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Chapter 20 of 78
黄帝内经·素问
Overall Paraphrase
This chapter discusses a systematic whole-body pulse examination method from ancient times—the Three Regions and Nine Indications. The Yellow Emperor asked Qi Bo for guidance: the teachings of the Nine Needles are vast and profound, and he wished to obtain the most essential principles to pass down to descendants, cherished as if carved into bone and stored in liver and lungs. These principles should accord with the Way of Heaven, corresponding above to the stars and calendar, below to the four seasons and Five Phases, and to the alternation of winter yin and summer yang, nobility and humility—how does the human body correspond to all this?
Qi Bo replied that this is the "supreme number of Heaven and Earth," which begins with One and ends with Nine. One is Heaven, Two is Earth, Three is Humanity; three times three makes nine, corresponding to the Nine Fields (the nine provinces). Thus the human body is divided into the Upper, Middle, and Lower regions, each with its own Heaven, Earth, and Human indications, together forming nine indications. The ancients used these nine indications to determine life and death, recognize all diseases, regulate deficiency and excess, and expel pathogenic qi.
Specifically:
The so-called "nine viscera" refers to the five spirit viscera (heart, liver, spleen, lungs, kidneys) plus the four form viscera, together making nine viscera. If the qi of the five viscera declines, the complexion becomes withered and lusterless, which the ancients regarded as a critical sign.
During examination, one must first assess the patient's body build—fat or thin—to judge whether qi is deficient or excess: excess conditions are treated with draining methods, deficiency with tonifying methods. One must also first remove blood stasis from the vessels before regulating; regardless of the disease name, the goal is to restore balance of yin-yang, qi, and blood.
How does one determine life or death? The ancients listed many observation points: if the body is robust but the pulse is thin and breathing is insufficient, this is dangerous; if the body is emaciated but the pulse is large with chest fullness and copious qi, this is a death sign; if body and pulse correspond, the prognosis is favorable. If the pulse is irregular and chaotic in its five-phase variations, there is disease; if all three regions and nine indications are completely disordered, this is a death sign. If the upper, lower, left, and right pulses are confused and uneven like pounding grain, the disease is severe; if the upper, lower, left, and right pulses completely fail to respond to palpation, this is a death sign. If the middle pulse alone is relatively harmonious but does not coordinate with the other visceral qi, this is a death sign. If the eyes are sunken, this too is a death sign.
How does one know where the disease is located? One observes among the nine indications which one is uniquely small, uniquely large, uniquely rapid, uniquely slow, uniquely hot, uniquely cold, or uniquely sunken—the region corresponding to that indication is the site of disease. There is also an ankle-tapping diagnostic method: press with the left hand on the area five cun above the ankle, and tap the ankle with the right hand. If the vibration reaches beyond five cun and feels soft and yielding, there is no major illness; if the vibration is urgent and the sensation is turbid and chaotic, there is disease; if the sensation is slow and weak, there is disease; if the vibration fails to reach five cun and there is no response to tapping, this is a death sign. If the body is already extremely emaciated, with flesh lost and the body unable to move, this too is a death sign. If the middle pulse is alternately rapid and slow, this is a death sign; if the pulse has intermittent qualities combined with hook-like characteristics, the disease lies in the collateral vessels.
Among the nine indications, the upper and lower should be coordinated as one, without disconnection. If one indication lags, there is disease; if two indications lag, the disease is severe; if three indications lag, the disease is critical. What is meant by "lagging" is that the expected pulse does not appear synchronously. One must also observe the corresponding viscera to infer the prognosis. One must first understand the normal meridians before one can recognize abnormal pulses. If a true visceral pulse is seen (a failing pulse not nurtured by stomach qi), the ancients considered the prognosis extremely poor. When the qi of the Foot Taiyang meridian is exhausted, the feet cannot flex or extend, and at the end of life, dai yan (eyes turning upward and fixed) appears.
Regarding "winter yin and summer yang," Qi Bo said: if all nine indications are deep, thin, and suspended-almost-separated, this is yin in nature, governing winter, and the ancients believed death would occur mostly at midnight; if the pulses are surging, restless, rapid, and gasping, this is yang in nature, governing summer, with death mostly occurring at midday. Cold-heat diseases mostly result in death at dawn; heat-in-the-middle and heat diseases mostly at noon; wind diseases mostly at dusk; water diseases mostly at midnight. If the pulse is alternately slow and rapid, alternately delayed and swift, the ancients believed death would occur during the transition hours of chen, xu, chou, and wei. If the flesh has already been lost, even if the nine indications are still harmonized, the prognosis remains poor.
Even if the seven indications (uniquely large, uniquely small, uniquely rapid, uniquely slow, uniquely hot, uniquely cold, uniquely sunken) appear, if the nine indications as a whole still correspond, death is not necessarily certain. What is meant by "not dying" is that conditions such as wind diseases or chronic monthly illnesses may manifest like the seven indications but are not true declining signs. If genuine seven-indication disease is present and the pulse signs have also declined, the prognosis is extremely poor, and hiccups and belching will appear. One must inquire in detail about the onset of illness and the current condition, then palpate each pulse, observing the superficiality and depth of the meridians, and the upward-downward, favorable-unfavorable flow. If the pulse comes rapidly, there is not necessarily disease; if the pulse comes sluggishly, there is disease; if the pulse does not come and go, and cannot be felt upon pressure, this is a death sign; if the skin is dry and adheres tightly to the flesh and bones, this is also a death sign.
For treatable conditions, one should select methods according to the location: if the disease is in the meridian, treat the meridian; if in the minute collaterals, prick the collaterals to let blood; for blood diseases with body pain, treat the meridians and collaterals. For pathogenic qi in strange collaterals, use miao ci (pricking the left for disease on the right, and the right for disease on the left). For chronic illness with emaciation where the disease site does not shift, one may needle near the joints. For upper excess and lower deficiency, press and search for bound collaterals, prick to let blood, and thus free the meridians. Tongzi gao (upward-turned eyes) indicates insufficiency of Taiyang meridian qi; dai yan indicates exhaustion of Taiyang meridian qi. These are the key points for determining life and death and must not be ignored. Retain the needle at the fingers and five cun above the lateral malleolus (the original text at this point is suspected of textual corruption, provided here only as scholarly discussion).
The core of this chapter is the Three Regions and Nine Indications whole-body pulse diagnostic method, which embodies several layers of important medical theory:
The Correspondence of Heaven, Earth, and Humanity
The human body is divided into upper, middle, and lower regions, each further divided into Heaven, Earth, and Human indications, together forming nine. This division is not arbitrary but is framed by the "supreme number of Heaven and Earth, beginning with One and ending with Nine," viewing the human body as a microcosm corresponding to the nine fields of Heaven and nine provinces of Earth. This understanding is a typical manifestation of the Huangdi Neijing concept that "humanity corresponds with Heaven and Earth."
The Core of Diagnosis Lies in "Coordination" Rather Than Single Indicators
The text repeatedly emphasizes that the nine indications should be "unified above and below, without mutual loss." Judging the severity of illness depends not merely on one pulse location but on whether the whole is coordinated and synchronous. One lagging indication means illness; two lagging indications mean severe illness; three lagging indications mean critical illness. This diagnostic approach emphasizing holistic coordination remains insightful today.
Correspondence Between Form and Qi Is an Important Principle for Prognosis
"Robust body with thin pulse" and "emaciated body with large pulse" both represent disharmony between form and qi, indicating critical conditions; while "those in whom form and qi correspond will survive." This shows that the ancients already recognized that external physique and internal qi-blood function must match—once disconnected, it indicates severely impaired regulatory capacity.
Treatment Prioritizes "Openness" and "Balance"
The text proposes "drain excess conditions, tonify deficiency conditions," "first remove stasis from the vessels, then regulate," and "regardless of the disease name, the goal is balance." Treatment does not fixate on disease names but first removes blood stasis to restore qi-blood circulation, ultimately achieving a state of "balance." This is an early expression of the TCM principle of "taking balance as the goal."
"True Visceral Pulse" and the Concept of Stomach Qi
The text mentions that "when the true visceral pulse appears, death prevails," reflecting the TCM emphasis on stomach qi. Normal pulses should possess stomach qi (calm, harmonious, and gentle). When the pulse loses stomach qi and reveals the "true visceral" appearance of the viscera, it indicates severely declining vitality.
From a modern standpoint, this chapter holds significant value in medical history but also clear historical limitations.
Three Regions and Nine Indications is an early whole-body pulse diagnostic method. Later clinical TCM gradually simplified to cunkou pulse diagnosis, but this chapter shows that early practitioners systematically palpated multiple arteries on the head, face, hands, and feet, comparing pulsation differences. This whole-body multi-site examination approach has some conceptual resonance with modern medicine's observation of circulatory status in different regions, though the technical means are entirely different.
Pulse characteristics are indeed related to circulation, neurology, and metabolism. For example, "uniquely rapid," "uniquely slow," "deep and thin," "surfacing and restless" may reflect changes in heart rate, vascular tone, blood volume, and sympathetic excitability. However, mapping pulse findings one-to-one to specific viscera and judging life and death accordingly is more ancient empirical observation and theoretical extrapolation, not equivalent to modern anatomy and physiology.
Time-based death predictions such as "death at midnight" or "death at midday" should not be interpreted mechanically. These belong to ancient yin-yang spatiotemporal medical concepts, using day-night yin-yang waxing and waning to explain patterns of worsening or death. While modern medicine also pays attention to circadian rhythms and disease, these specific ancient assertions lack systematic evidence and should not serve as predictive tools.
The ankle-tapping method resembles a simple circulatory/tissue elasticity test. The speed and strength of vibration conduction may relate to local blood circulation, tissue elasticity, and neurological responses, but the ancients' definitive death judgments based on these are clearly over-absolute empirical summaries.
Prognostic judgments including "true visceral pulse" and "dai yan" must be treated cautiously. The ancients lacked modern diagnostic tools and could only rely on external appearances such as complexion, pulse palpation, and eye observation to infer conditions. These experiences deserve respect but cannot replace modern diagnostics. Today, if similar manifestations appear, one should seek medical attention promptly and not self-diagnose solely based on ancient texts.
As general, non-therapeutic wellness insights, this chapter may be understood as follows:
Pay attention to "form-qi correspondence": Body weight, physical strength, mental state, and breathing should roughly match. If there is obvious emaciation with labored breathing, or obesity with significant shortness of breath after activity, do not endure it silently—take the initiative to have a health checkup and seek professional assessment.
Align with the four seasons and yin-yang rhythms: Try to keep a schedule coordinated with natural day-night rhythms. In winter, sleep earlier and rise later, keeping warm; in summer, avoid extreme fatigue and excessive sun exposure. Long-term reversal of day and night and excessive consumption can impair the body's regulatory capacity.
Avoid lifestyle patterns that create "blood stasis": Prolonged sitting, chronic cold exposure, and emotional suppression may all affect the movement of qi and blood. Moderate activity, keeping warm, and maintaining emotional well-being contribute to smooth circulation.
Do not self-diagnose by pulse: TCM pulse diagnosis requires systematic training. The general public need not consult ancient texts to self-assess "uniquely large," "uniquely small," or "true visceral pulse." If feeling unwell, visit a proper medical institution.
Associated Concepts
Further Reading
This content is based on classical Chinese medicine texts and is provided solely for traditional culture study and research. It does not constitute any medical diagnosis, medication, or treatment advice. If unwell, please seek timely medical attention.