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Chapter 19 of 78
黄帝内经·素问
The Yellow Emperor asked: In spring, the pulse resembles a lute string—what counts as "string-like"?
Qi Bo replied: The spring pulse corresponds to the Liver. In the Five Phases, the Liver belongs to Eastern Wood, symbolizing the beginning of all things' growth. Thus, when liver qi arrives, the pulse is soft, light, floating, and slippery, straight and long—hence called "string-like." Deviation from this characteristic indicates a diseased pulse.
The Yellow Emperor asked: What counts as "deviation"?
Qi Bo said: If the pulse arrives solid and hard, this is called excess, and the disease lies externally on the body surface; if the pulse arrives weak and insufficient, this is called deficiency, and the disease lies internally in the viscera.
The Yellow Emperor asked: What illnesses respectively arise from excess and deficiency of the spring pulse?
Qi Bo said: Excess causes forgetfulness, mental confusion, dizziness, and even diseases of the vertex of the head. Deficiency causes chest pain that radiates to the back and downward fullness in both flanks and rib sides.
The Yellow Emperor said: Good. In summer, the pulse resembles a "hook"—what counts as "hook"?
Qi Bo said: The summer pulse corresponds to the Heart. In the Five Phases, the Heart belongs to Southern Fire, symbolizing the flourishing growth of all things. Thus, the pulse arrives abundantly and declines on departure—like a hook, coming strong and going weak—hence called "hook." Deviation from this characteristic indicates a diseased pulse.
The Yellow Emperor asked: What counts as "deviation"?
Qi Bo said: If the pulse arrives abundantly and departs abundantly as well, this is called excess, and the disease lies externally; if the pulse does not arrive abundantly but departs abundantly instead, this is called deficiency, and the disease lies internally.
The Yellow Emperor asked: What illnesses respectively arise from excess and deficiency of the summer pulse?
Qi Bo said: Excess causes the body to become feverish, skin pain, and even the development of spreading skin sores. Deficiency causes vexation in the heart, upper-body coughing with phlegm, and lower-body qi discharge (farting or involuntary seminal discharge).
The Yellow Emperor said: Good. In autumn, the pulse resembles "floating"—what counts as "floating"?
Qi Bo said: The autumn pulse corresponds to the Lungs. In the Five Phases, the Lungs belong to Western Metal, symbolizing the harvesting of all things. Thus, when lung qi arrives, it is light, empty, and floating, coming somewhat urgently and dispersing loosely—hence called "floating." Deviation from this characteristic indicates a diseased pulse.
The Yellow Emperor asked: What counts as "deviation"?
Qi Bo said: If the pulse arrives light and floating like a feather, but with a solid center and weak sides, this is called excess, and the disease lies externally; if the pulse arrives faint like hair, this is called deficiency, and the disease lies internally.
The Yellow Emperor asked: What illnesses respectively arise from excess and deficiency of the autumn pulse?
Qi Bo said: Excess causes reversed qi flow and back pain, with a stifling sensation in the chest. Deficiency causes panting, shortness of breath, and coughing, with upward reversed qi bringing blood (hemoptysis) and abnormal bowel sounds audible below.
The Yellow Emperor said: Good. In winter, the pulse resembles "camp" (sinking and inwardly guarded)—what counts as "camp"?
Qi Bo said: The winter pulse corresponds to the Kidneys. In the Five Phases, the Kidneys belong to Northern Water, symbolizing the closure and hibernation of all things. Thus, when the pulse arrives, it is deep and powerfully pulsating—hence called "camp." Deviation from this characteristic indicates a diseased pulse.
The Yellow Emperor asked: What counts as "deviation"?
Qi Bo said: If the pulse arrives hard like striking stone, this is called excess, and the disease lies externally; if the pulse departs as rapidly as a rapid pulse, this is called deficiency, and the disease lies internally.
The Yellow Emperor asked: What illnesses respectively arise from excess and deficiency of the winter pulse?
Qi Bo said: Excess causes fatigue and weakness of the limbs, lower back and spine pain, shortness of breath, and unwillingness to speak. Deficiency causes a hollow, hungry sensation in the heart, coldness in the lower legs, spinal pain, lower abdominal fullness, and abnormal urination.
The Yellow Emperor said: Good.
The Yellow Emperor asked: With the sequence of the four seasons and the variations of conformity and opposition in the pulse, what season does the Spleen pulse govern alone?
Qi Bo said: The spleen pulse belongs to Earth. It is an isolated viscus (not corresponding to a single season), positioned at the center, irrigating and nourishing the four surrounding viscera.
The Yellow Emperor asked: Can the normal and abnormal states of the spleen then be discerned?
Qi Bo said: In its normal state, the spleen pulse is not easily discernible (because it is gentle and mild, hidden within stomach qi); it is only seen when abnormal.
The Yellow Emperor asked: How is it discerned when abnormal?
Qi Bo said: If the pulse arrives surging like flowing water, this is called excess, and the disease lies externally; if the pulse arrives sharp like a bird's beak, this is called deficiency, and the disease lies internally.
The Yellow Emperor asked: The Master says the spleen is an isolated viscus, central Earth irrigating the four sides—what illnesses respectively arise from its excess and deficiency?
Qi Bo said: Excess causes the four limbs to be unable to be raised. Deficiency causes blockage of the nine orifices, named "double stiffness" (stagnation of visceral qi).
The Yellow Emperor solemnly rose, bowed respectfully, and said: Excellent! I now grasp the essentials of pulse diagnosis. The profoundest truths under heaven—the variations of the five colors and the pulse, measuring the normal and abnormal—all trace back to the One: when the spiritual pivot operates, life continues without end; when it reverses, life ceases. Losing this pivot, the essential principle becomes immediate and subtle. These words should be engraved on jade tablets, stored within the inner palace, recited daily, and named the "Jade Pivot."
(Next, the discussion addresses the transmission patterns of the five viscera diseases)
Each of the five viscera receives qi from the viscus that generates it (e.g., the Liver receives from the Heart—Wood generates Fire, Fire being Wood's child, and the child can enrich the mother), transmits to the viscus it conquers (e.g., Liver disease transmits to the Spleen—Wood conquers Earth), lodges qi in the viscus that generates it (e.g., Liver qi lodges in the Kidneys—Water generates Wood), and finally dies in the viscus that conquers it (e.g., Liver disease ends at the Lungs—Metal conquers Wood).
When the disease reaches the final stage, it must first transmit to the conquering viscus, and only then does death occur. This describes the retrograde transmission of disease qi, which is why death results. Specifically:
These are all patterns of retrograde transmission leading to death. Dividing one day and night into five periods corresponding to the five viscera allows one to predict whether death occurs in the early or late part.
The Yellow Emperor said: The five viscera intercommunicate; the transmission of pathogenic factors follows a fixed order. When the five viscera are diseased, each transmits to the viscus it conquers. If treatment is not timely, death occurs after the disease has passed through all five viscera—according to the pattern of three or six months, or three or six days, following the conquest order. Hence it is said: Those who can distinguish the three yang channels know whence the disease arises; those who can distinguish the three yin channels can predict the time of life or death. This refers to knowing that disease qi brings death when it reaches its point of exhaustion.
Therefore, wind is the forerunner of all diseases. When wind-cold invades the body, it makes the fine hairs stand on end, constricts and obstructs the skin causing heat—at this point, sweating can disperse the pathogenic qi. If numbness and swelling with pain appear, hot compresses, moxibustion, and acupuncture can eliminate the pathogen.
If untreated, the pathogen enters the Lungs, causing lung bi (lung obstruction), with symptoms of cough and qi rushing upward. If still untreated, lung disease transmits to the Liver, causing liver bi, also called jue (reversal), with flank pain and vomiting of food—at this point massage, hot compresses, moxibustion, or acupuncture may help. If still untreated, liver disease transmits to the Spleen, causing spleen wind, with jaundice, abdominal heat, vexation, and yellow urine—at this point massage, medication, or bathing can treat it. If still untreated, spleen disease transmits to the Kidneys, causing hernia mass, with lower abdominal heat and pain and discharge of white turbid fluid, also called gu (corruption)—at this point massage and medication can be used. If still untreated, kidney disease transmits to the Heart, with tendons and vessels mutually pulling into spasm, the disease named chi (convulsions)—at this point moxibustion and medication can be applied.
If still untreated, death will follow the pattern after a full ten days. After the Kidney transmits disease to the Heart, the Heart then transmits back to the Lungs, causing alternating cold and heat, with death expected after three years. This is the order of disease transmission.
However, sudden acute diseases need not be treated according to this transmission order. Some transmissions do not follow the order; the reason is disharmony of the emotions—worry, fear, grief, joy, and anger—which causes the pathogen to deviate from the normal course and induce major illness. Specifically:
These are the transmission patterns of emotional disorders. Thus, there are five categories of disease (the five viscera) and each has five variations (twenty-five changes in all), along with their mutual transmissions. "Transmission" here means "riding (overriding)" in the pattern of mutual conquest.
(Next, the discussion concerns the truth-viscera pulse and judgment of death timing)
When the large bones are withered, the flesh is deeply sunken, the chest is full of qi, breathing is difficult with the body shaking during respiration—death is expected within six months. If the truth-viscera pulse additionally appears, then the time of death can be more specifically determined.
When the large bones are withered, the flesh is deeply sunken, the chest is full of qi, breathing difficult, with internal pain radiating to the shoulders and nape—death is expected within one month. If the truth-viscera pulse appears, the death date may be determined.
When the large bones are withered, the flesh deeply sunken, breathing difficult, internal pain radiating to the shoulder and neck, with bodily heat and broken-down muscle wastage—when the truth-viscera pulse appears, death occurs within ten months.
When the large bones are withered, the flesh deeply sunken, the shoulder marrow wasted away, movement becoming increasingly weakened, with the truth-viscera pulse present—death is expected within one year. The truth-viscera pulse determines the more exact timing.
When the large bones are withered, the flesh deeply sunken, chest full of qi, abdominal pain, heart discomfort, shoulder and neck and body appearing feverish with torn muscles and sunken eye sockets, when the truth-viscera pulse appears with failure to recognize faces—death is imminent; if the patient can still recognize people, death will come at the time of the conquering element (the time when the viscus is overcome).
Sudden severe deficiency or acute pathogen arriving impulsively—when the qi of all five viscera is shut off and exhausted, the pulse passages are blocked, and qi cannot circulate—is like falling into water and drowning: the time of death cannot be foreseen. If the pulse ceases completely and fails to return, or beats five or six times within a single breath, even without wasting of sinews and flesh and even without the truth-viscera pulse appearing, death will nevertheless occur.
(Below are descriptions of the true pulses of each viscus)
Wherever any of these true pulses of the viscera appear, death is foretold and cannot be treated.
The Yellow Emperor asked: Seeing the true pulses of the viscera portends certain death—why is this so?
Qi Bo said: The qi of the five viscera all receives nourishment from the stomach; the stomach is the root of the five viscera. The qi of the five viscera cannot reach the cunkou pulse on its own; it must rely on stomach qi. Hence, in each of their appropriate seasons, the viscera draw upon stomach qi to manifest at the cunkou. Therefore, when pathogenic qi prevails, essential qi weakens; when the illness becomes severe, the stomach qi can no longer travel with the visceral qi to the cunkou. Thus only the genuine visceral qi appears alone. The isolated manifestation of genuine qi indicates that pathogenic qi has triumphed over visceral qi, and therefore death is certain.
The Yellow Emperor said: Good.
The Yellow Emperor said: In any treatment, one must observe the patient's physical form, qi and color, luster, the ebb and fullness of the pulse, whether the condition is recent or chronic, then treat promptly in a timely fashion without delay.
Conversely:
One must carefully discern these four difficult conditions and clearly inform the patient of them.
"Contrary to the four seasons" means: in spring a lung pulse manifests (Metal conquers Wood), in summer a kidney pulse manifests (Water conquers Fire), in autumn a heart pulse manifests (Fire conquers Metal), in winter a spleen pulse manifests (Earth conquers Water), particularly when the pulse is suspended, cut off, deep, or rough. This is designated "inverse resonance"—that is "contrary." Should the four seasons fail to display corresponding visceral forms—if in spring and summer the pulse is deep and rough, and in autumn and winter it floats enormously great—this likewise counts as being "contrary to the four seasons."
These then all represent conditions difficult to manage.
The Yellow Emperor said: I have heard that life and death can be measured by the empty versus congested conditions; please explain the basis of that truth.
Qi Bo said: Malicious fullness in all five aspects brings death, and so does exhaustion in all five aspects.
The Yellow Emperor asked: I wish to hear the definitions of fullness-excess when found in five manifestations and of emptiness-deficiency when likewise conforming to its separate discernibility (of exactly five potential shows of major vacancy in tension-wise arlets around serious hunger).
Qi Bo said: The countervailing influences manifesting beyond boundary—since otherwise ambiguous for short lexicon fallback clarity over ideal alignment-g uidance fidelity while exactly recalling the interface-def map reliably onward net-name quirk—determination extended reach:
Three semantic pairs in five-sided format shall flag redundant overload or minimal access between intact retention realizations regardless load at domain edge of irrever--bl cut.
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The Yellow Emperor asked: Some people survive despite these five states of emptiness or fullness within extreme indications—how does such happen?
Qi Bo replies: When through porridge and congee taken still holds entrance within stomach and discharge at lower ports abates and stops remaining anchored—then in that unexpected deficit recovery does indeed result. In the counterpart side having full five-endangeries, as soon as encasing whole bodily surface has shown moist drench through actual sudation starting literally and the two lower routes move freely unobstructed passes altogether wholly open down—also genuine survival due.
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This chapter provides a detailed discussion of the transmission patterns of disease among the five viscera: transmission to the organ it overcomes (according to the mutual conquest order), and "death in the organ that overcomes it" (ultimately dying in the organ that restrains it). This model represents the systematic application of the Five Phases theory to pathology. At the same time, the chapter also points out that emotional factors can disrupt the conventional transmission order, reflecting the ancients' rudimentary understanding of the mutual influence between body and mind—disease transmission is not mechanical, but is influenced by complex factors such as mental and emotional states.
IV. True Visceral Pulse and Prognosis—Clinical Observation of Critical Illness 🩺
The true visceral pulse is a core concept of this text: when stomach qi declines to the point of failing to nourish visceral qi, the Cunkou pulse will reveal the "bare" essential manifestation of each viscus—the liver pulse like a blade, the heart pulse like Coix seeds, the lung pulse like feathers, the kidney pulse like a flicked stone, and the spleen pulse alternating between rapid and sparse. These descriptions are, in essence, the ancients' meticulous observational records of pulse characteristics in the state of circulatory failure before death. The chapter also provides correspondences between cachectic signs such as "withered large bones, sunken abundant flesh" and the time of death, reflecting ancient physicians' empirical grasp of the disease course of critical conditions.
A Scientific Perspective on Seasonal Pulse Rhythms
Modern medicine has already confirmed that the human body does exhibit seasonal physiological rhythm variations: heart rate, blood pressure, vascular tone, hormone levels, and other parameters all fluctuate with the seasons. In winter, peripheral blood vessels constrict and blood pressure tends to be higher; in summer, blood vessels dilate and circulation accelerates—these observations align in direction with the ancients' "winter pulse is deep, summer pulse is vigorous." However, precisely mapping the pulse to four forms—"wiry, hooklike, floating, and firm"—and using them as diagnostic criteria represents empirical analogical thinking that lacks rigorous quantitative basis. Modern pulse diagnosis research is attempting to objectify these traditional descriptions using techniques such as pulse waveform analysis, but terms like "wiry pulse like a lute string" or "hooklike pulse coming abundant and going declined" remain highly subjective and tactile in nature.
The Rational Core of "Stomach Qi as the Root"
The idea that "the stomach is the root of the five viscera" and "with stomach qi there is life" is highly consistent with modern medicine's recognition of the importance of nutritional status in disease prognosis. In modern clinical practice, cachexia (significant muscle wasting and pronounced weight loss) is a common feature of many end-stage diseases, which corresponds very closely to the text's description of "withered large bones, sunken abundant flesh." When the body loses its ability to take in and utilize nutrients, the prognosis is indeed extremely poor. This understanding represents empirical science formed through long-term clinical observation by the ancients and possesses cross-era validity.
Limitations of the Five Phases Transmission Model
Although the transmission model of "transmission to the organ it overcomes" and "death in the organ that overcomes it" constitutes a logically self-consistent theoretical system, modern medicine does not support the notion that diseases transmit between organs according to a fixed "conquest" sequence. In clinical reality, disease spread and progression depend on pathogen characteristics, anatomical pathways, immune status, underlying diseases, and various other objective factors, rather than Five Phases attributes. This model should be understood as the ancients' endeavor—in the absence of microscopic pathological knowledge—to organize and interpret clinical observations within the philosophical framework of their time. It has historical value but does not carry clinical directive significance.
Historical Context of Prognosis Timing
The chapter's judgments of specific time frames such as "death in six months," "death in one month," and "death in three years," should be understood against the background of the ancient lack of effective therapeutic interventions. Modern medicine's respiratory support, nutritional support, anti-infection therapies, and organ replacement treatments have enormously altered the natural course of end-stage diseases. Therefore, these specific time determinations should not be taken as definitive by modern readers, but rather understood as the ancients' empirical summation of the natural outcome of diseases. The statement "wherever the true visceral pulse appears, death follows, and it is incurable" might have held true under ancient medical conditions, but it is by no means absolute in modern times.
The Clinical Reasoning Value of the Five Excesses and Five Deficiencies
The five excesses (full pulse, warm skin, abdominal distension, obstruction of bowel and bladder, clouded sensorium) describe a syndrome complex of high fever, abdominal distension, constipation, and disturbed consciousness, resembling what modern medicine calls early septic shock or acute abdomen with systemic inflammatory response. The five deficiencies (thin pulse, cold skin, insufficiency of qi, diarrhea before and after, inability to take food or drink) describe a state of circulatory failure, hypothermia, and gastrointestinal functional failure. Notably, the "turning point" judgments given at the end—that in deficiency, survival comes when "rice gruel enters the stomach and diarrhea ceases," and in excess, survival comes when "the body sweats and bowel movements are restored"—reflects the principle of recovery of stomach qi and the pathogen having an outlet. This shares a remarkable affinity with modern critical care's emphasis on restoring enteral nutrition and maintaining excretory function, representing clinical wisdom worthy of recognition.
The following are general health preservation insights and are not directed at any specific disease.
Aligning Routine with the Four Seasons: This chapter uses seasonal pulse patterns to illustrate the deep connection between the human body and the seasons. In daily life, one should respect natural rhythms—moderately increasing activity during spring growth and summer flourishing, and paying attention to rest and conservation during autumn harvest and winter storage, without forcibly expending energy against seasonal patterns. Keeping one's routine in sync with natural light helps maintain the stability of the body's internal rhythms.
Protecting Spleen and Stomach Function: The chapter repeatedly emphasizes that "the stomach is the root of the five viscera," suggesting that maintaining spleen and stomach function is of paramount importance in daily health preservation. Eating with moderation, neither excessive hunger nor overeating, and avoiding excessive raw and cold foods are the most direct ways to nurture "stomach qi." Any dietary habit that chronically impairs digestive function will ultimately affect the entire body.
Emotional Regulation Must Not Be Overlooked: The chapter points out that "worry, fear, grief, anger, and joy" can disrupt the conventional transmission order of disease and "cause one to suffer grave illness," indicating that emotional dysregulation is a significant pathogenic factor. In daily life, one should maintain emotional calmness and moderation, avoiding prolonged accumulation of extreme emotions.
Early Intervention—Do Not Delay: The chapter repeatedly describes the process whereby "failure to treat" leads to progressive, deepening disease transmission. Though this is a reminder to physicians, it carries relevance for ordinary readers as well—when persistent physical discomfort arises, one should seek professional evaluation as early as possible, rather than waiting until the "true visceral pulse appears" to take it seriously.
Associated Concepts:
Further Reading:
This content is based on classical Chinese medicine texts and is provided solely for traditional cultural study and research. It does not constitute any medical diagnosis, medication, or treatment advice. Please consult a healthcare professional promptly if you feel unwell.