《黃帝內經素問補註釋文》Vol. 21

The Yellow Emperor asked: "Those who now suffer from febrile diseases all arise from illnesses of the Shanghan (cold damage) kind. Some recover and some die. Deaths mostly occur between the sixth and seventh days, while recoveries mostly come after ten days. What is the reason for this? Please explain the principle behind it."

The "cold" referred to here is the cold qi of winter. In the severe cold of winter, all things conceal themselves, and those who carefully nourish their life protect themselves so as not to be invaded by cold pathogens. Being invaded by cold pathogens is called shanghan. The seasonal qi of the four seasons can all cause illness, but the cold poison carried by shanghan is especially fierce. If it invades the body and causes illness immediately, it is called shanghan. If illness does not appear right away, the cold poison lies hidden beneath the skin and muscles. According to Wang Bing's commentary, febrile illnesses that arise before the summer solstice are called wenbing (warm disease), while those that arise after the summer solstice are called rebing (heat disease). Although the names differ with the time of onset, their root is shanghan, which is why it is said that all febrile diseases belong to the category of shanghan. The collators note that the Shanghan Lun (Treatise on Cold Damage) holds that cold poison turns into warm disease in spring and into summer-heat disease in summer. This differs from Wang Bing's account, because the two works rest on different ancient theories.

Qi Bo replied: "The Taiyang channel governs all the yang qi." Here, "juyang" (great yang) refers to the Taiyang channel, and "ju" carries the sense of "great." The channels, qi and blood, and the ying and wei qi of the Taiyang channel circulate throughout the body, and it is where the yang qi of the whole body is gathered. Its channel connects with Fengfu (Wind Mansion), an acupoint on the back of the neck, about one cun inside the hairline, in the depression. For this reason, the Taiyang channel is in charge of all the yang qi of the body.

When a person is invaded by cold pathogens, fever often follows. Even when the fever is very high, death is not necessarily the result. Cold pathogens invade the skin and prevent the yang qi from dispersing outward. It becomes trapped within the body, and so shanghan, paradoxically, shows itself as fever.

If cold pathogens invade the paired organs and channels at the same time, this is called "liangGan" (dual invasion). Qi Bo said that this kind of illness is usually difficult to survive. The Yellow Emperor then asked, "I hope to hear about the symptoms of this illness." Here, what he asks about is the ordinary shanghan illness, not dual invasion. Qi Bo answered: "On the first day of shanghan, the Taiyang channel is struck by pathogenic qi..."

In the three Yang qi, the Greater Yang channel (one of the Six Channels, governing the body's surface) has a floating pulse. A floating pulse indicates that the pathogenic influence is external, lodged between the skin and the body hair. Therefore, on the first day of Shanghan (cold damage, illness caused by external cold), the Greater Yang channel is the first to be attacked by pathogenic influence, so there is pain in the head and nape, and stiffness in the lumbar region and spine.

The preceding text says that the qi of the Greater Yang channel connects to the Fengfu point, which is a general statement. In detail, the Foot Greater Yang channel enters from the top of the head, connects to the brain, then branches downward through the nape, runs along the inner border of the shoulder blade beside the spine, and reaches the center of the lumbar region. This is why there is pain in the head and nape and stiffness in the lumbar region and spine. The New Collation notes that the Jiayi Jing and the Taisu both write "the head, nape, lumbar region and spine are all stiff," meaning that the head, nape, lumbar region, and spine are all stiff.

On the second day, the Yangming channel (one of the Six Channels, mainly associated with the stomach and the muscles) is affected. Yang qi responds to heat evil, and like responds to like, so the pathogenic influence passes from the Greater Yang channel into the Yangming channel. The Yangming channel governs the muscles, its network runs alongside the nose, and it connects to the eyes. Hence there is fever in the body, pain in the muscles, dryness of the nose, and inability to sleep soundly. The body becomes feverish because the muscles are affected by evil; heat in the stomach causes restlessness, so sleep is impossible. The remaining symptoms appear according to the regions through which the channels and their collaterals pass.

On the third day, the Shaoyang channel (one of the Six Channels, mainly associated with the gallbladder) is affected. The New Collation notes that the Quan Yuanqi edition writes "bone" here. Quan Yuanqi's commentary holds that Shaoyang is the external channel of the liver; the liver is related to the sinews, the sinews converge on the bone, and it is the bone that the qi of Shaoyang nourishes, so it is said that Shaoyang governs the bone. The Jiayi Jing, the Taisu, and other texts also write "bone." The Shaoyang channel runs along the ribs and flanks and connects to the ears, so there is pain in the chest and flanks and deafness.

At this point, all three Yang channels are affected, but the pathogenic influence has not yet entered the zang-fu organs, so sweating may be used to treat the illness. Because the illness is still in the body's surface, sweating is appropriate. The New Collation notes that the Quan Yuanqi edition writes "fu" (palace/organ) here; the commentary holds that cold damage first enters the skin and interstices and gradually affects the Yang channels, but has not yet entered the fu organs, so sweating should be used to disperse the cold and heat evils. The Taisu also writes "fu."

On the fourth day, the Taiyin channel (one of the Six Channels, mainly associated with the spleen) is affected. This is because, once the progression of the Yang channels reaches its extreme, the illness passes on to the Yin channels. The Taiyin channel runs through the stomach and connects to the throat, so there is abdominal distension and dryness of the throat.

On the fifth day, the Shaoyin channel (one of the Six Channels, mainly associated with the kidneys) is affected. The Shaoyin channel passes through the kidneys, connects to the lungs, and extends to the root of the tongue, so there is dryness of the mouth, a dry tongue, and thirst.

On the sixth day, the Jueyin channel (one of the Six Channels, mainly associated with the liver) is affected. The Jueyin channel runs around the genitals, connects to the liver, so there is vexation, abdominal distension, and retraction of the scrotum.

When the channels of the three Yin and three Yang and the five zang and six fu organs are all affected, the nutritive qi and the defensive qi do not circulate smoothly, the functions of the five zang organs are blocked, and death follows. Here, "death" means that the essential qi has been exhausted; therefore, death is always caused by illness.

Around six or seven days, the disease generally shows the following changes. If the patient has not simultaneously contracted two kinds of cold pathogen, then on the seventh day the illness of the Taiyang (taiyang) meridian lessens, and the headache also eases somewhat. As the pathogenic qi (xie qi) gradually recedes and the qi of the meridians slowly regulates and harmonizes, the patient begins to improve.

On the eighth day, the illness of the Yangming (yangming) meridian lessens and the fever recedes slightly. On the ninth day, the illness of the Shaoyang (shaoyang) meridian lessens, the deafness is relieved, and the patient can faintly hear sounds. On the tenth day, the illness of the Taiyin (taiyin) meridian lessens, the abdominal distension subsides and the abdomen returns to normal, and the patient begins to want food. On the eleventh day, the illness of the Shaoyin (shaoyin) meridian lessens, the thirst stops, the mouth no longer feels uncomfortable, and the tongue is no longer dry, after which the patient sneezes. On the twelfth day, the illness of the Jueyin (jueyin) meridian lessens, the scrotum relaxes, and the lower abdomen sinks slightly. When the great pathogenic qi has all withdrawn, the disease is cured.

The "great qi" mentioned here refers to powerful pathogenic qi. Therefore, when an illness lasts more than ten days before recovery, the reason is generally this.

The Yellow Emperor (Huangdi) asked: "How should it be treated?"

Qi Bo (Qi Bo) replied: "Treat according to each patient's condition, so that the meridians of the corresponding organs are unobstructed. Then the illness will gradually lessen and heal. If the disease has not reached three days, treat it by inducing sweating. If it has reached three days, treat it by purgation."

This outlines the general principles for exterior and interior patterns. The Zhengli Shanghan Lun (Treatise on the Principles of Cold Damage) states: when the pulse is large, floating, and rapid, the disease lies in the exterior and sweating may be used; when the pulse is fine, sunken, and rapid, the disease lies in the interior and purgation may be used. Therefore, even if the course of illness is already long, as long as exterior patterns persist and the pulse is large, floating, and rapid, sweating remains appropriate. Even if the course is short, as long as interior patterns appear and the pulse is fine, sunken, and rapid, purgation may still be used. In treatment, the choice between sweating and purgation should be determined by the pulse and the clinical signs.

The Yellow Emperor asked: "After a febrile disease has resolved, why does some residual illness sometimes remain?"

Qi Bo replied: "Although the pathogenic qi has declined, it has not been entirely eliminated, as if some remnant still lingers in the body. This situation often arises because the patient forced themselves to eat while the fever was still intense. Although the illness has lessened, residual heat remains hidden within. The qi of the food interacts with this residual heat, and the two heats combine to leave the illness behind."

The Yellow Emperor asked: "How should this lingering illness be treated?"

Qi Bo replied: "Distinguish the patient's deficiency from excess and harmonize whatever is out of balance, and the illness will be cured." That is, one must carefully determine whether the condition is deficiency or excess, and then apply tonification or reduction accordingly.

The Yellow Emperor asked: "What should be avoided in diet during a febrile disease?"

Qi Bo replied: "If meat is eaten just as the fever begins to improve, the illness may recur. Eating too much also leaves behind illness. These should all be avoided."

This speaks of avoiding improper diet and overexertion. Although the febrile disease has eased somewhat, residual heat has not been fully cleared, and the qi of the spleen and stomach remains weak and unable to fully digest food. Meat is dense and hard to digest. If it lingers in the stomach, it easily kindles heat again. Here, "recur" (fu) means the original illness returning.

Huangdi asked: "When two channels are simultaneously affected by cold pathogen, what should the pulse be like, and what are the symptoms?"

Qi Bo replied: "When two channels are struck by cold together, on the first day the Taiyang channel (called 'Juyang' in the original text) and the Shaoyin channel fall ill at the same time, with headache, dry mouth, and vexation with fullness in the chest."

The New Collation cites the Treatise on Cold Damage as writing that these symptoms should read "vexation, fullness, and thirst."

"On the second day, the Yangming and Taiyin channels fall ill together, with abdominal distension, fever, loss of appetite, and delirious speech. 'Zhan yan' (delirious speech) means confused speech without coherence. Yang Shangshan explains it as excessive talking."

"On the third day, the Shaoyang and Jueyin channels fall ill together, with deafness, retraction of the scrotum, and cold hands and feet. At this stage the patient cannot swallow water or food, and loses consciousness. By the sixth day, the patient will die."

"The Taiyang and Shaoyin channels are interior-exterior partners, as are the Yangming and Taiyin, and the Shaoyang and Jueyin. Therefore, when two channels take in cold pathogen together, it means a pair of interiorly and exteriorly related channels is attacked at once."

Huangdi asked: "When the five zang organs are already injured and the six fu organs are obstructed, and the ying qi (nutritive qi) and wei qi (defensive qi) cannot circulate, why does death still take three more days?"

Qi Bo replied: "The Yangming channel governs all twelve channels, and its blood and qi are abundant. So although the patient has already lost consciousness, the Yangming can sustain life for three days. After three days, when the Yangming qi is exhausted, the patient dies."

The commentary explains that the Yangming qi receives qi from the sea of qi (qihai), so death does not come until the third day, when that qi is spent.

In winter, those who contract cold pathogen and later develop warm disease are classified by timing. If the illness begins before the summer solstice, it is called warm disease (wen bing). If it begins after the summer solstice, it is called summer-heat disease (shu bing). For summer-heat disease, one should induce sweating so that the pathogen leaves with the sweat, and one should not block the sweating.

This distinction rests on the degree of yang heat. When yang heat is not yet vigorous and is suppressed by cold pathogen, the disease is called "warm." When yang heat is very strong and cold cannot suppress it, the disease is called "summer heat." For summer-heat disease, the patient should be made to sweat so that the condition improves. One should not stop the sweating, which would worsen the illness.

The New Collation notes that the passage beginning "Whenever disease arises from cold damage" was originally placed in the Chapter on Strange Diseases in Quan Yuanqi's edition, and that Wang Bing moved it here. Yang Shangshan explains that people who take in a lighter cold pathogen in winter fall ill before the summer solstice with warm disease, while those who take in a heavier cold pathogen fall ill after the solstice with summer-heat disease.

Chapter on Needling Heat Disorders (Ci Re Pian)

When a patient has liver heat, the urine often turns yellow first, followed by abdominal pain, drowsiness, and fever.

The liver channel wraps around the genitals, reaches the lower abdomen, and then runs upward. This is why urination becomes difficult, why the urine turns yellow first, and why abdominal pain appears. The patient also becomes drowsy. After cold pathogen invades the body, it transforms into heat, which is why the body becomes feverish.

When heat pathogens clash with upright Qi (zhengqi), the patient may become delirious, frightened, and experience distension and pain in the hypochondrium, restlessness of the hands and feet, and an inability to lie still. The "clash" here means that the channels have already been invaded by heat pathogens, while the organs that house the Shen (spirit) have not yet been fully affected, so the pathogen and the upright Qi are still contending with each other.

The Liver Channel rises from the lower abdomen, passes alongside the stomach through the diaphragm, spreads across the ribs and flanks, and then ascends behind the throat to connect with the root of the tongue. For this reason, when heat pathogens clash in a Liver disorder, the patient becomes delirious and suffers distension and pain in the ribs and flanks. The Liver is associated with tranquility and also with fright, so during the illness the patient is startled, the hands and feet are restless, and the patient cannot lie still.

The condition worsens on Geng and Xin days and the patient sweats profusely on Jia and Yi days. The Liver belongs to Wood, and Geng and Xin belong to Metal. Since Metal overcomes Wood, the condition worsens on Geng and Xin days. Jia and Yi also belong to Wood, so profuse sweating occurs on those days. If Qi counterflows, the patient may die on a Geng or Xin day.

Treatment involves needling the Foot Jueyin Liver Channel and the Foot Shaoyang Gallbladder Channel.

When the Liver Channel is disordered and its Qi is contrary, the patient experiences headache, with a sensation of pressure surging in the head, as the channel's pulse Qi pulls upward into the head. The Liver Channel runs from the root of the tongue, behind the throat, to the forehead, and joins the Governing Vessel (Dumai) at the crown of the head. Therefore, when the pulse Qi surges upward, this kind of headache arises. The term "yuanyuan" describes a sensation of tightness and urgency.

A person with a heat disease of the Heart first feels emotionally constrained and only develops fever several days later. This is because the Heart governs the Shen. When the Heart's pathogenic Qi enters the channels, the Shen becomes unsettled, so the patient first feels unhappy and only develops fever several days later.

When heat pathogens clash with upright Qi, the patient may suddenly experience pain in the heart, oppression in the chest, and a tendency to vomit, along with headache, flushed face, and absence of sweating. The Hand Shaoyin Heart Channel emerges from the center of the heart, and its branch ascends along the heart system, flanking the throat. The main channel of the Hand Taiyang Small Intestine Channel descends along the throat, passes through the diaphragm to reach the stomach, while its branch ascends from the supraclavicular fossa along the neck, through the cheek, to the outer corner of the eye. Therefore, pain in the heart, oppression, vomiting, headache, and a flushed face appear. In terms of bodily fluids, the Heart corresponds to sweat, so when heat pathogens are within but no sweat emerges, this indicates the imbalance.

The condition worsens on Ren and Gui days and the patient sweats profusely on Bing and Ding days. The Heart belongs to Fire, and Ren and Gui belong to Water. Since Water extinguishes Fire, the condition worsens on Ren and Gui days. Bing and Ding also belong to Fire, so profuse sweating occurs on those days. The original text does not describe the specific symptoms when Qi counterflows, but it states that if Qi counterflows, the patient may die on a Ren or Gui day.

Treatment involves needling the Hand Shaoyin Heart Channel and the Hand Taiyang Small Intestine Channel.

When a person has a heat disease of the Spleen, the patient first feels heaviness in the head, pain in the cheeks, oppression in the chest, a greenish complexion, a desire to vomit, and accompanying fever of the body.

The channel of the Stomach begins beside the nose, meets at the root of the nose (é, the depression at the upper end of the bridge), descends along the outer side of the nose, and enters the upper teeth. It then emerges, wraps around both sides of the mouth and the lips, and descends to meet at the Chengjiang (chéngjiāng) point, the depression below the lower lip. From there it follows the lower edge of the rear of the jaw, emerges at the Daying (dàyíng) point, ascends along the Jiache (jiáchē) point to the front of the ear, passes the Keziren (kèzhǔrén) point, also called the Shangguan (shàngguān) point, and follows the hairline to reach the forehead. Therefore, at the onset of a Spleen heat disease, the head feels heavy, the cheeks ache, and the complexion turns bluish. A branch of the Spleen channel also separates from the Stomach, ascends through the diaphragm, and flows into the heart. Its straight trunk passes upward through the diaphragm and runs alongside the throat, so the patient experiences vexation, nausea, and a feverish body. (Editorial note: The Jiayi Jing and the Taisu record that Spleen heat disease first causes heaviness of the head and pain in the cheeks, without the words "complexion turns bluish.")

When heat contends with upright Qi (zhèng qì), there is pain in the lumbar region, an inability to bend forward or lean back, abdominal distension, diarrhea, and pain beneath both sides of the jaw. A branch of the Stomach channel begins at the lower opening of the stomach, descends within the abdomen, and converges at the Qijie (qìjiē) region, the groin, before continuing downward into the thigh. The Qijie lies at the front of the waist, which is why there is lumbar pain. The Spleen channel enters the abdomen, connects to the Spleen organ, and links with the Stomach. The Stomach channel, in turn, runs from the Chengjiang point along the lower edge of the jaw, emerges at the Daying point, and follows the Jiache point. Thus abdominal distension and diarrhea appear together with pain beneath both sides of the jaw.

The illness worsens on the days of the Jia and Yi (jiǎ yǐ) stems, which belong to Wood. It resolves with profuse sweating on the days of the Wu and Ji (wù jǐ) stems, which belong to Earth. If Qi rebels upward, the patient dies on a Jia or Yi day. Spleen belongs to Earth, and Wood can overcome Earth, so the illness worsens on Jia and Yi days and may even prove fatal. Wu and Ji belong to Earth, the phase governing the Spleen, so the illness is resolved by profuse sweating on those days. The text does not discuss the signs of rebellious Qi.

Treatment should needle the Foot Taiyin (tàiyīn) Spleen channel and the Foot Yangming (yángmíng) Stomach channel. Taiyin refers to the Spleen channel, and Yangming refers to the Stomach channel. (Editorial note: The Jiayi Jing, Part Two on Heat Diseases, states that at the onset the patient has heaviness of the head, pain in the cheeks, vexation, and fever. When heat contends with upright Qi, there is lumbar pain with inability to bend forward, abdominal fullness, and pain in both jaws. Other signs include sudden diarrhea, hunger without desire to eat, frequent belching, heat in the middle burner, coolness of the feet, abdominal bloating, indigestion, frequent vomiting, discharge of pus and blood in the stool, and nausea without the ability to vomit. Treatment should first select Zusanli (zúsānlǐ), then Taibai (tàibái) and Zhangmen (zhāngmén).)

In Lung heat disease, the onset brings chills and shivering, raised body hair, aversion to wind and cold, a yellowed tongue coating, and fever. The Lung governs the skin and nourishes the fine body hair on the exterior. Therefore, when heat invades the Lung, shivering, aversion to cold, and raised hair appear first. The Lung channel begins in the middle burner, descends to connect with the Large Intestine, then turns back and ascends along the stomach's opening. Now that Lung heat has passed into the Stomach and the Stomach heat rises, the tongue coating turns yellow and the body becomes feverish.

When heat contends with upright Qi, there is wheezing and coughing, pain that wanders across the chest and back, an inability to take deep breaths, and fairly severe headache.

After sweating, one feels cold.

The lung lies above the diaphragm, and lung Qi governs the movement of the chest; when lung Qi is disordered, cough arises. The lung also stores Qi and governs breathing. The back is the place where the organs of the chest are reflected, so lung disease produces wheezing and cough, pain in the chest and back, and even breathing that cannot remain smooth. The luo (collateral) vessels of the lung, branches that separate from the jing (channel) vessels, converge upward into the ear. Now heat-evil steams upward, so there is headache; when the disease is severe, there is sweating with chills.

The illness worsens on bingding days, and on gengxin days there is profuse sweating. If Qi movement becomes reversed and chaotic, death occurs on bingding days. The lung belongs to Metal, while bingding belongs to Fire, and Fire overcomes Metal. This is why the illness worsens on bingding days and may even lead to death. Gengxin belongs to Metal, so profuse sweating occurs on gengxin days. The specific manifestations of disordered Qi movement are not recorded in the classic.

Needling the Hand Taiyin (Lung channel) and the Hand Yangming (Large Intestine channel) to release a drop of blood the size of a bean will bring immediate improvement. One should first observe which points on the Taiyin Lung channel and the Yangming Large Intestine channel show full collateral vessels, and then needle and bleed at those places.

Patients with kidney heat initially suffer lumbar pain, aching calves, thirst with frequent drinking, and fever. The Bladder channel descends from the inner side of the scapula beside the spine to reach the lumbar region, and the lumbar region is also the external correspondence of the Kidney, so lumbar pain appears first. The Kidney channel ascends from behind the inner ankle, passing along the inner side of the calf and the inner side of the popliteal fossa. Another branch rises from the Kidney, penetrates the Liver and the diaphragm, enters the lung, and ascends along the throat, flanking the root of the tongue. Therefore there are aching calves, thirst with excessive drinking, and fever.

When heat-evil contends with Zheng-Qi (upright Qi), there is pain and stiffness of the neck, cold and aching calves, heat in the soles of the feet, and reluctance to speak. The Bladder channel begins in the brain, and a branch descends through the neck. The Kidney channel begins beneath the small toe, runs obliquely to the center of the sole, and then passes beneath the Rangu (navicular bone) and behind the inner ankle. Another branch enters the heel and then ascends along the inner side of the calf. The main trunk of the Kidney channel also rises from the Kidney, penetrates the Liver and diaphragm, enters the lung, ascends along the throat, and flanks the root of the tongue. This explains the neck pain and stiffness, the cold and aching calves, the heat in the soles, and the reluctance to speak. The Newly Corrected notes indicate that the Jiayi Jing (Classic of Categories) writes this point as Rangu. The character for heel, gen, is to be read as the character for root, also gen.

The sinew-channels of the Kidney run up both sides of the spine to the neck, knot at the occipital bone, and join the sinew-channels of the Bladder. The Bladder vessels also pass through the neck and descend, so when Qi movement is reversed there is neck pain together with a sensation of dizziness and swaying, as if one could not stand steadily. The term dàndàn describes this unsettled, swaying feeling.

The illness worsens on wuji days, and on renkui days there is profuse sweating. If Qi movement becomes reversed and chaotic, death occurs on wuji days.

The kidney governs water. Wu and Ji belong to earth, and earth overcomes water, so the illness worsens and the patient may die on a wu day or a ji day. Ren and gui belong to water, so the patient sweats profusely on ren or gui days. In treatment, needle the foot shaoyin channel (kidney channel) and the foot taiyang channel (bladder channel).

For all sweating disorders, sweating should be induced on the days when the Five Phases (wu xing) overcome the pathogen. When qi is at its peak, that is the day it can overcome the pathogen, so sweating should be induced on the corresponding prosperous days.

In liver heat, the left cheek reddens first. Liver qi corresponds to wood, and wood qi corresponds to spring. When a person stands facing south, the left side corresponds to the east, so the left cheek is observed first. In heart heat, the forehead reddens first. Heart qi corresponds to fire, and fire tends upward. The forehead lies at the top of the face, so it is observed. In spleen heat, the nose reddens first. Spleen qi corresponds to earth, and earth occupies the center. The nose lies at the center of the face, so it is observed. In lung heat, the right cheek reddens first. Lung qi corresponds to metal, and metal qi corresponds to autumn. When a person stands facing south, the right side corresponds to the west, so the right cheek is observed first. In kidney heat, the chin reddens first. Kidney qi corresponds to water, and water tends downward, so the chin is observed.

When the reddening appears before the illness has fully developed, needling at that stage is called "treating what has not yet arisen" (zhì wèi bìng). The sage does not wait for illness to take shape before treating it, but treats what has not yet formed. He does not wait for disorder to erupt before governing it, but governs what has not yet occurred. This is the principle meant here.

Heat disease begins at the corresponding site and ends on its response day (yīng qī). The response day is the day of the great sweat. Liver corresponds to jia and yi days, heart to bing and ding days, spleen to wu and ji days, lung to geng and xin days, and kidney to ren and gui days. These are the response days for the heat disease of each organ.

If needling uses the reverse method of drawing qi (fǎn qǔ qì), the disease passes through three cycles of channel transmission before it ends. "Reverse drawing of qi" means needling the organ qi that overcomes the diseased organ. Examples include needling spleen for liver disease, kidney for spleen disease, heart for kidney disease, lung for heart disease, and liver for lung disease. All of these reverse the needling of the five organ qi. "Three cycles" refers to the pathogenic qi moving through the three yin and three yang channels in three rounds. Another account holds that in taiyang disease one drains the yangming channel, in yangming disease one drains the shaoyang channel, in shaoyang disease one drains the taiyin channel, in taiyin disease one drains the shaoyin channel, and in shaoyin disease one drains the jueyin channel. This is the reverse selection of qi from the three yin and three yang channels.

If one again violates the usual method and repeats this reverse needling, the patient will die. Having already needled in reverse and set the pathogenic qi in motion, one who needles in reverse a second time commits the offense of going against the method. Even a single reverse needling requires three cycles before the illness ends. How then could a patient survive continued violation of the method?

For conditions that call for sweating, sweat will pour forth abundantly when the day arrives that stands in controlling relation to the pathogenic qi. Wang Bing's commentary reads: "When upright Qi (zhèngqì) is in ascendance, it can overcome the evil qi, so each condition is made to sweat on the day its upright Qi prevails." The New Collation notes that this commentary runs to twenty-four characters, repeats the preceding text, and should be deleted, and that the Jiayi Jing and the Taisu do not record this repetition.

In treating heat disorders, one may first have the patient drink cold water and then needle. The patient must also be dressed in cool clothing and kept in a cold place, and treatment is stopped once the body has cooled. When cold water enters the stomach, yang qi surges outward, which is why cold water is given before needling. Once the heat recedes, coolness arises in its wake, and when the body is cool, needling may cease.

When heat first arises with chest and flank pain and restless movement of the hands and feet, one should needle the Foot Shaoyang channel (the gallbladder channel, zú shàoyáng) and supplement the Foot Taiyin channel (the spleen channel, zú tàiyīn). This is offered as an example of the correct method of treatment. Foot Shaoyang belongs to Wood, and by draining its Wood qi while supplementing the Earth qi of Foot Taiyin, one guards against the Wood qi passing further into the Earth channel. For chest and flank pain, one may select Qiuxu, located in the depression below the outer ankle, where the Foot Shaoyang channel passes. The needle may be inserted to a depth of five fen, a measure taken from the patient's own body in the ancient manner of the cun, and retained for seven breaths, a count based on respiration. If moxibustion is used, three cones of moxa may be burned. For restless hands and feet in heat disorders, the text does not specify a particular channel to treat, but when supplementing Foot Taiyin, one should select points at the Jing (well) and Ying (spring) positions, the first two of the five transporting points on each channel.

The New Collation further observes that, on closer examination, both the Quanyuanqi edition and the Taisu write "Hand Taiyin" rather than "Foot Taiyin." Yang Shanshan explains that the Hand Taiyin channel connects upward to the lung and emerges from the lung at the armpit, which accounts for chest and flank pain. The Lingshu Jing also records that when heat is accompanied by chest and flank pain and restless hands and feet, one should seek the tendon points, using the fourth of the Nine Needles to locate the site of the tendon disorder, and if it cannot be found in the liver channel, one should search the lung channel. By this reasoning, the reading "Hand Taiyin" is correct.

In severe cases, the method of "fifty-nine needlings" is used. The fifty-nine needlings consist of five rows of points on the head, with five points in each row, used to disperse the yang heat that rises in disorder throughout the body. Dazhu, Yingshu, Quepen, and the back-transporting points (these eight points, counted on both sides) are used to drain heat from the chest. Qijie, Zusanli, Shang Juxu, and Xia Juxu (these eight points) are used to drain heat from the stomach. Yunmen, Yugu, Weizhong, and Suikong (these eight points) are used to drain heat from the four limbs. Five points beside each of the five zang back-transporting points, ten points in all, are used to drain heat from the five zang organs. All fifty-nine points are distributed on both the left and right sides of the regions affected by the heat, which is why needling is performed in this manner in severe cases.

The points along the midline of the top of the head are Shangxing (Upper Star), Xinhui (Fontanelle Meeting), Qianding (Anterior Vertex), Baihui (Hundred Convergences), and Houding (Posterior Vertex). The points in the two adjacent rows are Wuchu (Five Places), Chengguang (Bright Receiving), Tongtian (Penetrating Heaven), Luoque (Connecting Retreat), and Yuzhen (Jade Pillow). Further out to each side are Linqi (Tears Overflowing), Muchuang (Eye Window), Zhengying (Upright Camp), Chengling (Spirit Receiving), and Naokong (Brain Void).

Shangxing lies on the midline of the vertex, on the straight line running upward from the bridge of the nose, one cun within the hairline. The cun is a body-inch, a unit of length measured against the patient's own proportions. The point sits in a depression about the size of a bean. It is needled to a depth of four fen. The editors note that the commentaries to the Jiayi Jing (Systematic Classic of Acupuncture and Moxibustion) and the Shuire Xuelun (Discourse on Water, Heat and the Points) both give three fen. Given the needling methods described below, they suggest that Shangxing should be needled to three fen and Xinhui to four, following those two texts. Xinhui lies one cun behind Shangxing, in a depression, and is needled in the same way as Shangxing. Qianding lies one cun and five fen behind Xinhui, in a depression between the bones of the skull, and is needled in the same way as Xinhui. Baihui lies one cun and three fen behind Qianding, at the crown of the head where the hair whorls, in a depression that can hold one finger. It is the meeting point of the Du channel and the Foot Taiyang channel, and is needled in the same way as Shangxing. Houding lies one cun and five fen behind Baihui, above the occiput, and is needled in the same way as Xinhui. All five points are places where the qi of the Du channel emerges. Shangxing is retained for six breaths, a count taken by respiration. If moxibustion is used, five zhuang (cones, each being one burning segment of moxa wool) are applied.

In the adjacent row, Wuchu lies one cun and five fen to each side of Shangxing. Chengguang lies one cun behind Wuchu. Tongtian lies one cun and five fen behind Chengguang. Luoque lies one cun and five fen behind Tongtian. Yuzhen lies seven fen behind Luoque. All five points are places where the qi of the Foot Taiyang channel emerges, and they may be needled to a depth of three fen. Wuchu and Tongtian are each retained for seven breaths, Luoque for five, and Yuzhen for three. If moxibustion is used, three zhuang may be applied. The editors note that the Jiayi Jing says Chengguang should not be moxibused, and that Yuzhen should be needled to a depth of two fen.

Among the points further out to each side, Linqi lies directly above the pupil, five fen inside the hairline. It is the meeting point of the Foot Taiyang, Foot Shaoyang, and Yangwei channels…

Ying (name of an acupoint; the original text continues from the preceding passage) lies one cun from Chengling, and Chengling lies one cun and five fen from Naokong. These five points are therefore all sites where the Foot Shaoyang channel meets the Yangwei vessel. Naokong may be needled to a depth of four fen, and the others to three fen. Linqi is retained for seven breaths, and if moxibustion is used, five cones may be applied.

Dazhu lies below the first vertebra behind the neck, in the hollows one and a half cun on either side of the spine. It is where the Governing Vessel (Dumai) collateral meets the qi of the Foot Taiyang and Hand Taiyang channels. It may be needled to a depth of three fen and retained for seven breaths. If moxibustion is used, five cones may be applied.

Newly collated note: The Jiayi Jing (Classic of Categorical Acupuncture) records seven cones, and the commentary on the Qi Xue (Qi Cavities) also records seven. The commentaries on the Ci Su (Puncturing Malaria) and the Re Xue (Heat Points) record five.

Yingshu refers to the Shu point within the chest, formally called Zhongfu. It lies six cun on either side of the midline of the chest, one cun below Yunmen, and in the first intercostal space above the nipple, in the hollow where the arterial pulse can be felt. The patient should lie supine for this point. It is where the Hand Taiyin channel meets the Foot Taiyin channel. It may be needled to a depth of three fen and retained for five breaths. If moxibustion is used, five cones may be applied.

Quepen lies in the hollow above the transverse bone of the shoulder and is where the qi of the Hand Yangming channel emerges. It may be needled to a depth of three fen and retained for seven breaths. If moxibustion is used, three cones may be applied.

The back-transport point (Beishu) should be Fengmen, also called Refu. It lies below the second vertebra, one and a half cun on either side of the spine, and is where the Governing Vessel meets the Foot Taiyang channel. It may be needled to a depth of five fen and retained for seven breaths. If moxibustion is used, five cones may be applied. However, the extant Mingtang Zhonggao Tujing (Illustrated Mingtang Classic) does not record a "back-transport point," so the exact location intended here remains uncertain.

Newly collated note: Wang Bing's commentary on the Shui Re Xue Lun (Treatise on Water and Heat Points) identifies Fengmen and Refu as back-transport points. In his commentary on the Qi Xue Lun (Treatise on the Qi Cavities), he also identifies Dazhu as a back-transport point. The phrase "not yet determined" here probably reflects doubt about which location the term "back-transport point" refers to.

Qichong lies in the abdomen, above the two ends of the transverse bone below the navel, one cun above the groin (the shuxi, or inguinal region), at the place where the arterial pulse can be felt. It is where the qi of the Foot Yangming channel emerges. It may be needled to a depth of three fen and retained for seven breaths. If moxibustion is used, five cones may be applied.

Zusanli lies three cun below the knee, on the outer side of the shin bone, between two tendons, on the Foot Yangming channel…

……The needle may be inserted to a depth of one body inch (tongshencun), and retained for seven exhalations. If moxibustion is used, three moxa cones may be burned.

Upper Juxu (Juxu Shanglian) lies at the intersection of the Foot Yangming channel (zu yangming jing) and the Foot Taiyang channel, three body inches below Zusanli, and is the point where the Foot Yangming channel qi emerges. The needle may be inserted eight fen of a body inch. If moxibustion is used, three moxa cones may be burned.

Lower Juxu (Juxu Xialian) lies at the intersection of the Foot Yangming channel and the Foot Shaoyang channel, three body inches below Upper Juxu, and is likewise the point where the Foot Yangming channel qi emerges. The needle may be inserted three fen of a body inch. If moxibustion is used, three moxa cones may be burned.

Yunmen lies below the Jugu point, on either side of the midline of the chest. The Song-dynasty editors' corrections note that the commentary in the "Qixue Lun" (Discourse on the Qi Points) reads "beside the Ren channel (ren mai)." Although the wording differs, the point indicated is the same. Its distance from the Ren channel is six body inches. The point where the arterial pulse can be felt is Zhongfu, and Yunmen lies one body inch below it. Yunmen is the point where the Hand Taiyin channel (shou taiyin jing) qi emerges, and it is located with the arm raised. The needle may be inserted seven fen of a body inch. If moxibustion is used, five moxa cones may be burned.

The "Yu Gu point" (Yu Gu Xue) is not recorded in the extant Mingtang, Zhonggao, or Tujing. It is conjectured that this may refer to Jianyu, which is used to disperse heat from the limbs. Jianyu lies between the two bones at the tip of the shoulder, and it is the point where the Hand Yangming channel (shou yangming jing) meets the Qiao channel (qiao mai). The needle may be inserted six fen of a body inch and retained for six exhalations. If moxibustion is used, three moxa cones may be burned.

Weizhong lies in the center of the transverse crease at the popliteal fossa, at the bend behind the knee, where the arterial pulse can be felt. The Song-dynasty editors' corrections note that Wang Bing also annotated Weizhong in the "Qixue Lun," the "Gukong Lun" (Discourse on Bone Hollows), and the "Ciyao Lun" (Discourse on Treating Malaria). The annotations in the other three passages do not contain the five characters "at the back of the knee where the leg bends," which differ from the wording here. This may reflect only a difference in detail, and the meaning is essentially unchanged. Weizhong is the point where the Foot Taiyang channel qi enters. The needle may be inserted five fen of a body inch and retained for seven exhalations. If moxibustion is used, three moxa cones may be burned.

Suikong, also called Yaoshu, lies in the intervertebral space below the twenty-first vertebra of the spine, and it is the point where the Du channel (du mai) qi emerges. The needle may be inserted one fen of a body inch. The Song-dynasty editors' corrections note that the Jiayi Jing (Canon of Acupuncture and Moxibustion) and the commentary in the "Shuire Xue Lun" (Discourse on Water-Heat Points) record the depth as two body inches, while the commentaries in the "Qifu Lun" (Discourse on the Palace of Qi) and the "Gukong Lun" record it as one fen. The needle is retained for seven exhalations. If moxibustion is used, three moxa cones may be burned.

The "five" in "the five points beside the Back-Shu points of the five viscera" refers to Pohu...

The original text breaks off here.

The five acupoints Shentang, Pohu, Hunmen, Yishe, and Zhishi all lie on either side of the spine, three cun apart from one another, and belong to the area where the qi and blood of the Foot Taiyang channel are transported and infused.

Pohu lies below the third vertebra, on either side of the spine. When locating the point, the patient sits upright. Needling may be inserted five fen, and if moxibustion is used, five moxa cones may be applied. Shentang lies below the fifth vertebra, on either side of the spine. Needling may be inserted three fen, and if moxibustion is used, five moxa cones may be applied. Hunmen lies below the ninth vertebra, on either side of the spine. With the patient seated upright, needling may be inserted five fen, and if moxibustion is used, three moxa cones may be applied. Yishe lies below the eleventh vertebra, on either side of the spine. With the patient seated upright, needling may be inserted five fen, and if moxibustion is used, three moxa cones may be applied. Zhishi lies below the fourteenth vertebra, on either side of the spine. With the patient seated upright, needling may be inserted five fen, and if moxibustion is used, three moxa cones may be applied.

This is what the text calls the "Fifty-Nine Needling Method" (wushijiu ci fa). The fifty-nine needlings recorded in the Zhenjing (Needling Classic) differ from the account given here. Although both approaches regard these points as important for treating febrile diseases, the principles and directions by which they are combined are entirely different. Therefore, points should be selected according to the disease signs and specific manifestations, and needling should be carried out in accordance with the corresponding classical methods.

When a febrile disease first manifests as pain in the arm, the Hand Yangming and Hand Taiyin channels should be needled to induce sweating, and the arm pain will cease. Lieque governs arm pain. Lieque is the luo-connecting point of the Hand Taiyin channel, located about two and a half cun above the wrist, where a collateral branches off and leads to the Hand Yangming channel. Needling may be inserted three fen, with the needle retained for three breaths. If moxibustion is used, five moxa cones may be applied. To promote sweating, Shangyang may be selected. Shangyang is the jing-well point of the Hand Yangming channel, located on the inner side of the index finger, about a leaf of leek's width from the corner of the nail, where the qi of the Hand Yangming channel emerges. Needling may be inserted one fen, with the needle retained for one breath. If moxibustion is used, one moxa cone may be applied.

When a febrile disease first appears in the head, the Foot Taiyang channel at the neck should be needled to induce sweating, and the condition will cease. Tianzhu governs this situation. Tianzhu lies in the depression beside the hairline at the back of the neck, outside the large tendon, where the qi of the Foot Taiyang channel emerges. Needling may be inserted two fen, with the needle retained for six breaths. If moxibustion is used, three moxa cones may be applied.

When a febrile disease first appears in the lower leg, the Foot Yangming channel should be needled to induce sweating, and the condition will cease.

The editors' note (Xinjiaozheng) states that this passage is absent from both the original Suwen (Plain Questions) and the Taisu (Great Simplicity). It has been supplemented from the Jiayi Jing (Systematic Classic of Acupuncture and Moxibustion).

At the onset of a heat disease, the patient first feels heavy in the body, aching in the joints, and deafness, and prefers to keep the eyes closed. The Shaoyin (lesser yin) channel of the foot should be needled. The text does not specify the principal points here, so it should be noted that the well points (jing xue) and spring points (ying xue) may be used. The editors add that the Lingshu Jing (Spiritual Pivot) records that for a patient with heaviness of the body, bone pain, deafness, and a desire to close the eyes, the fourth method of needling, which draws out the qi of the bone, may be applied at the bone level. If no pathogenic qi can be found at the bone level, one should instead treat the qi of the earth level, which corresponds to the Spleen. In serious cases, the ancient practice of the fifty-nine needlings (wushijiu ci), a set of needling methods for heat disease, may be applied.

If, at the onset of a heat disease, dizziness, blurred vision, confusion with fever, and fullness in the chest and flanks appear first, the Shaoyin and Shaoyang (lesser yang) channels of the foot should be needled. In other words, the well and spring points of these two channels should be treated.

The qi-complexion of the Taiyang (greater yang) channel appears on the cheekbones, and redness there signals heat disease. Rong (flourishing, manifestation) means "adornment" or "display," and refers to a red appearance on the cheekbone, as if it had been painted on. The cheekbone here refers to the area below the eye, close to the outer corner. Because Taiyang corresponds to Fire, the complexion is red. The editors note that Yang Shangshan held that red cheekbones signal bone heat, which differs from Wang Bing's commentary.

For the phrase "rong wei jiao" (flourishing not yet crossed), the editors note that the Jiayi Jing and the Taisu both read "rong wei yao" (flourishing not yet premature), and that some editions of the later "rong wei jiao" also read "rong wei yao."

An ancient source says: "Now first induce sweating, then wait for the appropriate days." Here, rong is a corruption of ying (nutritive qi). Yue (says) introduces a quotation from an ancient canon. The meaning is this: even when the complexion is clearly vigorous, as long as yin and yang have not yet crossed (jiao), one should first induce sweating according to the method. "Waiting for the days" refers to waiting for the days matched to the Five Phases (wuxing). For Liver disease, wait for the days Jia and Yi; for Heart disease, Bing and Ding; for Spleen disease, Wu and Ji; for Lung disease, Geng and Xin; and for Kidney disease, Ren and Gui. The meaning of "crossing" (jiao) here will be explained further below.

If the red disease complexion of the Taiyang channel appears together with the pulse of the Jueyin (terminal yin) channel, the patient will die within three days at most. In other words, a Taiyang red color appears on the body surface while the Jueyin wiry pulse should appear within. Taiyang disease ought normally to pass into Yangming (yang brightness); but now a Jueyin pulse appears, which shows that the Earth qi has declined, and that Wood qi, taking advantage of the void, overcomes Earth. Hence the illness is critical. With Earth qi already defeated and Wood qi in excess, Wood corresponds to the number three, so the death is judged to come within three days.

The character bing (disease) in "its heat disease connects inward to the kidney" may perhaps be read as qi (qi), a likely scribal error. If the red qi-appearance occurs beside the nose and connects inward, it is the complexion of the Shaoyang channel, not that of the Jueyin channel. Why? Because the area beside the nose belongs to the kidney region……

This passage discusses how changes in facial color during febrile disease relate to the course of the illness, and which spinal vertebrae correspond to which areas of heat disorder.

When a matching color appears on the part of the face near the nose, it may be related to the kidney (shèn). The collators note that some editions change "kidney" here to "nose," but the Jiayi Jing (Jiǎyǐ Jīng, Classic of Categories) and the Taisu (Tàisù, Plain Questions of the Great Ground) both write "kidney." Yang Shangshan (Yáng Shàngshàn) explains that Greater Yang (tàiyáng) belongs to Water, Reverting Yin (juéyīn) belongs to Wood, and Water can generate Wood. When Wood qi is vigorous and Water qi is weak, the Water color governed by Greater Yang appears, and a Wood color appears alongside it, competing for prominence. This shows that Water qi is failing. If the febrile disease draws inward to the kidney and the kidney is further harmed by heat, the condition becomes critical. The old editions do not contain the six characters shàoyáng zhī mài sè yě ("this is the color of the Lesser Yang vessel"). Wang Bing (Wáng Bīng) added them, and the collators judge that his commentary departs from the original meaning, so Yang Shangshan's explanation should be followed.

The color governed by the Lesser Yang (shàoyáng) channel appears on the front of the cheek, and heat that appears there is called a febrile disease. The phrase "front of the cheek" refers to the area just below the cheekbone, close to the sides of the nose. The collators note that the Jiayi Jing and the Taisu write the character for "front" (qián) in this phrase as the character for "sinew" (jīn). Yang Shangshan holds that the Foot Lesser Yang channel corresponds to the cheek, so a redness there shows that heat disorder has reached the sinews.

If the color governed by the Lesser Yang has not yet become intertwined with the colors of other vessels, but has only just appeared, the patient may still sweat, and the physician can wait and observe how the illness changes. If the color of the Lesser Yin (shàoyīn) then appears as well, death is a danger, and the text says the illness will not last beyond three days. The explanation is that the Lesser Yang belongs to Wood and the Lesser Yin belongs to Water. When the Lesser Yang is affected, the illness should normally pass into the Greater Yin (tàiyīn). If the Lesser Yin color now appears, Water qi is overpowering Wood qi, and Wood qi is therefore collapsing. The collators note that some have wanted to change "Lesser Yin" to "Reverting Yin," but the Jiayi Jing and the Taisu both read "Lesser Yin." They also observe that the six characters sǐ qī bù guò sān rì ("the period of death will not exceed three days") are absent from the old editions and from both of these books, and that Wang Bing supplied them.

The record of acupoints for febrile disease is as follows. The interspace below the third vertebra governs heat in the chest. The interspace below the fourth governs heat in the diaphragm. The interspace below the fifth governs liver heat. The interspace below the sixth governs spleen heat. The interspace below the seventh governs kidney heat. The area governed by kidney heat also extends down to the sacrum, the lower end of the spinal column near the coccyx.

"Vertebra" (zhuī) refers to the bones of the spinal column, and "sacrum" (dǐ) refers to the lower end of the spine. The text says that the qi of kidney heat connects outward with the tailbone and sacrum. A commentator observes that the organ-based heat disorders assigned to the interspaces in this passage do not exactly match the back-shu points (shū xué) of those organs. For this reason, the basis for these assignments is not fully clear.

The phrase "where the three vertebrae below the neck are depressed" describes a general method for counting the vertebrae. Starting from the neck and counting downward to the third vertebra, one locates the depression between the bones. The earlier statement that "the interspace below the third vertebra governs heat in the chest" means that, when using this point, one should take this depression as the place from which the qi emerges.

If an abnormality appears below the cheek and extends upward to the cheekbone, it indicates a possible large mass in the abdomen. An abnormality near the angle of the jaw indicates abdominal distension, and one behind the cheekbone indicates pain in the flanks and ribs.

An abnormality above the cheek indicates illness above the chest and diaphragm.

These are all methods of detecting disease in the abdomen by observing the Qi of the face's complexion.