《黄帝八十一难经纂图句解》Vol. 3

These two characters do not appear in the Original Meaning. “Er” may be a scribal error for “yi.” The Ling Shu, “Pulse Measures,” reads “always look inward through the seven apertures above.” “Liver” may be intended to read “spleen.” The character “ge” is written as “ge” in the Collected Commentaries.

Below “guan ge,” both the Original Meaning and the Collected Commentaries add eleven characters: “Those with obstructed gates and barriers cannot fulfill the span of their lives and die.” In the Collected Commentaries, “ge” is written as “ge.” “Yi” is written as “ru” in both the Original Meaning and the Collected Commentaries. “Zheng” is written as “zhi” in the Original Meaning.

In context, “yuan” seems as though it should read “huan,” and “xing” may be intended to read “cun.” “Four dou” may be an error: in Yu’s commentary on Difficulty Forty-Two in the Collected Commentaries, “dou” is written as “ban,” and “four” as “eight.” Below “zhi,” both the Original Meaning and the Collected Commentaries add the character “yi.” In Yang’s commentary on Difficulty Forty-Two in the Collected Commentaries, “shou” is written as “hua.”

“Three jin” does not match the main text and may be intended to read “two jin.” The original wording, “in the short lobe of the liver,” reads “left liver’s short cluster”; this has been emended on the basis of the Original Meaning and the Collected Commentaries. “Yi” is written as “er” in both the Original Meaning and the Collected Commentaries. The original “zong” reads “cong”; this has been emended on the basis of the Original Meaning and the Collected Commentaries. “Ten liang” is written as “twelve liang” in the Original Meaning. In Yang’s commentary on Difficulty Forty-Three in the Collected Commentaries, “se” is written as “xie.”

The other occurrence of “ten liang” is written as “twelve liang” in both the Original Meaning and the Collected Commentaries. The original “wei” reads “stomach”; this has been emended on the basis of Yang’s commentary on Difficulty Forty-Two in the Collected Commentaries. “Ji” is written as “ban” in that commentary. “Twelve liang” is written as “ten liang” in the Original Meaning. In context, “zu” seems as though it should read “ri.” In Yang’s commentary on Difficulty Forty-Four in the Collected Commentaries, “stomach” is written as “yi.” The original “shang” reads “earth”; this has been emended according to the meaning. “Yang qian” is written as “Yangfu” in both Ding’s and Yu’s commentaries on Difficulty Forty-Five in the Collected Commentaries. In context, “yu” may be intended to read “rong.”

Why is the human head and face especially able to withstand cold?

Answer: The head is where all the Yang channels converge. The Yin channels turn back once they reach the neck or chest; only the Yang channels all extend upward to the head. The head and face therefore have more abundant Yang Qi, enabling the face to withstand cold.

The Yin channels follow their own courses. The Hand Shaoyin channel passes beside the heart and through the throat, then ascends to the lung and emerges below the armpit, descending along the rear edge of the inner upper arm. The Foot Shaoyin channel ascends from the kidney, passes through the liver and diaphragm, enters the lung, follows the throat, connects with the heart, and flows into the chest. The Hand Taiyin channel emerges from the lung system below the armpit and descends along the inner upper arm. The Foot Taiyin channel ascends from the stomach, passes through the diaphragm, and flows into the heart. The Hand Jueyin channel follows the chest, emerges at the side of the ribs, descends from a point three inches below the armpit, and runs along the inner upper arm. The Foot Jueyin channel ascends through the diaphragm, spreads across the rib area, and runs behind the throat. None of the Yin channels reaches the head; only the Yang channels extend up to it. This is why the head and face can withstand cold.

Chapter Seven: Deficiency, Excess, Pathogenic Factors, and Upright Qi

The Forty-Eighth Difficulty asks: What are the “three deficiencies” and “three excesses” spoken of in the human body?

Answer: There are deficiencies and excesses in the pulse, and there are deficiencies and excesses in the patterns of illness.

In diagnosis, one must distinguish deficiency from excess.

From the pulse, a soft, weak pulse indicates deficiency, while a tight, firm pulse indicates excess. A soft pulse belongs to Yin and is therefore classified as deficiency; a tight, firm pulse belongs to Yang and is therefore classified as excess.

There are three ways to distinguish them from the signs of illness.

When pathogenic influences move outward, this indicates deficiency; when they move inward, it indicates excess. Yin and Yang govern the body’s interior and exterior. When Yang Qi is insufficient, Yin Qi takes advantage of the deficiency and moves outward, so this is classified as deficiency. When Yin Qi is insufficient, Yang Qi takes advantage of the deficiency and moves inward; at the exterior, this appears as an excess of Yang, so it is classified as excess.

Speaking indicates deficiency, while silence indicates excess. The Lungs govern the voice, and sound enters the Heart and becomes speech; therefore, speaking is classified as deficiency. The Liver governs deliberation, and when deliberation enters the Heart, it manifests as silence; therefore, silence is classified as excess.

A relaxed, slack body indicates deficiency; urgency and tension indicate excess. Yang governs emptiness and urgency: when the skin is full and tense, this indicates excess. Yin governs stillness and slackness: when the skin is loose and relaxed, this indicates deficiency.

There are four further signs used to diagnose deficiency and excess.

Soft, slack skin indicates deficiency; firm, rigid skin indicates excess. Itching of the body indicates deficiency, while a painful area indicates excess.

The sensations on palpation also provide clues. Pain under light pressure indicates exterior excess, with the illness located nearer the surface. A feeling of comfort under deeper pressure indicates interior deficiency, with the illness located deeper within.

When pressure on the inside causes pain, but pressure on the outside feels relieving, this is a pattern of internal excess and external deficiency.

If firm pressure causes pain inside, this indicates internal excess and a deeper location of the illness. If light pressure instead feels relieving, this indicates external deficiency and a shallower location. This is how deficiency and excess are expressed. The foregoing is a general account of deficiency and excess.

The Forty-Ninth Difficulty says:

Sometimes the primary channels, which carry Qi and blood through the body, fall ill on their own.

When the primary channels are weak, the interstices—the skin’s texture and pores—open. Once they open, pathogenic influences arise spontaneously from within the body; they have not entered from outside.

In other cases, the primary channels are attacked by pathogenic influences.

Because the Five Phases restrain one another, pathogenic influences can invade from outside and harm a person.

How can these two situations be distinguished?

The text says: Sorrow and excessive rumination injure the heart.

The heart governs Shen (spirit) and is the sovereign of the five zang organs. A person’s intelligence and abilities all arise from the heart. Excessive sorrow and overwork damage the heart and weaken the spirit.

Exposure to cold and drinking cold beverages injure the lungs.

The lungs govern the skin and body hair, so exposure to cold means that the skin and body hair are chilled. The lungs also govern the intake of fluids and do not tolerate things that are too cold; they are averse to cold, which is why such things are said to injure them.

Anger makes Liver Qi flow counter to its proper course, surging upward and failing to descend; this injures the liver.

The liver governs planning, while the gallbladder governs decision-making. Anger is an emotion, and excessive anger can also harm the body.

Irregular eating and drinking, and excessive exertion, injure the spleen.

Eating too much damages the stomach and intestines. When a person eats until overly full, the stomach Qi becomes congested and the spleen’s connecting vessels often grow tense. Running or jumping at that point, or excessive sexual activity, may also injure the spleen.

Sitting for a long time in a damp place, exerting oneself by force, or wading through water injures the kidneys.

The lower back is the kidneys’ outer residence. Sitting for a long time prevents Kidney Qi from moving freely and can therefore damage the kidneys. The kidney point on the sole of the foot is called Yongquan (“Bubbling Spring”); living or sitting for a long time in a damp place can also injure the kidneys. “Exerting oneself by force” refers to actions such as lifting heavy objects or drawing a bow. “Entering water” refers to falling while wading, causing labored, rapid breathing and thereby damaging the kidneys. For women, forcing sexual intercourse before menstrual bleeding has ended is also considered a way of injuring the kidneys.

The main channels can be damaged at the Yongquan point on the day one is born. Living for a long time in a damp place can also damage the main channels. Excessive exertion includes lifting heavy objects and drawing a powerful bow. Wading through water refers to falling while crossing a river, becoming frightened and gasping for breath, thereby damaging Kidney Qi. Another case is when a woman has intercourse by force before her menstruation has ended.

These are all illnesses arising within the main channels themselves.

The five conditions above are all illnesses arising within the main channels themselves. Together, they are called “internal pathogens.”

What are the five pathogens?

This asks about cases in which the five Zang organs are attacked by external pathogens.

One is wind strike.

“Strike” means to be affected or afflicted. The Liver corresponds to wind. When wind pathogen spreads into the five Zang organs, it manifests in the color associated with each organ. If one is affected by wind pathogen in spring and the pathogen remains lodged without dispersing, severe diarrhea may occur.

Another is summer-heat injury.

Summer-heat pathogen readily enters the Heart. When it enters the five Zang organs, it manifests in the odor associated with each organ. If one is affected by summer-heat in summer, a wasting form of malaria may develop in autumn.

Another is improper eating and drinking, together with overwork and fatigue.

The Spleen governs flavors. When pathogen enters the five Zang organs, it manifests as changes in the taste associated with each organ. Improper eating and drinking, together with overwork and fatigue, was also mentioned earlier among illnesses arising within the main channels themselves. In that context, illness of the main channels means that they are weakened. Irregular eating and drinking can also damage the Spleen and cause illness.

Another is cold damage.

The Lung governs dryness and corresponds to the clear, cold Qi of its season; it also governs the voice. When cold pathogen spreads into the five Zang organs, it manifests as changes in the sound associated with each organ. The Lung governs the skin and body hair, so aversion to cold may readily occur. If one is affected by cold pathogen in winter, a warm disease may develop in spring.

Another is dampness strike.

The Kidney governs water and also corresponds to dampness. When dampness pathogen enters the five Zang organs, it manifests as changes in the fluids associated with each organ. If one is affected by dampness in autumn, the dampness may rise counter to its proper course and cause coughing. It may also develop into wilting and reversal, meaning weakness of the limbs and coldness of the hands and feet.

These are called the five pathogens. All five illnesses are caused by pathogens that invade from outside.

Suppose the Liver is ill—that is, the Liver has been attacked by pathogen.

How can one tell that the illness was caused by wind strike?

Answer: The patient’s complexion should be greenish. Xun symbolizes wind and belongs to Wood among the Five Phases. When wind pathogen affects Liver Wood, it may cause Qi to surge upward and produce coughing, followed by wilting and reversal.

These are called the five pathogens. These five illnesses are caused by pathogens invading from outside.

Suppose the Liver is ill—that is, the Liver has been attacked by pathogen.

How can one tell that someone has suffered a windstroke?

This asks what causes windstroke.

The answer is that the patient’s complexion should be bluish-green.

Xun represents wind and belongs to Wood in the Five Phases. The color associated with Wood is bluish-green.

Why is this so? The Liver governs color. The Qi of the Five Phases each manifests in a different color, and also gives rise to the relationships of generation and control among the five zang organs, as well as the transmission of pathogenic Qi. When the pathogenic Qi remains in its own channel—that is, when the Liver itself is affected—the color is bluish-green. If it passes to the Heart, the color is red; to the Spleen, yellow; to the Lung, white; and to the Kidney, black. This is because pathogenic Qi from the Liver takes on the color associated with whichever organ it enters.

Here it also says that when pathogenic Qi from the Liver passes to the Heart, the color should be red, in keeping with the account of transmission among the five zang organs. The Liver governs windstroke, while the Heart governs damage from summer heat. Since the Heart now shows signs of windstroke, we can infer that pathogenic Qi from the Liver has passed into the Heart.

The patient will have a fever and fullness and pain below the ribs. The Heart is associated with summer heat, which can cause fever during illness. The Liver channel runs along both sides of the ribs, so the area below the ribs becomes full.

The pulse is floating, large, and wiry: floating and large are features of the Heart pulse, while wiry is a feature of the Liver pulse.

How can one tell that someone has suffered damage from summer heat?

This asks what causes damage from summer heat.

The answer is that the patient should be averse to odors. The Heart governs summer heat and is also associated with odors. The Heart belongs to Fire, whose transformation produces a scorched odor. When pathogenic Qi remains in the Heart, it manifests as a scorched odor. When Fire affects the Spleen, the odor is fragrant; when it affects the Liver, the odor is rancid; when it affects the Kidney, the odor is putrid; and when it affects the Lung, the odor is rank. Here, “odor” refers broadly to smells, not only unpleasant ones.

Thus, if the Heart is affected by illness caused by damage from summer heat, the patient will be averse to odors.

When a heart disorder is caused by damage from summer heat, the patient will dislike foul odors.

The patient will have a fever, feel restless, and experience pain in the chest.

See the commentary on the Sixteenth Difficulty.

The pulse is floating, large, and scattered.

This is the pulse pattern when the heart itself is diseased.

How can we tell that the illness was caused by an improper diet and excessive exertion?

This asks why illness arises from dietary excess and overwork. See the commentary on the Sixteenth Difficulty.

The pulse is floating, large, and scattered. This is the pulse pattern when the heart itself is diseased.

The patient should have a preference for bitter flavors. If the Spleen’s Qi is weak, the patient will not want to eat; if it is congested and excessive, the patient will want to eat.

The Spleen governs flavor, so the cause of illness can be discerned from appetite and taste preference: when the Spleen channel is weak, the patient does not want to eat; when it is congested and excessive, the patient wants to eat.

Why is this so? This asks which flavor the patient prefers.

The Spleen governs sweetness and also receives all five flavors.

If Spleen-related pathogenic influence enters the Liver, the patient will prefer sourness; if it enters the Heart, bitterness; if it enters the Lung, pungency; if it enters the Kidney, saltiness; and if it remains in the Spleen itself, sweetness. Here, “Spleen-related pathogenic influence” refers to pathogenic influence arising in the Spleen.

Thus, when Spleen-related pathogenic influence enters the Heart, we know the patient will prefer bitter flavors. The Heart corresponds to heat, and the Spleen corresponds to fatigue and overexertion. Since the heart disorder here is caused by dietary excess and overwork, we can infer that Spleen-related pathogenic influence has entered the Heart, causing the patient to prefer bitterness.

The patient will have a fever and feel heavy and drowsy, with weakness in the limbs and difficulty moving them freely. Fever is associated with the Heart, and heaviness of the body with the Spleen. The Spleen also governs the limbs, so their movement will become impaired.

The pulse is floating, large, and moderate. Floating and large indicate the Heart pulse; moderate indicates the Spleen pulse.

How can we tell that this is caused by cold damage?

This asks about the signs of illness caused by cold damage.

The patient should have delirium and speak incoherently. Having been affected by cold pathogen, the patient’s speech becomes disordered.

Why is this so?

How can one tell whether speech is delirious and confused?

The lungs govern the voice. Metal produces sound when struck, so all five types of sound arise from the lungs.

When sound enters the liver, it becomes a cry. Wood is overcome by Metal, so it cries out.

When it enters the heart, it becomes speech. Metal and Fire face one another like husband and wife meeting, so one speaks and laughs.

When it enters the spleen, it becomes song. Earth is the mother of Metal, and Metal is the child of Earth. When mother and child meet, one sings.

When it enters the kidneys, it becomes a groan. Metal is the mother of Water. When a child sees its mother, it gives a frail, plaintive groan.

When sound returns to the lungs, it becomes weeping. The lungs govern autumn, and autumn qi brings sorrow. The sound of the lungs belongs to Shang, a tone associated with grief, so one weeps.

Therefore, when pathogenic influence from the lungs enters the heart, it makes a person speak incoherently and utter confused words. The heart governs summer heat, while the lungs govern cold. Delirious speech is always caused by pathogenic influence from the lungs invading the heart. The patient develops fever and aversion to cold; in severe cases, there may also be wheezing and coughing. Fever is a heart disorder; aversion to cold, wheezing, and coughing are lung disorders. The pulse is floating, large, and rough: floating and large are qualities of the heart pulse, while roughness is a quality of the lung pulse.

How can one tell that this illness is caused by dampness?

This asks why the person has been affected by pathogenic dampness. The answer is that the patient sweats continuously, and the sweating cannot be stopped. When pathogenic dampness takes hold, spontaneous sweating continues without end.

Why does this happen?

This asks why spontaneous sweating occurs. The kidneys govern dampness. They govern Water, and dampness tends to gather wherever water flows. Dampness affecting any of the five zang organs is connected to the kidneys.

When pathogenic dampness enters the liver, it becomes tears. Sorrow and grief bound up within injure the Hun. When the Hun is injured, tears well up and flow. The lungs govern sorrow; sorrow causes Metal qi to become excessive, thereby suppressing Wood. Water is the mother of Wood, and a mother worries for her child. Thus pathogenic dampness enters the liver and makes a person shed tears.

When it enters the heart, it becomes sweat. Water and Fire meet; when heated by steaming, they turn into sweat.

When it enters the spleen, it becomes saliva. Earth and Water also combine to produce saliva. Sorrow causes Metal qi to become excessive and suppresses Wood; Water is the mother of Wood, so pathogenic dampness enters the liver and makes a person shed tears.

When Water Qi enters the heart, it transforms into sweat. Water and Fire interact, and when Water is steamed by Fire, it becomes sweat.

When Water Qi enters the spleen, it transforms into saliva—the thin, clear fluid in the mouth. Earth is the husband and Water the wife; the wife follows the husband’s transformation, so Water Qi becomes saliva.

When Water Qi enters the lungs, it transforms into nasal discharge. The north corresponds to Water; Water generates cold, and cold returns to the kidneys. When cold Qi affects the skin and body hair, it moves inward and joins with the lungs. When the lungs are affected by cold, the nose runs.

When Water Qi enters the kidneys, it transforms into spittle. The channels of the Kidney meridian extend upward to connect with the tongue, so when the kidneys themselves are diseased, excess spittle may appear.

Thus, when kidney pathogenic Qi enters the heart, it causes sweating that does not stop. From this we can understand that persistent spontaneous sweating is caused by kidney pathogenic Qi entering the heart.

The patient may have a fever, pain in the lower abdomen, cold channels in the feet, and Qi moving upward in counterflow.

The fever is a heart disorder; the other symptoms are all kidney disorders. For details, see The Sixteenth Difficulty. The pulse is deep, soggy, and large: a large pulse belongs to the heart, while a deep and soggy pulse belongs to the kidneys. This is the method for diagnosing the Five Pathogenic Influences and the basis for distinguishing their pulse patterns.

The Fiftieth Difficulty says: Illness may arise from deficient pathogenic influence, excessive pathogenic influence, slight pathogenic influence, or proper pathogenic influence. How are these distinguished?

Question: How should these five kinds of pathogenic Qi be distinguished?

Answer: When pathogenic Qi comes from the organ that generates the affected organ, it is called a deficient pathogenic influence. When the heart governs the season, its pulse should be surging and long. If instead the pulse is wiry, small, and rapid, this shows that Liver Qi has entered the heart and disrupted its seasonal governance. The liver belongs to Wood and the heart to Fire; the liver is the heart’s mother. The mother’s Qi encroaches upon its child, so this is called a deficient pathogenic influence.

When pathogenic Qi comes from the preceding organ in the generating sequence, it is called an excessive pathogenic influence. After the heart’s period of governance ends, it should pass to the spleen. But here, before the heart’s period has ended, spleen Qi counterflows and usurps its position. Thus, the pathogenic Qi comes from the organ preceding it. The spleen is the heart’s child; the child’s Qi encroaches upon its mother, so this is called an excessive pathogenic influence.

When pathogenic Qi comes from the organ that restrains the affected organ, it is called a thieving pathogenic influence. Water restrains Fire, so if the Qi of the Kidney pulse encroaches upon the heart, this is a thieving pathogenic influence.

When pathogenic Qi comes from the organ restrained by the affected organ, it is called a slight pathogenic influence. Later in the original text, however, the phrase “when it comes from what cannot overcome it, it is a thieving pathogenic influence” is repeated.

Fire does not normally overpower Water. Yet during illness, if the Kidney pulse appears and assails the Heart pulse, this is called a “hostile pathogen”: a pathogenic influence arising when Kidney Water, which restrains Heart Fire, invades it.

A pathogen transmitted from the organ that the Heart controls is called a “mild pathogen.”

Heart Fire can restrain Lung Metal. If, during Heart illness, the Lung pulse appears and assails the Heart pulse, this is therefore called a “mild pathogen.”

Illness arising from the organ itself is called a “proper pathogen.”

In the season when the Heart governs, if the Heart pulse is instead full and forceful, this indicates an excess. If a weak, faint pulse appears instead, this is called a “proper pathogen,” because no pathogenic influence from another organ is invading it.

Why is this so?

A further question: If the illness arises from the Heart itself, why is it called a “proper pathogen”?

The Heart corresponds to summer heat. When illness arises from the Heart itself, it is because the person has been harmed by summer-heat pathogens, so it is called a “proper pathogen.”

Illness caused by irregular eating or excessive exertion is called a “substantial pathogen.”

The pathogen is transmitted from the preceding organ: Spleen Qi invades Heart Qi, so it is called a “substantial pathogen.”

Illness caused by cold damage is called a “mild pathogen.”

The pathogen is transmitted from the Lung, the organ controlled by the Heart: Lung Qi invades Heart Qi. The Lung corresponds to cold, while Heart Fire can restrain Lung Metal, so this is called a “mild pathogen.”

Illness caused by exposure to dampness is called a “hostile pathogen.”

The pathogen comes from the force that restrains Heart Fire: Kidney Qi invades Heart Qi. The Kidney corresponds to Water and dampness, and Water can restrain Fire, so this is called a “hostile pathogen.”

The Fifty-First Difficult Issue says:

Some patients want to stay somewhere warm, while others want to stay somewhere cool. Some want to see people, while others do not. Which organs are these different symptoms associated with?

Answer: When patients want to see people, the illness is in the six fu organs. People with illness in the six fu organs often want to be with others.

When patients want to stay somewhere warm but do not want to see people, the illness is in the five zang organs.

The five zang organs belong to Yin. When they are diseased, patients usually seek warmth and do not wish to see other people. The six fu organs belong to Yang. When they are diseased, patients usually seek coolness and are willing to see other people.

Why is this so? The three Yin and three Yang channels in the hands correspond to Heaven and govern warmth and dryness. Thus, when the six fu organs are diseased, patients seek coolness and are willing to see other people. The five zang organs belong to Yin, while the Yin and Yang channels in the feet correspond to Earth and govern cold and warmth. Thus, when the five zang organs are diseased, patients seek warmth. Yin governs the interior and stillness, so patients also wish to close the door and be alone, and dislike hearing people’s voices. These preferences can help distinguish whether an illness lies in the five zang organs or the six fu organs.

The Fifty-second Difficulty asks: When the five zang and six fu organs become diseased, is the underlying pattern the same?

The answer: It is not the same.

The question: How do they differ?

The answer: When the five zang organs are diseased, the illness remains in place and does not shift; its location is fixed. When the six fu organs are diseased, the illness surges and moves up and down, with no fixed place where it settles.

“Transmission of Illness among the Zang and Fu,” Chapter Eight

The Fifty-third Difficulty asks: The medical classics say that when an illness changes according to the pattern of “seven transmissions,” it leads to death.

The Classic of Difficult Issues (Nan Jing) says that when illness is transmitted in the order of the Five Phases overcoming one another, death comes after the seventh transmission; when it is transmitted in the order of the Five Phases generating one another, there is a chance of recovery.

The Five Phases overcome one another in this order: Wood overcomes Earth, Earth overcomes Water, Water overcomes Fire, Fire overcomes Metal, and Metal overcomes Wood. For example, when a heart illness is transmitted to the lungs, Fire overcomes Metal; when it passes from the lungs to the liver, Metal overcomes Wood; from the liver to the spleen, Wood overcomes Earth; from the spleen to the kidneys, Earth overcomes Water; and from the kidneys to the heart, Water overcomes Fire. Illness transmitted according to this pattern of overcoming is called “seven transmissions.” The text says that an organ cannot be injured repeatedly by the organ that overcomes it. Once the illness has been transmitted to an organ, it does not continue further; hence the saying, “Those transmitted through seven stages die.”

The Five Phases generate one another in this order: Wood generates Fire, Fire generates Earth, Earth generates Metal, Metal generates Water, and Water generates Wood. When illness passes from one organ to the organ it generates, this is called “transmission across the organ.” The term “inter-organ transmission” also refers to this pattern. For example, when a heart illness passes to the spleen, the heart belongs to Fire and the spleen to Earth; Fire generates Earth, so the spleen thereby receives vitality. This mother-to-child pattern of illness transmission is considered to offer a chance of recovery. The text then says that the spleen passes the illness on to the lungs.

The Spleen overcomes the Kidney, and the Lung asks about the Spleen’s condition.

The Lung’s illness is transmitted to the Kidney.

The Lung overcomes the Spleen, and the Kidney asks about the Lung’s condition.

The Kidney’s illness is transmitted to the Liver.

The Kidney overcomes the Heart, and the Liver asks about the Kidney’s condition.

The Liver’s illness is transmitted to the Heart.

The Liver overcomes Wood, and the Heart asks about the Liver’s condition.

Illness Qi passes back and forth between mother and child, turning around and around like a ring with no end. This is therefore called “generation.”

Mother and child transmit illness to each other in an endless cycle. This is the principle of ceaseless generation.

The Fifty-Fourth Difficulty says:

The relative difficulty of treating diseases of the Zang and Fu organs.

Diseases of the Five Zang organs are the most difficult to treat.

Diseases of the Six Fu organs are easier to treat. Why is this?

Why are diseases affecting the Six Fu organs comparatively easier to treat?

This is because Zang diseases are difficult to treat when illness Qi passes to the organ they overcome.

Liver disease is difficult to treat because the Liver overcomes the Spleen, the Spleen overcomes the Kidney, the Kidney overcomes the Heart, the Heart overcomes the Lung, and the Lung overcomes the Liver. Illness Qi passes along these overcoming relationships, making the disease difficult to treat.

Diseases of the Six Fu organs are easier to treat because illness Qi passes to the child organ.

Wood passes to Fire, Fire to Earth, Earth to Metal, Metal to Water, and Water back to Wood. The illness follows the generating relationships, so it is easier to treat.

This follows the same principle as the “seven transmissions” and “inquiring of the Zang” discussed earlier.

Accumulations and Gatherings in the Zang and Fu: Chapter Nine

The Fifty-Fifth Difficulty says:

Diseases are called “accumulations” and “gatherings.” How are they distinguished?

It says that “accumulations” form when Yin Qi congeals, while “gatherings” form when Yang Qi collects.

Yin is still, so accumulations tend to remain deep within the body. Yang is mobile, so gatherings tend to move about without a fixed location.

When Qi congeals and accumulates, it is called an “accumulation”; when Qi collects, it is called a “gathering.”

Accumulations (ji) are disorders produced by the five viscera. The five viscera belong to Yin. When Yin Qi becomes congested and cannot disperse in time, it remains lodged and forms an accumulation. At the onset of an accumulation disorder, its location is fixed: a liver accumulation lies beneath the left ribs, a lung accumulation beneath the right ribs, a heart accumulation above the navel, a kidney accumulation below the navel, and a spleen accumulation in the abdomen. The pain remains in the corresponding location and does not move elsewhere; the affected area has clear boundaries above and below, and from side to side. An accumulation disorder can therefore be identified by the viscus and location where it occurs.

Concretions (ju) are disorders formed by the six bowels. The six bowels belong to Yang. When a concretion disorder occurs, it has no fixed origin or place where it stays; the location of the pain often changes, which is why it is called a “concretion.” The difference between accumulations and concretions is that an accumulation has a fixed location, while a concretion comes and goes unpredictably.

The Fifty-Sixth Difficulty asks: Do the accumulations formed by the five viscera each have a name? “Accumulation” means something stored up and obstructed. When the flow of the blood vessels is impeded, what has accumulated can give rise to illness. What are the names of these disorders? And in which month and on which day did each one arise?

The answer: A liver accumulation is called “Fatty Qi.”

“Fat Accumulation” refers to a mass shaped like a thick piece of flesh. It is a liver disorder marked by accumulation and is commonly found in people of sturdy build. It forms beneath the left ribs, resembling an overturned cup, with a head and a tail. As the mass protrudes and resists treatment over a long period, it can cause coughing and rebellious Qi, and may also bring on symptoms such as wasting and weakness or malaria that persist year after year.

The condition flares up on a Wu or Ji day during late summer—the sixth lunar month, a season associated with Earth in the Five Phases. The ancients held that the spleen corresponds to Earth, and that late summer is when spleen Qi is at its strongest; for this reason, they said the illness arose on Wu and Ji days.

This is because the lungs correspond to Metal and the liver to Wood, and Metal restrains Wood, so illness in the lungs can pass to the liver. The liver corresponds to Wood, which restrains Earth, so illness in the liver can then pass to the spleen. But in late summer, spleen Earth is at its height and cannot receive the pathogenic influence, so the liver tries to send it back to the lungs. The lungs, too, refuse to receive it. The pathogenic Qi therefore remains and congeals, gradually forming the mass known as Fat Accumulation. On this basis, the ancients held that Fat Accumulation formed on Wu and Ji days in late summer.

The heart’s disorder of accumulation is called “Hidden Beam.” This means a mass lying across the body like a beam in a house. It begins above the navel, is about the size of an arm, and extends upward to just below the heart.

Accumulations of Qi in the heart region begin above the navel. They are about the size of an arm and extend upward to below the heart; this condition is called “Fuliang” (a disease caused by an accumulation in the heart region). If the accumulation persists for a long time, it can cause distress and unease in the heart.

Fuliang flares up on Geng or Xin days in autumn. This is explained through the Five Phases’ cycles of generation and overcoming and the transmission of illness between the organs: kidney illness can pass to the heart, since the kidney belongs to Water and the heart to Fire. The heart may then pass the illness to the lungs, but in autumn Metal governs the season, so the lungs do not receive the pathogenic influence. The heart then tries to pass the illness back to the kidneys, but they too do not receive it. The pathogenic Qi therefore remains and congeals, forming an accumulation. This is why Fuliang is said to flare up on Geng and Xin days in autumn.

An accumulation of Qi in the spleen region is called “Pi Qi” (a disease caused by obstructed and congealed spleen Qi). “Pi” means blocked or impeded. Pi Qi is located in the stomach area—the upper abdomen, where the stomach lies—and has the shape of an upturned dish. If it persists for a long time, it can make the limbs difficult to move and cause jaundice, turning the body, hands, and feet yellow. Food can no longer be transformed into muscle, making it difficult for the body to nourish and grow its flesh.

The Spleen and Stomach are the organs that store and receive food and drink. The normal act of eating and taking in food is called “eating.”

Pi Qi (a disease caused by a mass forming in the Spleen) develops on Ren or Gui days in winter. Winter is the season when Kidney Water governs, and both Ren and Gui belong to Water. This is why Pi Qi is said to arise on Ren and Gui days.

Why is this so? Liver disease can be transmitted to the Spleen. When Liver disease first begins, Liver Wood restrains Spleen Earth, so the pathogenic influence passes to the Spleen. According to the Five Phases’ cycle of restraint, Spleen Earth in turn restrains Kidney Water, so Spleen disease should then pass to the Kidneys. But in winter, Kidney Water is in command, and an organ in command is not easily affected by pathogenic influences. The Kidneys therefore do not receive the pathogenic influence transmitted from the Spleen. The Spleen then tries to send it back to the Liver, but the Liver refuses it as well. The pathogenic influence consequently remains lodged and congeals, forming a mass of Pi Qi. This is why Pi Qi is said to arise on Ren and Gui days.

A mass in the Lungs is called Xi Ben (a disease caused by a mass forming in the Lungs). Xi means “surface,” and Ben means “diaphragm.” Here, the term refers to the Lungs’ position above the diaphragm: when Lung Qi does not flow freely, the mass gradually grows and presses downward toward the diaphragm, hence the name Xi Ben.

Xi Ben is located below the right ribs. It is shaped like an overturned cup and is about the same size. If it persists for a long time without dispersing, it causes alternating chills and fever. When the Lungs are deficient, the person feels cold; when they are replete, there is fever and discomfort in the chest. Cold in the Lungs obstructs the airways, causing wheezing and coughing and resulting in congestion of Lung Qi.

Xi Ben develops on Jia or Yi days in spring. Spring is the season when Liver Wood governs, and both Jia and Yi belong to Wood. The patient feels cold and feverish and has symptoms including wheezing, coughing, and congestion of Lung Qi.

When the lungs are chilled, the airways become constricted and obstructed, causing wheezing, coughing, and congestion of Lung Qi.

Xi Ben (rapid breathing and a buildup caused by obstructed Lung Qi) flares up in spring on days of the Jia or Yi stems.

Spring is the season when Liver Wood is in command, and Jia and Yi also belong to Wood. Xi Ben is therefore likely to flare up on Jia and Yi days.

Why is Xi Ben said to flare up on Jia and Yi days?

A heart disease can pass to the lungs. When the heart disease first arises, Heart Fire constrains Lung Metal, so the pathogenic influence passes to the lungs.

Lung disease should then pass on to the liver. Lung Metal constrains Liver Wood, so the disease may be transmitted to the liver.

But spring is when Liver Wood is in command, and Liver Qi is strong, so it is not invaded by the pathogenic influence from the lung disease.

Since the lung pathogen cannot pass to the liver, which is in command, it tries to return to the heart. The heart, in turn, refuses to receive it. The pathogen then lodges and congeals, forming a buildup. We can therefore understand why Xi Ben flares up in spring, when Liver Wood is in command: the liver rejects the pathogen arriving from the lungs, so it returns to the heart and finally settles there as a buildup.

The kidney’s buildup is called Ben Tun (literally, “galloping pig”). Here, “ben” means to gather, while “tun” means a piglet; together they name a kidney buildup.

Ben Tun begins in the lower abdomen and surges upward to below the heart. It resembles a pig, sometimes rushing upward and at other times descending, with no fixed pattern.

If the illness persists, it causes panting and counterflow of Qi. It may also lead to bone wilting (weakness of the sinews and bones) and Qi deficiency. The kidneys govern the bones; when Kidney Qi is insufficient, the bones lose nourishment and the marrow becomes depleted, resulting in bone wilting.

Ben Tun flares up in summer on days of the Bing or Ding stems.

Summer is the season when Heart Fire is in command, and Bing and Ding also belong to Fire. Ben Tun is therefore likely to flare up on Bing and Ding days.

Why is the Ben Tun buildup said to flare up on Bing and Ding days?

When a Spleen disease reaches summer, the months when Heart Fire is in command, the days Bing and Ding belong to Fire. If the Spleen disease changes on a Bing or Ding day, it develops into “Bending Piglet” (a type of accumulation disorder that the ancients believed surged like a pig breaking into a run during an attack).

Why is this so?

The Spleen disease passes to the Kidney. When the disease first appears, the Spleen belongs to Earth, and Earth overcomes Kidney Water, so the pathogenic influence passes from the Spleen to the Kidney. In principle, the Kidney disease would then pass to the Heart. But the Kidney does not receive the pathogenic influence transmitted from the Spleen, because Kidney Water overcomes Heart Fire; the pathogenic influence therefore passes on to the Heart.

The Heart is at its height in summer. A flourishing organ’s Qi does not receive pathogenic influences, so when Heart Fire is in command in summer, the Heart does not accept the pathogenic influence transmitted from the Kidney.

The Kidney then tries to return the pathogenic influence to the Spleen, but the Spleen also refuses to receive it. The influence therefore remains and congeals, forming an accumulation. From this we can infer that the Bending Piglet accumulation forms on Bing and Ding days in summer.

This is an essential principle for explaining the causes of the five accumulations—diseases involving accumulations in the five organs.

This is the textual collation record for Volume Six of Collected Diagrams and Explanatory Phrases for the Yellow Emperor’s Classic of Eighty-One Difficulties. It explains, item by item, variations and suspected errors in the text. In some places, characters are supplied, changed, or reordered on the basis of the context; elsewhere, it notes variant readings in editions such as Collected Commentaries and Original Meaning. At several points, the wording is suspected of being corrupt because the meaning is unclear. The emendations concern terms such as the Five Viscera, the Five Phases overcoming one another, pulse patterns, and pathogenic influences. Many character changes are intended to make the classic’s text fit its context or the relationships among the Five Phases.

How many types of diarrhea are there, and does each have its own name?

Answer: There are five types of diarrhea, each with a different name: stomach diarrhea, spleen diarrhea, large intestine diarrhea, small intestine diarrhea, and kidney diarrhea.

In stomach diarrhea, food is passed before it has been digested, and the stool is yellow.

In spleen diarrhea, the abdomen feels distended and full. The scripture goes on to say that the diarrhea pours out like water.

“Zhu” refers to persistent diarrhea that expels food without digesting it. When the diarrhea is yellow, it is usually associated with the Spleen. The Spleen corresponds to Earth; when it is diseased, its transforming and transporting functions become impaired, resulting in yellow diarrhea. Abdominal distension and fullness occur when pathogenic Dampness affects Spleen-Earth. The Spleen does not favor Dampness, and when the two affect each other, the abdomen becomes distended and full.

“Xiezhu” means diarrhea that cannot be controlled. An excess of pathogenic Dampness can cause loose, watery stools. When Dampness enters the Spleen and Stomach, fluids and food cannot be properly separated and transformed, so the diarrhea continues without stopping.

The Spleen and Stomach are the organs that receive, store, and transform food and drink. When the Spleen is diseased and cannot transform food and fluids, eating causes vomiting.

With diarrhea involving the Large Intestine, an urgent need to defecate arises after eating. This is because the Qi of the Large Intestine is weak: after food is eaten, the urge to defecate comes on suddenly and is difficult to hold back. If the stool is white, the Five Phases’ system of color correspondences associates white with the Lung. Rumbling in the intestines accompanied by severe pain describes movement and noise in the empty intestines, with pain like being cut by a knife.

With diarrhea involving the Small Intestine, pus and blood may be passed. The Small Intestine is the fu organ governed by the Heart, and the Heart governs blood, so the stool may contain blood. Pain in the lower abdomen occurs because the area where urine is held lies in the lower abdomen.

Diarrhea involving the Large Intestine may also cause “tenesmus”: urgent abdominal pain accompanied by a dragging, distending pain near the anus. Repeatedly feeling the need to go to the toilet but passing little or nothing occurs because the Kidneys open into the front and rear yin orifices. When Kidney Qi is weak, the urge to defecate recurs, yet it remains difficult to pass stool even after reaching the toilet. The pain may also radiate to the penis in the anterior yin.

The above describes the symptoms and causes of five kinds of diarrhea.

The fifty-eighth difficulty asks: How many kinds of cold damage (illness caused by exposure to cold) are there? Does a patient’s pulse change as the illness develops?

The answer says: There are five kinds of cold damage, one of which is wind strike.

When the human body is invaded by pathogenic wind, illnesses such as windstroke may occur.

Cold Damage: In the severe cold of winter, the body may be invaded by cold Qi and fall ill afterward. Common symptoms include headache, pain throughout the body, and aversion to cold in the skin. For this reason, the illness is called Cold Damage.

Damp-Warmth: Someone who has previously been affected by pathogenic dampness may then be invaded by pathogenic wind. As wind and cold pathogens transform into one another, Damp-Warmth disease may develop. During the illness, the circulation of Qi and blood through the channels becomes disordered. Symptoms may include profuse sweating on the chest, pain in the head and eyes, and even delirious speech.

Heat Disease: When a person is exposed to cold in winter, the cold pathogen may remain latent and later erupt, transforming into heat. This becomes Heat Disease, commonly marked by fever, aversion to cold, headache, and pain throughout the body.

Warm Disease: If the weather is unusually cold in spring or summer, or unusually warm in autumn or winter, people may be affected by epidemic Qi—the pathogenic Qi that causes contagious disease—and fall ill. When many people, young and old alike, suddenly contract similar illnesses within a single year, this is an epidemic that spreads with the seasons, commonly known as a “great outbreak.”

The symptoms and suffering caused by different illnesses vary.

The pulse of windstroke: The Yang pulse is floating and slippery; the Yin pulse is soft and weak. The Yang pulse runs near the surface of the muscles, so under light pressure it feels abundant. The Yin pulse runs deep within the muscles, so under pressure it feels insufficient. A pulse that feels insufficient when pressed but abundant when lifted can therefore indicate windstroke.

The pulse of Damp-Warmth: The Yang pulse is soft and weak; the Yin pulse is fine, small, and rapid. The Yang pulse lies near the surface of the muscles, and its softness and weakness indicate an excess of dampness. The Yin pulse lies deep within; its fine, small, and rapid quality indicates that dampness in the Earth phase is unable to restrain Wood Qi.

The pulse of Cold Damage: Both the Yin and Yang pulses are vigorous, with a tight, obstructed quality. The pulses at both the cun and chi positions are extremely forceful and also feel tight and rough.

The pulse of Heat Disease: Both the Yin and Yang pulses are floating, and the pulses at both the cun and chi positions are also floating.

In febrile illness, both the yin and yang pulses are floating.

In a patient with fever, the pulses at both the inch and cubit positions are floating. Under light pressure, the pulse feels floating and slippery; this indicates that the Heart has been injured by pathogenic heat. Under heavy pressure, it feels deep, scattered, and rough; this indicates a deficiency of body fluids.

The pathogenic influence in warm disease can travel through any of the channels. When the illness begins, it is difficult to tell in advance which channel has been affected, so examination and treatment should be guided by the channel actually involved.

Warm disease arises when a pestilential ghostly influence—a plague pathogen—spreads through the channels. One cannot know beforehand which channel it will invade. Only after the illness appears can examination determine where the pathogen is, so treatment can be directed accordingly.

In cold damage, some patients recover after sweating but die if purged; others die after sweating but recover if purged. Why is this?

When yang is deficient and yin cold is strong, sweating brings recovery, while purging leads to death. Yang deficiency makes the body’s exterior sensitive to cold, and strong yin cold also makes it sensitive to cold. Cold pathogen contends between the nutritive and defensive Qi, causing fever and aversion to cold. The pulses at both the inch and cubit positions are floating and large, yet there is no agitation within. Even if the patient feels somewhat oppressed, they still want warm food and dislike cold food. This is a case of yang deficiency and strong yin. Inducing sweating will bring recovery; mistakenly using purgation will lead to death.

When yang is strong and yin fluid is deficient, the condition is different: the patient will die after sweating but may recover with purgation. Strong yang causes internal heat, and deficient yin also causes internal heat. Cold pathogen contends within the nutritive and defensive Qi; as yang grows strong and yin declines, the cold pathogen at its height turns into heat. Heat enters the interior and gathers in the Stomach, exhausting the body fluids and drying the stool into constipation. The patient has no aversion to cold, but instead has persistent fever and agitation; in severe cases, they may speak incoherently. This condition calls for purgation. Mistakenly inducing sweating will lead to death.

How should cold and heat illnesses be examined?

The cold and heat of the skin refers to…

The Lungs govern the skin and body hair and are paired with the Large Intestine as interior and exterior. Illness of the Lung organ tends to manifest as Cold; illness of the Large Intestine bowel tends to manifest as Heat.

The skin is sensitive to cold, and the person cannot bear to go near a sleeping mat.

The three Yin channels of the hand and the three Yang channels of the hand correspond to Heaven, whose celestial bodies are always in motion. When the channels become diseased, the person feels cold and does not want to go near a sleeping mat.

The hair becomes dry and brittle, and the nose becomes dry.

When Fire in the Heart is present, dryness and heat can cause illness. The hair therefore becomes scorched and brittle, and the nose becomes dry.

Sweating must not be induced.

When these symptoms are present, treatment must not induce sweating. This may lead to death; purging the bowels can bring recovery.

A condition in which the muscles alternate between Cold and Heat.

The Spleen governs the muscles and is paired with the Stomach as interior and exterior. Illness of the Spleen organ tends to manifest as Cold; illness of the Stomach bowel tends to manifest as Heat.

The skin is painful.

The Spleen belongs to Earth, and Earth governs dampness. Dampness flows into the joints, causing pain.

The lips become dry and brittle.

The Spleen’s vital essence is reflected around the lips. Fluids are depleted outward, so the lips become dry and brittle.

There is no sweat.

This results from an imbalance of dryness and dampness. Treatment must not induce sweating: doing so will obstruct the Stomach and intestines, while purging will cause unremitting diarrhea. The Middle Burner should be warmed and the movement of Qi regulated.

A condition in which the bones alternate between Cold and Heat.

The Kidneys govern the bones and are paired with the Bladder as interior and exterior. When the illness is in the Yang aspect, the body is hot and feels heavy, yet the person is sensitive to cold. When it is in the Yin aspect, the condition manifests as Cold.

The patient feels restless throughout the body.

Sweat flows continuously.

The fluid produced by the Kidneys rises to the Heart and becomes sweat. The term “pouring” means that it is without restraint; hence the sweat does not stop.

The roots of the teeth become dry and painful.

The teeth are the surplus of the bones. The Kidney fluid is depleted outward, so the roots of the teeth become dry and painful.

The Fifty-Ninth Difficulty asks:

How should mania and withdrawal be distinguished?

How should mania and epilepsy, which are two different illnesses, be distinguished?

Answer: During an episode of mania, Yang Qi is excessive. When pathogenic influences affect the three Yang channels and the patient is then mistakenly treated with a method that induces sweating, Yang Qi becomes even more vigorous, and the patient may become manic. The patient feels no hunger and has no desire to sleep. They consider themselves exceptionally wise and capable, enjoy arguing, regard themselves as superior, act arrogantly, and resent others. They laugh and sing for no apparent reason, taking pleasure in themselves. They may also act without stopping, climbing to high places, scaling walls, and doing things they normally could not do.

During an episode of epilepsy, Yin Qi is predominant. The patient is despondent, stares straight ahead, and falls to the ground with the body rigid. On examination of the cun, guan, and chi positions of the pulse, both the Yin and Yang pulses appear exuberant.

The Sixtieth Difficulty says:

Headache and heart pain each have two forms: counterflow pain and true pain. What do these terms mean?

Answer: Here, “counterflow” refers to the disorder and reversal of Qi movement. Headache may be counterflow headache or true headache, and heart pain may be counterflow heart pain or true heart pain. When the channels of the three Yang meridians of the hand are affected by wind and cold, and the pathogenic influences lie hidden and remain lodged, obstructing the flow, this is called counterflow headache.

When pathogenic Wind enters the body’s three Yang meridians and remains without dispersing, it obstructs the meridians and causes Qi to surge upward to the head. This is therefore called “reversal headache,” a headache brought on by surging Qi.

If the pathogenic influence penetrates deep into the brain, the condition is called “true headache.” The brain is the “Sea of Marrow,” where brain marrow gathers. When pathogenic Wind enters the brain through Fengfu, an acupuncture point at the back of the neck, it causes intense pain. The hands and feet grow cold, with the cold reaching the elbows and knees; this is true headache.

Pain caused by the interacting Qi of the Five Zang organs is called “reversal heart pain.” All the meridians are connected with the heart. When a meridian becomes diseased and its pulse Qi flows in reverse, it can invade the heart and bring on heart pain. This is why it is called reversal heart pain. The pain results from the Qi of the Five Zang organs surging upward; it does not mean that the heart itself is diseased.

When the pain is severe and concentrated in the heart, while the hands and feet turn bluish, the condition is called “true heart pain.” If true heart pain begins during the day, the person may die that night; if it begins at night, the person may die the following morning. For details, see “Difficulty Sixteen.”

“Divine, Sagely, Skillful, and Clever” (Section Eleven)

Difficulty Sixty-One asks:

The classic says, “To know a person’s illness by observing them is called ‘divine.’” This means diagnosing the illness by observing the patient’s outward signs.

“To know a person’s illness by hearing them is called ‘sagely.’” This means diagnosing the illness by listening to the patient’s account.

“To know a person’s illness by questioning them is called ‘skillful.’” Asking about the illness before examining the patient often yields accurate information. Learning about the illness through questioning is called skillful.

“To know a person’s illness by feeling the pulse is called ‘clever.’” This means learning about the illness by feeling the pulse and examining its qualities.

What do these four methods of diagnosis mean?

Answer: Diagnosis through observation means examining the patient’s Five Colors—the five colors that appear on the face and elsewhere—and using them to determine the illness.

For example, if a liver illness presents with a green-blue color, this indicates that the liver itself is diseased. If it presents with a red color, this indicates that Heart Qi is overpowering the liver, causing it to become diseased as well. Thus, the illness can be determined by observing the Five Colors.

Diagnosis through hearing means distinguishing the patient’s Five Tones in order to identify the illness.

The Five Tones are Gong, Shang, Jue, Zhi, and Yu, and each corresponds to one of the Five Zang organs. For example, if a patient often feels like crying, this indicates a disorder of the Lungs; if they like to sing, it indicates a disorder of the Spleen.

Using listening to understand an illness means listening to the patient’s voice, then identifying the disorder through the correspondences between the Five Tones and the Five Zang organs.

Using questioning to understand an illness means asking which flavors the patient prefers, in order to determine the cause and location of the illness. A preference for pungent flavors may indicate a Lung disorder; sour flavors, a Liver disorder; sweet flavors, a Spleen disorder; bitter flavors, a Heart disorder; and salty flavors, a Kidney disorder. A preference for raw, cold foods indicates heat within the body.

Using pulse examination to understand an illness means examining the pulse at the cun kou and observing whether its quality is deficient or replete, thereby determining which Zang-Fu organ is affected.

When examining the cun kou, a wiry pulse is usually associated with the Liver. If the pulse feels wiry under light pressure, the disorder is in a Fu organ. If it feels wiry under firm pressure, the disorder is in a Zang organ; this should be judged together with what was learned through listening. The same principle applies to the other Zang-Fu organs.

The Jing says, “Understanding illness from external signs is called sagehood.” This means judging a patient’s condition by observing outward signs such as the pulse and the sound of the voice: all are ways of knowing from the outside.

“Understanding illness from within is called spirit-like insight” means grasping the root of the illness in one’s mind; this is knowing from within.

The sixty-second question asks: “Each of the Five Zang organs has five categories of acupuncture points: Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea. Why do the Six Fu organs have one additional category of point?”

The answer is: Jing-Well, Shu-Stream, Ying-Spring, Jing-River, and He-Sea are the five categories of points associated with the Five Zang organs. In addition to these five categories, the Six Fu organs have one more point, the Yuan-Source point.

The Six Fu organs are Yang. Qi from the Sanjiao circulates through all the Yang meridians, so an additional Shu point is established, called the Yuan-Source point.

The Sanjiao serves as an official who assists the ruler and conveys commands. It corresponds to ministerial Fire and is responsible for transmitting the commands of sovereign Fire as it circulates through the Yang channels. Thus, the Sanjiao has an acupoint called the “source point.” “Source” means “origin” and carries the sense of a root or beginning.

There are six Fu organs, and the Sanjiao receives the same Qi as they do. The six Fu organs belong to Yang, and the Sanjiao also belongs to Yang; that is why they are said to share one Qi.

The Sixty-Third Difficulty

The Ten Transformations says that the Rong points, He points, and other points of the five Zang and six Fu organs all take the Jing point as their starting point. Why is this?

Why are the five categories of points—Jing, Rong, Shu, Jing, and He—arranged beginning with the Jing point?

Answer: The Jing point corresponds to the East and to spring. Spring symbolizes benevolence. In terms of the Five Phases, benevolence belongs to Wood, whose Qi is expansive. In the order of the seasons, the year begins with spring; in the reckoning of the months, the count begins with the Jia day; and among the points along the channels, the Jing point comes first.

Spring is the season when all things begin to grow. Everything newly born depends on the Qi of spring. Plants sprout and insects begin to stir; creatures that fly or crawl gradually become active. Nothing that is meant to grow does so without the Qi of spring.

Therefore, the sequence of the year begins with spring, and the sequence of the months begins with the Jia day. In the East, Jia and Yi belong to Wood. The first month and the Jia and Yi days all correspond to spring, so the beginning of the twelve months corresponds to Jia. The points along the channels follow the same principle, taking the Jing point as their starting point.

The Sixty-Fourth Difficulty

The Ten Transformations says that the Jing points of the Yin channels belong to Wood, while the Jing points of the Yang channels belong to Metal.

The “well” referred to here is where spring water first wells up in a mountain valley, not a well dug by people. The same kind of point belongs to Wood on the Yin channels and to Metal on the Yang channels.

The Rong points of the Yin channels belong to Fire, while the Rong points of the Yang channels belong to Water.

When a spring first wells up and gathers nearby, its channel is still shallow and has not yet joined into a larger stream. Such a water hollow is called a “Well.” The volume of water in a Well is small. Here, the same category of Well is meant: the Yang Well belongs to Wood, and the Yin Well belongs to Metal.

The Yin Well belongs to Fire, and the Yang Well belongs to Water.

After a spring wells up and gathers nearby, its channel has not yet joined into a larger stream. This kind of water hollow is called a “Spring” (a category of acupoint in the classic). “Spring” describes a fine, small flow. Here, the same category of Spring is meant: the Yang Spring belongs to Water, and the Yin Spring belongs to Fire.

The Yin Stream belongs to Earth, and the Yang Stream belongs to Wood.

When water gathers more deeply, it forms a place where the current surges, pours in, and swirls. This place is called a “Stream” (a category of acupoint along the meridians). Here, the same category of Stream is meant: the Yin Stream belongs to Earth, and the Yang Stream belongs to Wood.

The Yin Meridian belongs to Metal, and the Yang Meridian belongs to Fire.

“Meridian” carries the sense of a road or a course of movement. As water gathers and flows along its course, it gradually forms channels and waterways; this is called a “Meridian.” Here, the same category of Meridian is meant: the Yin Meridian belongs to Metal, and the Yang Meridian belongs to Fire.

The Yin Confluence belongs to Water, and the Yang Confluence belongs to Earth.

“Confluence” means a meeting. When water gathers more deeply, forming a place where currents meet, surge, and swirl, an acupoint of this kind is called a “Confluence.” Here, the same category of Confluence is meant: the Yin Confluence belongs to Water, and the Yang Confluence belongs to Earth.

The attributes paired with Yin and Yang are all different. What is the reason for this?

The attributes of Yin and Yang are indeed different. How should this be understood?

This is the principle of pairing firmness with yielding. The five Zang organs belong to Yin and yielding; the six Fu organs belong to Yang and firmness. Yang alone cannot bring forth growth, and Yin alone cannot nourish. Yin and Yang are like husband and wife: firmness and yielding depend on one another, and only together can they generate life.

The Yin Well is paired with Yi Wood, and the Yang Well with Geng Metal.

Yi belongs to Yin and Wood; Geng belongs to Yang and Metal. According to the Five Phases’ pattern of overcoming one another, the one that is overcome takes the role of wife. Thus the Yin Well, Yi Wood, is paired with the Yang Well, Geng Metal. The pairing of Yi and Geng expresses the union of husband and wife.

The Yang Well belongs to Geng Metal. Geng is firm and strong: it is the firm counterpart to Yi’s yielding nature.

Geng belongs to firmness, husband, and Yang, so Geng is regarded as Yi’s husband.

The Yin Jing point is associated with Yi. Yi is yielding, while Geng is firm, so Geng represents Yi’s firm aspect. Geng is Yang and the husband; Yi is Yin and the wife. Thus, Geng is Yi’s husband, and Yi is Geng’s wife. Yi belongs to Wood, so it is called “Yin Jing Wood.” The East is associated with Jia and Yi; Yi is Yin, and therefore belongs to Wood. Geng belongs to Metal, so it is called “Yang Jing Metal.” The West is associated with Geng and Xin, and Geng is Yang. Metal can overcome Wood, so the Yang Jing point is associated with Metal.

The other points are derived in the same way, through the correspondences of Yin and Yang, firmness and yielding. The Yin Rong point is associated with Fire, and the Yang Rong point with Water: Ren Water is firm, Ding Fire is yielding, and Ding and Ren unite. The Yang Shu point is associated with Wood, and the Yin Shu point with Earth: Jia Wood is firm, Ji is yielding, and Jia and Ji unite. The Yin Jing point is associated with Metal, and the Yang Jing point with Fire: Bing Fire is firm, Xin Metal is yielding, and Bing and Xin unite. The Yin He point is associated with Water, and the Yang He point with Earth: Wu Earth is firm, Gui Water is yielding, and Wu and Gui unite.

The sixty-fifth difficulty asks: The classic says that the place where Qi and blood flow out of the channels is called a “Jing” point, and the place where they flow in is called a “He” point. What is the principle behind this system of classification?

The answer is: The place where Qi and blood flow out is called a “Jing” point. The body’s Yang Qi moves in accordance with the seasons, sometimes spreading outward and sometimes drawing inward. Jing points symbolize the moment when Yang Qi first begins to arise.

Jing points symbolize the East and spring. The East is the beginning of the four directions, spring the beginning of the four seasons, and Jing points the starting point of the flow of Qi and blood through the channels. In spring, all things begin to grow; therefore, the place where Qi and blood first flow out of the channels is called a “Jing” point. The place where flowing water enters is called a “He” point.

The place where all things first begin to grow is called a “Well.” The water of the channels begins to flow and emerge like all things sprouting in spring. Therefore, the points where channel water flows out are called “Wells.”

The place where channel water gathers is called a “Union.” “Union” signifies Yang energy in a state of concealment and fullness. It also corresponds to the north and to winter: the north is the endpoint of the four directions, winter is the endpoint of the four seasons, and the “Union” is the endpoint of the channels’ flow. At the winter solstice, Yang energy withdraws northward and lies hidden; therefore, the places where channel water gathers are called “Unions.”

The Sixty-Sixth Difficulty says:

The classic says that the source point of the Lung, where the original Qi of the organs and bowels gathers, emerges at Taiyuan. Taiyuan lies on the palm side of the wrist, below the thenar eminence. It is where the pulse Qi gathers and where the pulse of the Hand Taiyin Lung Channel can be felt.

The source point of the Heart emerges at Tail­ing, in the hollow between the two tendons at the back of the wrist. It is the source point of the Pericardium.

The source point of the Liver emerges at Taichong, two cun behind the joint at the base of the big toe.

The source point of the Spleen emerges at Taibai, below the prominent bone on the inner side of the foot.

The source point of the Kidney emerges at Taixi, behind the inner ankle, between it and the heel bone.

The Shaoyin channel also has a source point, which emerges at the “spindle bone.” All five organs use transport points as their source points. Shaoyin refers to the true Heart channel, which also has its own source point. It lies in the hollow beside the end of the spindle bone at the back of the palm and is called Shenmen, or Zhongdu. The Heart source point mentioned earlier, Tail­ing, refers to a point on the Pericardium channel. The Heart disorders discussed here all refer to disorders of the Pericardium channel. The true Heart is not invaded by pathogenic influences, so it has no corresponding transport point. When it is said here to have a source point, this refers to illness in the channels at the body’s surface, not to treatment of the internal organ itself.

The source point of the Gallbladder emerges at Qiuxu, slightly forward of the area below the outer ankle.

The source point of the Stomach emerges at Chongyang.

Five cun above the ankle, a pulse can be felt between the bones.

The Sanjiao’s source point, where source Qi is conveyed and gathers, is Yangchi, in the hollow on the back of the hand between the little and ring fingers, behind the knuckles.

The bladder’s source point is Jinggu, below the prominent bone on the outer side of the foot, where the reddish and pale skin meet.

The large intestine’s source point is Hegu, between the thumb and index finger.

The small intestine’s source point is Wangu, near the wrist bone on the outer, little-finger side of the palm.

Why do all twelve channels take the “Shu” point as their source point?

Here, “Shu” means the Shu points among the five categories of points: Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea. It does not refer to the separate set known as the “Twelve Shu.” Why do all twelve channels use the Shu point as their source point?

The answer: The Shu points of the five Zang organs are places where the Sanjiao circulates Qi and where Qi gathers. The Sanjiao conveys Qi through these Shu points, and Qi flows through and collects there as well.

The stirring Qi between the kidneys below the navel is the root of human life and the root of the twelve channels; this is why it is called the “source.” The commentary here refers to the Eighth Difficulty.

The Sanjiao and the source Qi in the kidneys come together, which is why it is called the “source.” The Sanjiao is the messenger through which source Qi is distributed everywhere. The commentary here refers to the Thirty-Eighth Difficulty.

The Sanjiao governs the circulation of the three Qi. Following the Three Qi of Heaven and Earth, the body’s Sanjiao sets them in motion, carrying them through the five Zang and six Fu organs: the upper Jiao lies between the heart and lungs, the middle Jiao between the spleen and stomach, and the lower Jiao between the liver and kidneys. Qi circulates throughout the whole body.

“Source” is an honorific name for the Sanjiao.

“Origin” means “primordial.” Primordial Qi is the Qi of the Triple Burner. Because this Qi is noble in status and great in power, it is called the “Origin.” The place where Qi resides is called an “Origin.”

When any of the five viscera or six bowels is diseased, the corresponding Origin point can be selected for treatment.

The sixty-seventh difficulty says:

The Alarm points of the five viscera are all on the body’s Yin side. The abdomen belongs to Yin, so all the Alarm points of the five viscera are located there. The Alarm point of the Lung is Zhongfu, with one point on each side, one inch below Yunmen and in the third intercostal space above the breast. The Alarm point of the Heart is Juque, with one point on each side, one inch below Jiuwei. The Alarm point of the Spleen is Zhangmen, with one point on each side, below the floating ribs and opposite the navel. The Alarm point of the Liver is Qimen, with one point on each side, one and a half inches beside Burong. The Alarm point of the Kidney is Jingmen, with one point on each side, at the floating ribs in the lower back.

The Transport points of the five viscera are all on the body’s Yang side. The back belongs to Yang, so all the Transport points of the five viscera are located there. Feishu is below the third vertebra, one and a half inches on either side of the spine. Xinshu is below the fifth vertebra, one and a half inches on either side of the spine. Ganshu is below the ninth vertebra, one and a half inches on either side of the spine. Pishu is below the eleventh vertebra, one and a half inches on either side of the spine. Shenshu is below the fourteenth vertebra, one and a half inches on either side of the spine.

Why are the Alarm points on the Yin side, while the Transport points are on the Yang side?

This is because illness on the Yin side can affect the Yang side, and illness on the Yang side can also affect the Yin side. When the internal organs are diseased, the pathogenic Qi manifests on the body’s outer, Yang side, so the Transport points on the back can be selected. When the exterior of the body is diseased, the pathogenic Qi affects the inner, Yin side, so the Alarm points on the abdomen can be selected. That is why the Alarm points are on the Yin side and the Transport points on the Yang side.

Each of the five zang organs and six fu organs has five categories of acupuncture points: Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea points. These are different categories of points along which Qi and blood flow through the meridians.

On the Liver meridian, the Jing-Well point is Dadun, the Ying-Spring point is Xingjian, the Shu-Stream point is Taichong, the Jing-River point is Zhongfeng, and the He-Sea point is Ququan. On the Lung meridian, they are Shaoshang, Yuji, Taiyuan, Jingqu, and Chize, respectively. On the Heart meridian, they are Shaochong, Shaofu, Shenmen, Lingdao, and Shaohai. On the Kidney meridian, they are Yongquan, Rangu, Taixi, Fuliu, and Yingu. On the Spleen meridian, they are Yinbai, Dadu, Taibai, Shangqiu, and Yinlingquan. On the Pericardium meridian, they are Zhongchong, Laogong, Daling, Jianshi, and Quze. These are the Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea points associated with the five zang organs.

On the Gallbladder meridian, the Jing-Well point is Zuqiaoyin, the Ying-Spring point is Xiaxi, the Shu-Stream point is Zulinqi, the Jing-River point is Yangfu, and the He-Sea point is Yanglingquan; its Yuan-Source point is Qiuxu. On the Large Intestine meridian, these points are Shangyang, Erjian, Sanjian, Yangxi, and Quchi, with Hegu as the Yuan-Source point. On the Small Intestine meridian, they are Shaoze, Qiangu, Houxi, Yanggu, and Xiaohai, with Wangu as the Yuan-Source point. On the Stomach meridian, they are Lidui, Neiting, Xiangu, Jiexi, and Zusanli, with Chongyang as the Yuan-Source point. On the Bladder meridian, they are Zhiyin, Tonggu, Shugu, Kunlun, and Weizhong, with Jinggu as the Yuan-Source point. On the Triple Burner meridian, they are Guanchong, Yemen, Zhongzhu, Zhigou, and Tianjing, with Yangchi as the Yuan-Source point. These are the Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea points associated with the six fu organs; each also has a Yuan-Source point.

What conditions are these points used to treat? What are the respective functions of the five categories of Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea points?

The phrase “flowing out from the well point” is like spring water surging from a spring in a mountain valley. As the water flows onward but has not yet gathered into a larger stream, it is called “Rong” (also known as “Ying”). When the water pools, gradually sinks deeper, and forms a flowing channel, it is called “Shu.” When it runs forward along a ditch, it is called “Jing.” When it finally joins the sea, it is called “He.”

The well point treats fullness and distension below the heart. In the Five Phases, the well point belongs to Wood and corresponds to the liver. The spleen’s fluids collect below the heart. If pathogenic Qi is in the liver, Liver Wood can affect Spleen Earth, causing fullness and distension below the heart. Needling the well point at this time prevents Wood Qi from encroaching on Earth Qi.

The Rong point treats fever throughout the body. It belongs to Fire and corresponds to the heart; the lungs belong to Metal and govern the skin and body hair. If Heart Fire scorches Lung Metal, fever may result, indicating that the pathogenic Qi is in the heart. Needling the Rong point at this time prevents Fire Qi from encroaching on Metal Qi, thereby easing the fever.

The Shu point treats heaviness in the body and joint pain. It belongs to Earth and corresponds to the spleen. When pathogenic Qi is in Earth, Earth Qi can restrain Water Qi. Water corresponds to the kidneys, which govern the bones, so joint pain may occur. When Earth Qi itself is diseased, the body feels heavy. The Shu point is therefore the appropriate point to treat.

The Jing point treats panting, coughing, and alternating episodes of chills and fever. It belongs to Metal and corresponds to the lungs. When pathogenic Qi is in the channels and affects the lungs, exposure to cold causes coughing, while exposure to heat causes panting. If the pathogen is in Metal, Metal Qi may also restrain Wood Qi. Wood corresponds to the liver, which governs anger among the emotions; anger causes Qi to surge upward and can also bring on panting. Needling the Jing point therefore treats pathogenic Qi in the channels and prevents Metal Qi from further restraining Wood Qi.

The He points treat Qi rising counterflow and diarrhea.

The He points belong to Water and correspond to the Kidneys. When Kidney Qi is deficient, the Thoroughfare Vessel is impaired, and Qi may rise counterflow, throwing the Qi in the abdomen into disorder. The Kidneys govern the opening and closing of the two lower orifices. If Kidney Qi cannot secure and contain them, diarrhea occurs. When Water pathogens grow strong, they can affect the Heart, which belongs to Fire. Liver Wood is both the mother of Heart Fire and the child of Kidney Water: it worries that its mother will be invaded by pathogens, and also that it will itself be overcome. In emotional terms, the Liver governs anger. Worry can give rise to anger, and anger in turn makes Qi rise counterflow. Treating the He points at this time prevents Water pathogens from invading Heart Fire. The Liver Wood then ceases to worry, and the counterflow of Qi subsides; the Kidneys are no longer afflicted, and the diarrhea stops.

This explains the disorders treated by the five kinds of points—Jing-Well, Ying-Spring, Shu-Stream, Jing-River, and He-Sea—on the five Zang organs and six Fu organs. Treatment at these points should take the changing seasons into account: seasonal pathogens often lodge at the corresponding Ying-Spring points, Shu-Stream points, and other such points.

Supplementation and Drainage with Needles, Chapter Twelve

The Sixty-Ninth Difficulty says:

The classic says that deficiency should be treated with supplementation.

When the Zang-Fu organs are weak, use supplementation.

Excess should be treated with drainage.

When the Zang-Fu organs are overly abundant and full, promote free flow to disperse the excess.

When there is neither deficiency nor excess, select points according to the relevant meridian.

If the Zang organs are not transmitting illness to one another, and there is no case in which one organ is deficient while another is excessive, then simply apply supplementation or drainage according to the sequence of the relevant meridian.

Why is this?

How should these three cases be understood?

Answer: In deficiency, supplement the mother organ. For example, if the Kidney pulse is found to be deficient in spring, this indicates that the Kidneys are weak and cannot transmit Qi to the Liver; therefore, the Kidneys should be supplemented. When the Kidneys are diseased, they transmit the illness to the Liver. The Liver is the child of the Kidneys, which is why this is called “supplementing the mother.”

In spring, if the pulse at the Heart channel shows excess, this indicates an excess pathogen. The Heart Qi is too strong and is attacking the Liver in turn, so the Heart should be drained. Once the Heart Qi is balanced, the Liver Qi can flow freely. The Liver is the mother organ of the Heart, so this is described as draining the child organ—that is, draining the Heart.

In treatment, tonification should come first, followed by draining.

The mother organ can make the child organ full, so the mother must be tonified first. The child organ can weaken the mother organ, so the child must be drained afterward.

If there is neither excess nor deficiency, treatment should follow the organ’s own channel. This is illness arising within the organ’s own channel, without invasion by another pathogen, so treatment should be applied directly along that channel. Hence the phrase, “treat according to the channel.”

Neither excess nor deficiency means that the organs are not overpowering one another—that is, no organ’s Qi is so strong that it attacks another organ. In spring, the pulse is often wiry, or wiry alone; this indicates a disorder of the Liver itself. Tonification and draining should then be prescribed according to the pattern on the Foot Jueyin Liver channel and the Foot Shaoyang Gallbladder channel. The points on these channels each correspond to one of the Five Phases (Wood, Fire, Earth, Metal, Water), and the appropriate points should be chosen according to the season.

The Seventieth Difficulty says:

The classic says that in spring and summer, needling should be shallow.

When needling the Well and Spring points in spring and summer, the points selected are in the relatively shallow areas where the flesh is thin.

In autumn and winter, needling should be deep.

When needling the River and Sea points in autumn and winter, the points selected are in the deeper areas where the flesh is thick.

What does this mean?

How should shallow and deep needling be understood in practice?

Answer: In spring and summer, Yang Qi is in the upper part of the body, and the body’s Qi is also concentrated above. Needling should therefore reach only shallowly.

In spring, Qi is at the fine body hairs; in summer, it is in the skin. Since both Yang Qi and the body’s Qi are above, needling should target these shallow areas—the fine hairs and the skin.

In autumn and winter, Yang Qi is in the lower part of the body, and the body’s Qi is also concentrated below. Needling should therefore reach deeply.

In autumn, Qi is at the divisions between the muscles; in winter, it is in the sinews and bones. Since both Yang Qi and the body’s Qi are below, needling should target the deeper muscles and the areas near the sinews and bones.

In both spring and summer, draw in one part of Yin Qi.

Spring and summer belong to Yang. “Draw in” means to bring forth or attain. Even while nourishing Yang in spring and summer, one should draw in a part of Yin Qi to bring it into balance and prevent Yang from becoming excessive and isolated.

In both autumn and winter, draw in one part of Yang Qi.

Autumn and winter belong to Yin. During these seasons, Yin should be nourished and protected, but some Yang Qi must also be drawn in to nourish it, lest Yin become excessive and turn into isolated Yin. Yang Qi, too, must be attended to, so that it does not become isolated. A suitable amount of Yang Qi should be introduced in both autumn and winter.

Why is this so? The Yin and Yang Qi mobilized by needling differ from season to season. How, specifically, should this be done?

In spring and summer, the weather is warm, so needling should draw in some Yin Qi. Since illnesses in spring and summer tend to affect the Yang aspect, Yin Qi should be guided in to harmonize Yang Qi. When inserting the needle, first place it relatively deep, reaching the areas associated with the Liver and Kidneys. After Qi arrives, guide in Yin Qi to harmonize Yin and Yang. The areas associated with the Liver and Kidneys here refer to the region beneath the skin, where the Yin Qi of the channels flows. According to the commentary, the needle should be inserted about five fen.

In autumn and winter, the weather is cold, so needling should draw in some Yang Qi. Since illnesses in autumn and winter tend to affect the Yin aspect, Yang Qi should be drawn into the body to harmonize Yin Qi. When inserting the needle, first prick shallowly, allowing it to move near the surface in the areas associated with the Heart and Lungs. After Qi arrives, advance the needle to draw in Yang Qi. The areas associated with the Heart and Lungs here refer to the region near the skin’s surface. According to the commentary, the needle should be inserted about three fen to draw in Yang Qi and harmonize Yin Qi.

Thus, needling in spring and summer should draw in one part Yin Qi, while needling in autumn and winter should draw in one part Yang Qi.

The Seventy-First Difficulty says:

The classic states that when needling Rong Qi (nutritive Qi, which flows within the vessels), one must not injure Wei Qi (protective Qi, which flows outside the vessels and guards the body). When needling Wei Qi, one must not injure Rong Qi. What does this mean?

When needling the Yang aspect, the needle should be inserted from the shallow surface of the body.

Weizhi belongs to Yang. Therefore, when needling the Yang aspect, the needle enters two fen beneath the skin. When the illness is in Weiqi, needling should be shallow: insert the needle at a low, shallow angle and avoid going too deep, which could injure Yingqi. When needling the Yin aspect, first press with the left hand on the Ying point to be needled. Once the local Qi has dispersed, insert the needle.

Yingqi belongs to Yin, and the needle enters five fen beneath the skin. Needling should be shallow: insert the needle at a low, shallow angle to avoid injuring Yingqi. When needling the Yin aspect, first press with the left hand on the Ying point to be needled. Once the Qi has dispersed, insert the needle. Yingqi belongs to Yin, and the needle enters five fen beneath the skin to reach where Yingqi resides. Thus, first press the point and wait for the local Qi to disperse before inserting the needle, so as not to injure Weiqi.

This is called needling Yingqi without injuring Weiqi, and needling Weiqi without injuring Yingqi.

The passage above restates what was said earlier.

The Seventy-second Difficulty says:

The classic says that understanding the Qi of greeting and following enables one to harmonize it.

“Greeting” means going against the direction in which Qi moves; it also carries the sense of attacking and draining. “Following” means going along with the direction in which Qi moves; it also carries the sense of supplementing and nourishing. Weiqi moves in reverse, while Yingqi moves forward. Understanding this allows one to harmonize them.

The key to regulating Qi lies in Yin and Yang.

The method for harmonizing Yingqi and Weiqi also depends on whether Yin and Yang are deficient or excessive.

Why is this so?

The principle is that what is called greeting and following means understanding how Yingqi and Weiqi circulate, as well as the patterns by which Qi and blood flow back and forth through the channels.

Only by understanding the circulation of Yingqi and Weiqi and the movement through the channels can one needle in opposition to or along the direction of Qi, and apply supplementation and drainage.

Taking points and treating illness in accordance with whether Qi moves forward or in reverse is therefore called “greeting and following.”

Weiqi moves in reverse, while Yingqi moves forward. Applying supplementation and drainage according to the directions in which they move is therefore called “greeting and following.”

The key to regulating Qi lies in Yin and Yang: when Yin is deficient and Yang excessive, supplement Yin and drain Yang; when Yang is deficient and Yin excessive, supplement Yang and drain Yin. If Yang Qi is excessive and enters the Yin aspect, supplementation and drainage should likewise be applied according to the deficiency or excess of Yin and Yang. This is what is meant by greeting and following.

The key to regulating Qi lies in Yin and Yang.

When Yin is deficient and Yang is in excess, tonify Yin and drain Yang; when Yang is deficient and Yin is in excess, tonify Yang and drain Yin. Whether abundant Yang Qi suppresses Yin Qi, abundant Yin Qi suppresses Yang Qi, or both Yin and Yang are deficient or excessive, treat the Yin or Yang that corresponds to the location of the illness. In this way, the disease can be cured.

Determine whether the illness is internal or external, on the exterior or in the interior.

Observe whether the pulse is floating or deep, and distinguish deficiency from excess. Infer the condition of the body’s surface from what is happening inside, and infer the internal condition from signs on the surface. Examine exterior patterns to understand interior patterns, and interior patterns to understand exterior patterns; in this way, distinguish deficiency from excess.

Treatment should be guided by whether Yin or Yang is predominant or deficient.

Treat according to which category of Yin-Yang meridian the illness affects.

Thus the classic says: in regulating the movement of Qi, the key lies in Yin and Yang.

This reviews the preceding discussion.

The Seventy-Third Difficulty

Someone asked: The flesh around the Jing-well points of the meridians—the points at the tips of the fingers and toes—is thin, and there is little Qi and Blood there. What should be done when needling them?

The Jing-well points are all at the tips of the fingers and toes, where the flesh is thin and Qi and Blood are scant. Needling them is difficult. How should one proceed?

The answer was: The Jing-well points belong to Wood, and the Ying-spring points, one of the Five Shu points located beyond the Jing-well points, belong to Fire. Wood generates Fire, so Fire is the “child” of Wood.

When Liver-Wood has an excess pattern, the Five Phases principle says to drain the child. Fire is the child of Wood, and the Ying-spring points belong to Fire, so one can select an Ying-spring point to drain it. In spring, when Liver-Wood is in season, needling an Ying-spring point draws away the flourishing Wood Qi. According to the explanation here, this constitutes an excess pathogenic factor, so the Ying-spring point should be drained. For example, when the Liver meridian itself is diseased, an excess pattern can be treated by draining a Fire point on the Liver meridian; a deficient pattern can be treated by tonifying a Wood point on the Liver meridian.

Thus the classic says: what should be tonified must not be treated as though it should be drained, and what should be drained must not be treated as though it should be tonified.

The Seventy-Fourth Difficulty

The classic says: In spring, needle the Jing-well points. The Jing-well points belong to Wood, so in spring select them.

In summer, needle the Ying-spring points. The Ying-spring points belong to Fire, so in summer select them.

In late summer—the final month of summer, usually the sixth lunar month—needle the Shu-stream points. The Shu-stream points belong to Earth, so in late summer select them.

“Needling the Jing points in autumn” means that in autumn one should needle the Jing point, one of the Five Shu points. Jing points correspond to Metal, so the Jing point is selected in autumn. “Needling the He points in winter” means that in winter one should needle the He point, another of the Five Shu points. He points correspond to Water, so the He point is selected in winter.

Why are different acupuncture points selected in each season?

In spring, needle the Jing-Well point because pathogenic Qi is in the Liver. To prevent the Liver’s Wood pathogen from further harming the Spleen’s Earth, needle the Jing-Well point. In summer, needle the Ying-Spring point because pathogenic Qi is in the Heart. To prevent the Heart’s Fire pathogen from harming the Lung’s Metal, needle the Ying-Spring point. In late summer, needle the Shu-Stream point because pathogenic Qi is in the Spleen. To prevent the Spleen’s Earth pathogen from harming the Kidney’s Water, needle the Shu-Stream point. In autumn, needle the Jing-River point because pathogenic Qi is in the Lung. To prevent the Lung’s Metal pathogen from harming the Liver’s Wood, needle the Jing-River point. In winter, needle the He-Sea point because pathogenic Qi is in the Kidney. To prevent the Kidney’s Water pathogen from harming the Heart’s Fire, needle the He-Sea point.

Why are the Liver, Heart, Spleen, Lung, and Kidney associated respectively with spring, summer, late summer, autumn, and winter? How do the five Zang organs correspond to the four seasons?

When any of the five Zang organs is ill, the condition often shows itself through five kinds of signs: the five tones, five colors, five flavors, five odors, and five fluids. Take Liver illness as an example: green belongs to the Liver, the rancid odor belongs to the Liver, sour flavor belongs to the Liver, shouting belongs to the Liver, and tears belong to the Liver as well. The related explanation appears in the Thirty-Fourth Difficulty of the Nanjing. The signs of illness in the Zang-Fu organs are many and cannot all be described one by one. Each season has its own fixed order, and these correspondences run throughout spring, summer, autumn, and winter.

The subtle art of acupuncture lies in grasping these fine relationships, with the precision of an autumn hair.

The Seventy-Fifth Difficulty asks: The classic says, “The East is replete, the West is deficient; drain the South and supplement the North.” What does this mean? The explanation continues below.

The scripture says, “The East is excess, the West is deficient; drain the South and supplement the North.” What does this mean?

The East corresponds to Wood and the liver; the West corresponds to Metal and the lungs. The passage means that Liver Qi is excessive while Lung Qi is deficient, so the Heart’s Fire in the South should be drained and the Kidney’s Water in the North supplemented.

The Five Phases—Metal, Wood, Water, Fire, and Earth—restrain one another and maintain balance: Metal restrains Wood, Wood restrains Earth, Earth restrains Water, Water restrains Fire, and Fire restrains Metal. The five viscera also correspond to the Five Phases. Treatment should follow these relationships of mutual restraint, using supplementation or draining as appropriate.

The East corresponds to Wood, and the West to Metal. When Wood Qi is excessive, Metal can restrain it. If Liver Qi is strong while Lung Qi is weak, it is as though Wood is turning against and suppressing Metal. Metal’s restraining force is insufficient, so it cannot bring Wood Qi into check.

When Fire Qi is excessive, Water should restrain it. If Heart Qi is strong while Kidney Qi is weak, it is as though Fire is turning against and suppressing Water. Water’s strength is insufficient, so it cannot bring Fire Qi into check.

When Earth Qi is excessive, Wood should restrain it. If Spleen Qi is strong while Liver Qi is weak, it is as though Earth is turning against and suppressing Wood. Wood’s strength is insufficient, so it cannot bring Earth Qi into check.

When Metal Qi is excessive, Fire should restrain it. If Lung Qi is strong while Heart Qi is weak, it is as though Metal is turning against and suppressing Fire. Fire’s strength is insufficient, so it cannot bring Metal Qi into check.

When Water Qi is excessive, Earth should restrain it. If Kidney Qi is strong while Spleen Qi is weak, it is as though Water is turning against and suppressing Earth. Earth’s strength is insufficient, so it cannot bring Water Qi into check.

Since the East corresponds to the liver, we can understand “the East is excess” to mean that Liver Qi is excessive. Since the West corresponds to the lungs, “the West is deficient” means that Lung Qi is deficient. When pathogenic Qi is strong, the condition is described as “excess”; when healthy Qi is damaged and depleted, it is described as “deficiency.”

Excessive Wood Qi means that Wood is in surplus, which in turn disturbs Earth. When Earth is disturbed, it affects the nourishment of Metal and leaves Metal Qi deficient.

Therefore, drain the Fire of the South and supplement the Water of the North. The South corresponds to Fire, which is the child phase of Wood; the North corresponds to Water, which is the mother phase of Wood. Water can restrain Fire, so supplementing Water and draining Fire helps regulate excessive Wood Qi.

Take the liver as an example. Fire is the child of Wood. If Fire is not drained and its Qi grows excessive, it will melt and injure Metal. Metal then restrains Wood, and Metal and Wood struggle, each harming the other. Water is the mother of Wood. If Water is not replenished and its Qi grows weak, it cannot nourish Wood.

A child can make its mother abundant, and a mother can make her child weak.

Therefore, Fire should be drained and Water replenished, so that Metal will no longer take advantage of Wood’s weakness and restrain it. When using the needling method of draining, first examine the signs of illness, then drain the Heart. Once the Heart Qi flows freely, the Liver Qi can recover. Then replenish the Kidney so that its Qi is full and can nourish the Liver. When the Liver Qi is settled, the Lung Qi will no longer come to restrain the Liver.

An ancient classic says, “If even deficiency patterns cannot be treated, what else is there to discuss?” This is the principle it refers to.

When the Lung is deficient and the Liver is replete, drain Fire and replenish Water to regulate and nourish the Liver Qi. Once the Liver Qi is settled, the Lung Qi will no longer come to restrain the Liver. If one does not understand the essentials of treating deficiency patterns, why ask about other methods of treatment?

Question 76

What are the methods of tonification and draining? What do “tonifying” and “draining” mean?

When carrying out tonification, where should Qi be drawn from? When carrying out draining, where should Qi be drawn from?

Answer: When carrying out tonification, draw Qi from Wei Qi, the Qi that circulates at the body’s surface and protects the body. The Lung circulates the Five Qi, infuses the five zang organs, moves through the six channels, and ultimately returns to the hundred vessels. When needling, draw Qi from the Wei Qi. Once Qi has been obtained, advance the needle into the deficient channel, adjusting the depth of insertion according to the layers and the location of the illness. This is the method of tonification.

When applying the draining method, guide the flow of Qi from the nutritive level, the level at which nutritive Blood circulates. If pathogenic Qi remains at this level, insert the needle into the channel where it is congested and excessive. Once Qi arrives, manipulate the needle to drain the pathogen.

If Yang Qi is deficient and Yin Qi is excessive, first supplement Yang, then drain Yin. For example, if Gallbladder Qi is deficient and Liver Qi is excessive, first supplement the Foot Shaoyang Gallbladder Channel, then drain the Foot Jueyin Liver Channel.

If Yin Qi is deficient and Yang Qi is excessive, first supplement Yin, then drain the Yang channel. For example, if Liver Qi is deficient and Gallbladder Qi is excessive, first supplement the Foot Jueyin Liver Channel, then drain the Foot Shaoyang Gallbladder Channel.

The key is to keep nutritive Qi and defensive Qi flowing freely. When Yin or Yang is excessive or deficient, first supplement what is deficient, then drain what is excessive. This allows nutritive and defensive Qi to circulate; it is the essential principle of needling.

Seventy-Seventh Difficulty

The classic says, “A superior physician treats illness before it arises.”

A “superior physician” is one whose medical skill is advanced and whose diagnosis and treatment are thorough, able to prevent and treat illness before it develops. A physician of middling skill treats illnesses that have already arisen. Such a physician has not yet fully understood how illness passes from one organ to another, and therefore often focuses treatment on a single organ.

What does “treating illness before it arises” mean? What is its principle?

Answer: “Treating illness before it arises” means that when one sees the Liver is diseased, one knows the pathogen may pass to the Spleen. One therefore first regulates and supplements Spleen Qi, preventing the Spleen from being invaded by the Liver pathogen.

The Five Zang organs of the body stand in relationships of generation and control: when the Qi of one organ is excessive, it may control another; when an organ’s Qi is deficient, it is more vulnerable to pathogenic invasion. When one sees disease in the Liver Channel, one should preemptively supplement the Spleen, which belongs to Earth and is controlled by the Liver, so that the Liver pathogen does not pass to the Spleen. This is what “treating illness before it arises” means.

A physician of middling skill sees Liver disease but does not understand that illness can pass and transform between the Zang-Fu organs, and focuses only on treating the Liver itself.

“Seeing that the Liver is diseased, but not understanding that Liver disease may spread to the Spleen, and focusing only on treating the Liver channel” means observing that the Liver is diseased without understanding that the illness may pass to the Spleen, and treating only the Liver channel.

This, then, is merely treating a disease after it has already arisen.

These words continue the discussion above.

The Seventy-Eighth Difficulty says: “Acupuncture has tonifying and draining methods. In tonification, the needle is withdrawn as the patient exhales; in draining, the needle is inserted as the patient inhales. What does this mean? What is the principle behind it?”

The answer is: Tonification and draining are not necessarily determined solely by inserting or withdrawing the needle during inhalation or exhalation. The key is how one manipulates the needle—advancing or withdrawing it—after Qi has arrived at the needle, thereby applying tonification or draining.

Those who understand needling are skilled in using the left hand. In other words, mastery of acupuncture begins with coordinating the left hand. Those who do not understand needling rely only on the right hand.

When needling, first use the left hand to press the Rong and Shu points (acupuncture points along the channels). Then use the right hand to tap the area being pressed, encouraging the local Qi and blood to stir and gather. Next, press the point with a fingernail to mark where the needle will enter.

When Qi arrives, the left hand will feel it pulsing beneath the fingers. Then guide the needle in along that path. Once Qi has arrived at the needle, push it deeper into the channel; this is called tonification. After Qi has arrived, shake and rotate the needle, then draw it out; this is called draining.

If Qi has not arrived, …

If the needle has been retained for a long time and no needling response appears—that is, no arrival of Qi or response of the channel Qi after needling—first retain the needle in the defensive level, the part of the channels closer to the body’s surface and associated with Yang, and wait for Qi. If no response appears even after waiting a long time, insert the needle into the nutritive level, the part of the channels deeper within the body and associated with Yin, and continue waiting for Qi. If there is no response beneath the needle at any of these three sites, this indicates that both Yin and Yang Qi have been depleted, and needling should not be performed.

If needling according to the method of selecting points with men on the outside and women on the inside still fails to bring Qi, this is called “ten deaths, one chance of life,” meaning that the condition is extremely critical and the prospect of survival is slight.

The defensive level belongs to Yang and governs the body’s surface. Men’s Yang Qi circulates at the surface, so pressure on the point should be light. The nutritive level belongs to Blood and governs the interior. Women’s Yin Qi circulates within the body, so pressure on the point should be firm. If the appropriate time to wait has passed and Qi still has not arrived, and the left hand detects no response, needling should not continue. The patient’s condition is extremely critical, with little chance of survival.

The seventy-ninth difficulty says:

The classic says, “Meet it and drain it.” How can this fail to weaken the righteous Qi?

When the channel Qi has just begun to arrive, one uses the needle to draw it out. This is called “meeting it and draining it.” “Meet” means to meet and draw out the channel Qi; “drain” means to disperse it. Since the Qi is drawn out and drained, how could this fail to weaken the righteous Qi?

“Follow it and reinforce it.” How can this make the righteous Qi abundant?

“Follow” means to draw Qi in accordance with the defensive Qi; this is the reinforcing method. “Reinforce” means to replenish a channel that is deficient. If one follows its course and replenishes it, how could this fail to make the righteous Qi abundant? After the channel Qi has completed one cycle, insert the needle; once it is withdrawn, press the needle opening with the hand. This is called “following it and reinforcing it.”

When a channel is weak, using the reinforcing method described above to strengthen it brings changes in what is gained and what is lost.

When a channel is strong and replete, using the needle to make it deficient likewise involves gain and loss.

What does this mean?

It means that “meeting it and draining it” is draining the child channel. When the Qi of the Five Zang is abundant and replete, one may drain the child organ that it engenders.

“Following it and reinforcing it” is supplementing the mother channel.

When the five Zang organs are weak, reinforce their mother organ.

The treatment of heart disease is used here as an example to explain this method.

Drain the Shu point of the Hand Heart Master, one of the Five Transport Points. The heart is the ruler of the five Zang organs; according to this account, the heart itself does not fall ill. The organ that actually becomes diseased is the Heart Enveloping Network. “Hand Heart Master” refers to the Hand Jueyin Heart-Pericardium channel, whose Shu point belongs to Earth. The heart belongs to Fire, and Earth is what Fire generates—its child. So draining the Shu point of the Hand Heart Master means draining the child; this is called “draining the child.”

This is a method of countering the pathogenic Qi and making it recede.

Reinforce the Jing point of the Hand Heart Master, the first of the Five Transport Points. The heart belongs to Fire, while the Jing point belongs to Wood. Wood generates Fire and is therefore its mother. So reinforcing the Jing point of the Heart-Pericardium channel means reinforcing the mother.

This is called following the channel Qi and supporting it.

“Excess” and “deficiency” refer to whether the pulse feels firm or soft. A soft pulse indicates deficiency; a firm pulse indicates excess. When Qi arrives, a firm pulse shows that the treatment is appropriate. A soft pulse shows that the treatment has not yet taken effect. Hence it is said to be as though something has been gained, and as though something has been lost.

Before applying a reinforcing or draining method, first examine the pulses of the five Zang organs and the Qi at the points to be needled. If the pulse feels firm when Qi arrives, draining may be applied; if it feels weak and soft, reinforcing may be applied. If, while holding the needle, you cannot tell whether the pulse or the Qi at the point is firm or soft, the treatment’s effect will seem uncertain.

The Eightieth Difficulty says:

The text says, “There is a perception, as though the needle has entered,” and also, “There is a perception, as though the needle has come out.” What do these statements mean?

“ There is a perception, as though the needle has entered” means that only after the left hand senses the arrival of Qi does one insert the needle.

When needling, first use the left hand to press and feel the acupoint, observing changes in the Qi within it. Once the Qi has arrived, insert the needle into the point; when its force has subsided, withdraw the needle. This refers to observing the arrival and ebbing of Qi and then deciding when to insert or withdraw the needle. It does not refer to the method of supplementing or draining by greeting or following the Qi.

The Classic of Difficulties (Nanjing) says: “Medical texts speak of making excess even fuller and deficiency even weaker; of diminishing what is insufficient and adding to what is already abundant.” What does this mean? Is it asking about deficiency and excess as seen in the pulse at the cun-kou—the wrist site where the pulse is examined—or about deficiency and excess in the illness itself? And how should one carry out diminution and augmentation—that is, supplement deficiency and drain excess?

Suppose Liver Qi is excessive and Lung Qi is deficient. The Liver belongs to Wood, and the Lung to Metal. Metal and Wood should restrain one another and remain in balance. Now suppose Lung Qi is excessive: we can then infer that Liver Qi is weak, subtle, and insufficient. If, when needling, one fails to supplement Liver Qi and instead further supplements the already excessive Lung Qi, one makes excess more excessive and deficiency more deficient, diminishing what is insufficient and adding to what is already abundant. This is the harm caused by someone who has not yet mastered the art of medicine.

Collected Diagrams and Phrase-by-Phrase Explanation of the Yellow Emperor’s Classic of Eighty-One Difficulties, Volume Seven.

Editorial notes: At the first marked passage, “earth” may need to read “above.” At the second, the original text has “vomit”; following Benyi, this has been changed to “pour.” At the third, the phrase “after eating, quickly wanting to go to the toilet” is written in Yu’s commentary on Difficulty Fifty-Seven in Jizhu as “after finishing a meal, quickly thinking of going to the toilet”; it means that one soon feels the need to use the toilet after eating. The editorial note following the word “illness” is incomplete.