occur in the current season. In summer, slightly hook-like (钩) is normal; more hook and less stomach qi indicates heart disease; hook only without stomach qi indicates death; if accompanied by the winter "stone" (石) pulse, illness is predicted for winter; if the stone quality is pronounced, illness occurs now. In long summer (late season), slightly weak and soft is normal; more weak and less stomach qi indicates spleen disease; weak only without stomach qi indicates death; weak-soft accompanied by winter stone predicts illness in winter; pronounced weakness indicates illness now. In autumn, slightly fine (毛) is normal; more fine and less stomach qi indicates lung disease; fine only without stomach qi indicates death; if accompanied by spring wiry pulse, spring illness is predicted; pronounced wiriness indicates illness now. In winter, slightly stony (石) is normal; more stony and less stomach qi indicates kidney disease; stony only without stomach qi indicates death; if accompanied by summer hook pulse, summer illness is predicted; pronounced hook indicates illness now.
The genuine qi of the five viscera is distributed to corresponding tissues: the liver stores the qi of sinews and fascia, the heart stores the qi of blood vessels, the spleen stores the qi of muscles, the lungs regulate nutritive and defensive qi, yin and yang, and the kidneys store the qi of bone marrow.
The major collateral of the stomach is called 虚里. It passes through the diaphragm, connects with the lungs, and emerges below the left breast. Its pulsation can be felt against the clothing—this is the manifestation of 宗气 (the great qi of the chest, formed by the combination of food essence and natural air). If the pulsation at 虚里 is excessive, rapid, and interrupted, there is disease within the chest and abdomen. If the pulsation is knotted and laterally forceful, it indicates accumulations (积聚) within the body. If the pulsation ceases, it is a fatal sign. If the pulsation below the left breast is so strong that it moves the clothing, it indicates external leakage of 宗气.
Examining 寸口 (the pulse-taking site at the radial artery of the wrist) can determine excess and deficiency: A short pulse indicates headache. A long pulse indicates pain in the lower leg and foot. A rapid, rising pulse indicates shoulder and back pain. A deep and firm pulse indicates disease in the interior. A floating and vigorous pulse indicates disease in the exterior. A deep and weak pulse indicates cold-heat disorders, hernia aggregations (疝瘕), and lower abdominal pain. A deep and transverse pulse indicates accumulated lumps with pain below the ribs or in the abdomen. A deep and rapid-noted (as if panting) pulse indicates cold-heat disorders.
A pulse that is vigorous, slippery, and firm indicates disease in the exterior. A pulse that is small, firm, and hard indicates disease in the interior. A pulse that is small, weak, and choppy indicates chronic disease. A pulse that is slippery, floating, and rapid indicates recent disease. A hurried (急着) pulse indicates hernia aggregations and lower abdominal pain. A slippery pulse indicates wind. A choppy pulse indicates bi syndrome (painful obstruction). A moderate (缓) and slippery pulse indicates heat in the middle. A vigorous and tight (紧) pulse indicates abdominal distension.
When pulse manifestations correspond to yin-yang attributes and the changes of the four seasons, disease is easy to resolve. When contrary, it is difficult.
Prominent green veins visible on the arms indicate blood loss (脱血). A moderate and choppy pulse at the chi section (尺部) indicates a body weary and without strength. When lying still yet the pulse is full and vigorous, it indicates blood loss. A choppy chi pulse with a slippery overall pulse indicates profuse sweating. Cold skin on the forearm with a fine pulse indicates diarrhea. Persistently warm forearm skin indicates heat in the middle.
The ancients also used the Heavenly Stems matched with the Five Phases for mutual restraint to prognosticate: liver disease worsening on geng-xin days, heart disease on ren-gui days, spleen disease on jia-yi days, lung disease on bing-ding days, and kidney disease on wu-ji days—these were considered genuine visceral pulses appearing, all deemed fatal. This mode of derivation carries the limitations of its time and should be viewed rationally.
Prominent pulsation at the Renying (carotid) pulse in the neck, accompanied by wheezing and coughing, indicates water illness (edema). Slight swelling of the eyelids, like the appearance of rising silkworms, indicates water illness. Dark yellow urine with a tendency to sleep indicates jaundice. Hunger soon after eating indicates stomach jaundice (胃疸). Facial edema indicates wind pathogen. Swelling of the lower leg and shin indicates water. Yellow discoloration of the eyes indicates jaundice.
In women, pronounced pulsation at the Hand Shaoyin heart meridian (near the Shenmen point) was considered by the ancients to be a sign of pregnancy.
Pulses have aspects of compliance with or violation of the four seasons. If the corresponding visceral pulses do not appear in their respective seasons—for example, in spring and summer the pulse should be floating and large but instead is deep and small; in autumn and winter the pulse should be deep and small but instead is floating and large—this is called violating the four seasons. Likewise, for wind-heat syndrome the pulse should be floating and rapid, but if quiet; for diarrhea with blood loss the pulse should be deficient, but if excess; for interior disease the pulse should be excess, but if deficient; for exterior disease the pulse should be floating and slippery, but if choppy and firm—these are all difficult to treat and are called contrary to the four seasons.
Human life is rooted in water and grain; when water and grain are cut off, death follows. A pulse without stomach qi likewise leads to death. What is meant by absence of stomach qi is seeing only the genuine visceral pulse without stomach qi. What is meant by the pulse not obtaining stomach qi is that the liver pulse loses its gentle wiriness, the kidney pulse loses its gentle stoniness, and so on.
The pulse manifestations of the three yang channels: When the Taiyang pulse arrives, it is great and long. When the Shaoyang pulse arrives, it is alternately fast and slow, short and long. When the Yangming pulse arrives, it is floating, large, and short.
The specific forms of the five viscera's normal, diseased, and fatal pulses: The normal heart pulse is like a string of beads, smooth and moist to the touch like jade. The diseased heart pulse is rapid and continuous with slight curvature in the middle. The fatal heart pulse is curved in the front and straight in the back, like holding a hooked staff. The normal lung pulse is light, floating, and gentle, like elm seeds drifting down. The diseased lung pulse neither rises nor falls, like touching the middle of a chicken feather—hard and astringent. The fatal lung pulse is like an object floating on water, like wind scattering scattered hair. The normal liver pulse is soft, light, and buoyant, like the tip of a long pole slightly quivering. The diseased liver pulse is substantial and slippery, like touching a whole long pole. The fatal liver pulse is tight and forceful, like a newly drawn bowstring. The normal spleen pulse is gentle, soft, and light, like a chicken stepping on the ground. The diseased spleen pulse is full, rapid, and hurried, like a chicken lifting its foot. The fatal spleen pulse is sharp and hard like a crow's beak or a bird's claw, or intermittent like a leaking roof, or scattered like flowing water. The normal kidney pulse is deep yet forceful like a hook, firm when pressed. The diseased kidney pulse is like being pulled by a kudzu vine, firmer when pressed. The fatal kidney pulse is like a rope being violently snatched, springing back against the finger like flicking a stone.
The core of this chapter is the pulse diagnosis system centered on stomach qi as the root. The ancients believed that the pulse of a healthy person must be calm, gentle, and regular in rhythm, a quality arising from stomach qi produced by the spleen and stomach transforming food and drink into essential nourishment. The normal pulse manifestations of the four seasons and five viscera are not isolated wiry, hook, fine, or stony presentations, but rather "slightly wiry" (微弦), "slightly hook" (微钩), "slightly fine" (微毛), and "slightly stony" (微石)—meaning the inherent qi of each viscus must be accompanied by stomach qi. If stomach qi decreases, it is a diseased pulse; if stomach qi completely disappears, leaving only the genuine qi of the viscus exposed, this is the genuine visceral pulse, which the ancients regarded as fatal. Furthermore, the diagnostic approaches of using one's own healthy breath as a standard, examining 虚里 for the state of 宗气, joint examination of 寸口 and forearm skin, and determining prognosis from pulse-season, pulse-yin-yang, compliance-contrariety interactions all reflect a holistic, dynamic, and norm-referenced way of thinking.
From a modern physiological perspective, the ancient "four to five beats per breath" roughly corresponds to a resting heart rate of around sixty to seventy beats per minute, indicating that early observers had already made basic observations of the rhythmic relationship between respiration and heartbeat. The calm and gentle quality of so-called stomach qi may comprehensively reflect digestive-nutritional status, circulatory function, autonomic nervous regulation, and other factors. Certain pulse patterns, such as "genuine visceral pulses," "alternating sparse and rapid beats," and "pulse stopping Without return," likely correspond to critical conditions such as severe arrhythmias and circulatory failure. The ancients' ability to recognize their danger based on experience holds clinical observational value. However, ancient pulse diagnosis relied heavily on subjective physician sensation and lacked quantitative standards. The Five-Phase/Heavenly Stem derivation of death dates, such as "liver disease dying on geng-xin days," belongs to mechanical analogy and cannot serve as a prognostic basis in modern medicine. Pregnancy determination by strong pulsation at the Hand Shaoyin meridian is also a historical anecdote; modern scientific testing should prevail.
The principal message for ordinary people from this chapter lies in daily care of the spleen and stomach and protecting stomach qi. Diet should be regular, avoiding extremes of hunger or fullness, minimizing cold, raw, and greasy foods, so that food essence is fully transformed. In daily routine, avoid chronic sleep deprivation and overexertion so as not to deplete the chest's 宗气. In emotions, maintain equanimity, avoiding prolonged irritability or suffocation, so that qi movement stays free and smooth. Breathing should be natural and even, without forced control, though moderate, soothing exercise is beneficial for harmonizing qi and blood. Seasonal living should follow nature's rhythm—extend upward and outward in spring and summer, and contract and store inward in autumn and winter. These are all general healthy lifestyle habits, not targeted at any specific disease.
Related Concepts: Stomach qi (胃气), genuine visceral pulse (真脏脉), 虚里, ancestral qi (宗气), cunkou (寸口), forearm skin (尺肤), four-season five-viscera pulses, pulse without stomach qi, pulse contrary to the four seasons, pulse of healthy persons.
Further Reading: Su Wen: Chapter 17 — Essential Subtleties of Pulse Taking, Su Wen: Chapter 19 — True Visceral Pulses and their Manifestations, Ling Shu: Rooted Knots, Nan Jing: Difficulty 15, Bin Hu Mai Xue (Lake of Pulse Study).
This content is based on classical Chinese medical texts and is provided for traditional cultural learning and study only. It does not constitute medical diagnosis, medication guidance, or treatment advice. Please consult a qualified medical professional if you feel unwell.