《黃帝內經素問補註釋文》Vol. 48

The Yellow Emperor asked, “How is Qi distributed through the upper and lower parts of the human body?”

Qibo replied, “The body is divided at its midpoint. Above it are three kinds of Qi, belonging to the realm of Heaven and governed by Heavenly Qi. Below it are also three kinds of Qi, belonging to the realm of Earth and governed by Earthly Qi. Their names identify the kinds of Qi; the kinds of Qi identify the regions they occupy. Then, by considering whether the Qi in each region is cold or hot, one can determine where an illness has arisen. This is what is called the ‘midpoint,’ the location of the Celestial Pivot.”

The midpoint of the body referred to here is the navel. Some people take the waist to be the body’s midpoint, understanding “midpoint” as somewhere roughly central; this view is also common among people in the Central Plains. But if you straighten your arms toward Heaven and stretch your feet toward Earth, then measure the distance between them with a cord, the exact middle lies at the navel. It is therefore called the “midpoint,” the location of the Celestial Pivot. The Celestial Pivot lies on either side of the navel, two body inches away on each side. A “body inch” is a unit of measurement based on the proportions of a person’s own body.

The statement that there are three kinds of Qi above and below refers to the distribution of the Six Qi. For example, when lesser Yin governs Heaven—meaning that the lesser Yin Qi governs the season among the Six Qi—there is heat in the upper part, while the middle part also has greater Yang Qi, making three kinds of Qi in all. The same principle applies to all Six Qi: three govern Heaven, and three govern Earth. Thus, there are three kinds of Qi above the body’s midpoint and three below it. Their names identify the kinds of Qi, and the kinds of Qi identify the regions they occupy. The cold or heat of the Qi in each region then helps determine the symptoms of illness.

For example, the Qi of foot Jueyin is distributed along the inner side of the foot, lower leg, and thigh. It runs upward through the lower abdomen and along the ribs. The Qi of foot Yangming is distributed over the top of the foot, the outer lower leg, and the front of the thigh. It runs upward to the abdomen and beside the navel, then ascends along the chest and breasts to the face. The Qi of foot Taiyang begins above the eyes, passes over the forehead and head, and runs down along the back of the neck and trunk. It passes through the waist, crosses the hip joint, then descends along the back of the thigh into the foot. It passes through the calf and reaches the outer side of the little toe from behind the outer ankle.

The Qi of foot Taiyin runs upward along the foot and the inner side of the lower leg and thigh, passing through the abdomen and the front of the ribs. The route of foot Shaoyin Qi is the same. The Qi of foot Shaoyang runs upward along the outer lower leg, passes through the abdomen and both sides of the ribs, then passes over the cheeks and ears to the outer corners of the eyes, and spreads across both sides of the head. These are the regions governed by the Qi of the six foot channels.

The Qi of hand Jueyin, hand Shaoyin, and hand Taiyin runs outward across the chest from the heart area, then along the inner side of the arms to the tips of the middle, little, and big fingers. The Qi of hand Yangming, hand Shaoyang, hand…

Yang Qi gathers and rises, moving from the outer side of the hand up along the outer side of the arm. It passes over the shoulder and above the shoulder blade, reaching the head.

This is the area governed by the six Qi of the hand. To understand a condition and make a diagnosis, judge it according to where the Qi is located: illness in the Yin division is classified as a cold illness; illness in the Yang division is classified as a heat illness. Thus, when excess Qi and responding Qi take effect, if illness appears first and cold or heat must then be distinguished, the same principle applies.

The New Collation says: According to the “Treatise on the Subtle Patterns of the Six Qi,” above the Celestial Pivot—the axis where the Qi of Heaven and Earth meet—the Qi of Heaven governs; below it, the Qi of Earth governs. Where the Qi of Heaven and Earth converge, the Qi within the human body changes accordingly.

Therefore, when the Qi of Heaven prevails and the lower region falls ill along with it, the illness is named after Earth. When the Qi of Earth prevails and the upper region falls ill along with it, the illness is named after Heaven.

When the Qi of one side has prevailed and the other side has not yet recovered, the latter is suppressed and its movement obstructed. Advancing, it meets resistance; retreating, it is blocked by stagnation. Thus, when the Qi of Heaven prevails, the lower region also falls ill; when the Qi of Earth prevails, the upper region also falls ill. If the Qi of Heaven prevails and the lower region becomes ill, the Qi of Earth has been suppressed and obstructed, so the illness is named an Earth illness, after the “suppression of Earth Qi.” If the Qi of Earth prevails and the upper region becomes ill, the Qi of Heaven has been blocked, so the illness is named a Heaven illness, after the “blocking of Heaven Qi.”

For illnesses named after Heaven, treatment should accord with the Qi of Heaven and counter the Qi of Earth. For illnesses named after Earth, treatment should accord with the Qi of Heaven. For example, when Yangming governs Heaven and Shaoyin governs the spring, if the Qi of Heaven prevails and the lower region also falls ill, the illness arises because the lower region is suppressed. Since the upright Qi of Heaven has prevailed, treatment may counter the Qi of Heaven: the method should accord with the Qi of Heaven and use cooling. The same principle applies to cases in which Shaoyin and other Qi govern Heaven and one side prevails over the other.

The New Collation says: According to the “Treatise on the Cycles of the Six Epochs,” “When the upper region prevails, the Qi of Heaven descends and reaches the lower region; when the lower region prevails, the Qi of Earth moves in reverse and rises.” This describes the same situation.

“Excess arrives” means that excess Qi has come. “Responding Qi” refers to the side that has been suppressed and temporarily subdued, but has not yet taken effect. When the responding Qi takes effect, the names Heaven and Earth are no longer distinguished; treatment is based entirely on the nature of the responding Qi.

When excess Qi arrives but responding Qi has not yet taken effect, if illness has already arisen, it is judged according to whether it is named after the Qi of Heaven or the Qi of Earth. Once responding Qi has taken effect, whether the upper or lower region prevailed earlier, the illness’s cold or heat nature should be judged according to the responding Qi.

The Yellow Emperor asked, “Do the activities of excess Qi and responding Qi occur according to fixed patterns? Is their force necessarily as described?”

Qibo replied, “The timing has fixed positions, but the force is not necessarily so.”

In other words, although the timing and positions are set, whether the Qi becomes active is not certain.

The Yellow Emperor asked, “Please explain the principle.”

Qibo replied, “From the first Qi through the third Qi, the Qi of Heaven…”

The ebb and flow of climatic Qi includes the dominance and counteraction of both ruling Qi and guest Qi; this is a normal pattern. When the Qi of the four seasons reaches its final phase, Earth Qi takes charge. Where there is dominance, there will be counteraction; without dominance, there will be no counteraction.

The Yellow Emperor asked, “Why does dominant Qi appear again after counteracting Qi has arisen?” Qibo replied, “As soon as dominant Qi arrives, counteracting Qi follows; there is no fixed number of times this happens. When the dominant Qi declines, the counteracting Qi also stops. If the dominant Qi is slight, the counteracting Qi is slight. If dominant Qi appears again after the counteraction, and it is strong, the counteracting Qi will be strong too. Thus, dominant Qi rarely appears again after counteracting Qi. Even when it does, the counteraction will correspond to the strength of the dominant Qi. Although dominance and counteraction have no fixed number of occurrences, both naturally cease when their force declines.”

If dominant Qi appears again after counteracting Qi, but the counteracting Qi can no longer respond, harm will result and life will be injured. When dominant Qi appears without any counteraction, it is because the Qi responsible for responding has already weakened. If it has weakened so much that it cannot respond, the Heaven-given Qi that sustains life has been damaged. When that damage is severe, the force of life is exhausted.

The Yellow Emperor asked, “Why does counteracting Qi sometimes cause illness?” Qibo replied, “It is because the Qi is occupying a place unsuited to it, and the two cannot harmonize. When counteracting Qi becomes too strong, it makes the Qi that originally held dominance even stronger, and illness follows.”

This is like leaving one’s own palace and going somewhere else. One’s own strength has already weakened, and one does not harmonize with the ruling Qi of that place; resentment and harm then follow, leaving one able only to adapt and seek an advantage. So when counteracting Qi reaches its peak, the ruling Qi instead encroaches upon it, and counteracting Qi is harmed in turn.

“Fire, dryness, and heat” here refer to lesser Yang belonging to Fire, Yangming belonging to dryness, and lesser Yin belonging to heat. When lesser Yin or lesser Yang is in control below, Fire Qi occupies the position of Water; when Yangming governs above, Metal Qi occupies the position of Fire. When Metal Qi counteracts and restrains the dominant Qi, Fire Qi instead becomes dominant; when Fire Qi counteracts, Water Qi becomes dominant in turn. Among the other remaining Qi, dominance and counteraction do not count as the “fire, dryness, and heat” discussed here unless the ruling Qi’s dominance and restraint have caused illness.

The Yellow Emperor asked, “How should this be treated?” Qibo replied, “For dominant Qi, gently harmonize it when it is mild, and restrain it when it is severe. For counteracting Qi, bring it into balance when it is moderate, and weaken it when it is sudden and violent. In treatment, follow the Qi that currently has the advantage and settle the Qi that is being suppressed. Do not be bound by how many times the Qi has appeared; the aim is to restore balance. That is the principle of treatment.”

Here, “follow” means to treat in accordance with the force of the Qi; “settle” means to accord with the dominant Qi and make it moderate. “Restrain” means to check excess, “balance” means to harmonize, and “weaken” means to reduce the Qi that has the advantage. Treatment is not based on how many times the Qi has appeared, but on restoring the movement of Qi to balance.

The Yellow Emperor asked, “What happens when guest Qi and ruling Qi dominate and counteract one another?” Qibo replied, “Guest Qi refers to the six Qi of Heaven; ruling Qi refers to the fixed positions of Qi corresponding to the Five Phases. Each Qi has times when it is suited or unsuited to its position, so corresponding dominance and counteraction occur. When guest Qi and ruling Qi dominate one another, counteracting Qi does not necessarily follow.”

Guest Qi and Host Qi each have their own relative strength. Which one prevails, and the effects when it prevails, differ in each case.

The Yellow Emperor asked, “How can we tell when Guest Qi and Host Qi oppose or accord with one another?”

Qibo replied, “When Host Qi prevails over Guest Qi, it is called ‘opposition’; when Guest Qi prevails over Host Qi, it is called ‘accord.’ This is the pattern by which Heaven and Earth operate.

“Guest Qi receives the mandate of Heaven and governs its appointed direction. Host Qi resides beneath it and should, by nature, respectfully follow Heaven’s mandate. If Host Qi disobeys that mandate and instead prevails over Guest Qi, Heaven’s mandate cannot be carried out; hence this is called ‘opposition.’ When Guest Qi prevails over Host Qi, it receives Heaven’s mandate and carries it into effect, in keeping with the proper order; hence this is called ‘accord.’”

The Yellow Emperor asked, “What illnesses do these conditions cause?”

Qibo replied:

When Jueyin governs Heaven (the Qi of Jueyin governs the season), if Guest Qi prevails, there may be tinnitus and dizziness; in severe cases, coughing. If Host Qi prevails, there may be pain in the chest and flanks, an unresponsive tongue, and difficulty speaking. This occurs in years of the Snake and the Pig.

When Shaoyin governs Heaven, if Guest Qi prevails, there may be nasal congestion and sneezing, stiffness of the neck, a dull, feverish feeling in the shoulders and back, headache, shortness of breath, fever, deafness, and dim vision. In severe cases, there may also be swelling, bleeding, sores, coughing, and wheezing. If Host Qi prevails, there may be heat and agitation in the heart; in severe cases, pain in the ribs and fullness in the chest and flanks. This occurs in years of the Rat and the Horse.

When Taiyin governs Heaven, if Guest Qi prevails, the head and face may swell, and breathing may become rapid and labored. If Host Qi prevails, there may be fullness in the chest and abdomen, and drowsiness after eating. This occurs in years of the Ox and the Sheep.

When Shaoyang governs Heaven, if Guest Qi prevails, red rashes may appear on the skin, or red sores may form. There may also be vomiting, obstruction and pain in the throat, headache, swelling in the throat, deafness, and bleeding; convulsions may also occur inside the body. If Host Qi prevails, there may be tightness in the chest and coughing, with the head raised to breathe. In severe cases, there may be coughing of blood and heat in the hands. This occurs in years of the Tiger and the Monkey.

When Yangming governs Heaven, the clear, descending Qi returns and remains in the body, causing coughing, nosebleeds, obstruction in the throat, and heat in the chest. If the coughing continues and blood is coughed up that is pale red and resembles flesh or lung tissue, death will follow.

Here, “returns” means that something goes back to its original position. “White blood” means pale red blood coughed up in a form resembling flesh or lung tissue. This occurs in years of the Hare and the Rooster. The New Commentary on the Corrected Texts says: “On close examination, this passage does not say whether Guest Qi or Host Qi prevails. This is because Metal Qi occupies the position of Fire, where, by principle, Guest Qi cannot prevail; therefore, the text does not mention it.”

When Taiyang governs Heaven, if Guest Qi prevails, there may be discomfort in the chest and a runny nose with clear discharge; exposure to cold may bring on coughing. If Host Qi prevails, there may be a ringing sound in the throat. This occurs in years of the Dragon and the Dog.

When Jueyin governs Earth (the Qi of Jueyin governs the Earth Qi), if Guest Qi prevails, the major joints may become difficult to move, and the body may develop spasms, stiffness, rigidity, and convulsions; movement of the limbs may also become impaired. If Host Qi prevails, the tendons and bones may shake or become rigid together, with frequent pain in the lower back and abdomen. This occurs in years of the Tiger and the Monkey. “Major joints” here refers to the lower back and knees.

When Shaoyin governs Earth, if Guest Qi prevails, there may be pain in the lower back, buttocks, thighs, knees, thigh bones, calves, shins, and feet, or illness affecting these areas.

Dizziness, fever, soreness, and swelling may occur, along with an inability to stand for long and changes in urination and bowel movements. When the governing Qi is dominant, counterflow may arise among these symptoms.

When Qi surges upward, it may cause heart pain and fever, along with various kinds of painful obstruction between the chest and diaphragm. The pain occurs around the flanks and ribs.

Sweating may become continuous and impossible to contain, followed by coldness of the hands and feet from counterflow.

“Five Mao” and “Five You” refer to the five years associated with Mao years and You years, respectively.

When Taiyin is in charge below—meaning that the Qi of Taiyin presides beneath the earth and governs the latter half of the year—and the guest Qi is dominant, the feet may become weak and the body heavy, while bowel and urinary movements become irregular. Dampness invading the lower burner—the lower part of the body, including areas such as the kidneys and bladder—may cause loose stools, edema, and disorders in concealed, curved parts of the body. When the governing Qi is dominant, cold Qi may counterflow upward, causing distension and fullness in the chest and abdomen and difficulty swallowing food. In severe cases, hernia may develop.

“Five Chen” and “Five Xu” refer to the five years associated with Chen years and Xu years, respectively. “Disorders in concealed, curved parts” means illnesses affecting hidden or curved areas of the body.

When Shaoyang is in charge below and the guest Qi is dominant, pain may occur in the lower back and abdomen, accompanied by an unusual aversion to cold. In severe cases, there may be white discharge and white urine. When the governing Qi is dominant, heat may counterflow upward and lodge in the heart, causing heart pain and fever, obstruction between the chest and diaphragm, and vomiting. The same symptoms may also occur when Shaoyin is in charge below.

“Five Si” and “Five Hai” refer to the five years associated with Si years and Hai years, respectively.

When Yangming is in charge below and the guest Qi is dominant, cold, clear Qi disturbs the lower body, causing hardness and distension in the lower abdomen and frequent diarrhea. When the governing Qi is dominant, the lower back may feel heavy, the abdomen may hurt, and the lower abdomen may feel cold. Diarrhea may be thin and loose like duck droppings. Cold Qi makes the intestines cold and counterflows upward into the chest. In severe cases, there may be panting and an inability to stand for long.

“Five Zi” and “Five Wu” refer to the five years associated with Zi years and Wu years, respectively. “Duck” here describes stools that are soft and loose like duck droppings.

When Taiyang is in charge below, if cold Qi grows strong again and lingering cold remains in the body, pain may occur in the lower back and buttocks, with difficulty bending and stretching. The thighs, lower legs, feet, and knees may all hurt.

“Five Chou” and “Five Wei” refer to the five years associated with Chou years and Wei years, respectively. The supplementary note by later editors says that this passage does not discuss whether the guest Qi or governing Qi is dominant. Presumably, this is because Taiyang belongs to Water and occupies the position of Water, so no such distinction is made.

The Yellow Emperor asked, “Good. How should these conditions be treated?”

Qi Bo replied, “If the illness is in the upper part of the body, make it descend; if it is in the lower part, make it rise. If there is excess, reduce it; if there is deficiency, supplement it. Then use suitable methods to support the treatment and adjust it according to the condition, so that the governing Qi and guest Qi are both settled, and cold, heat, warmth, and coolness are all brought into balance. When the governing and guest Qi are alike, treat with the opposite method; when their natures differ, follow the direction of the illness.”

To “make what is in the upper part descend” means to restrain its excess; to “make what is in the lower part rise” means to support its deficiency. To “reduce what is in excess” means to curb its excessive force; to “supplement what is deficient” means to preserve its original Qi. Even after excess has been restrained and deficiency supported, the governing Qi and guest Qi must still each be brought to rest. If any Qi loses its proper place, they may struggle against one another like spears clashing and thorns tangling, each seeking an opening and neither tolerating the other. In the end, pathogenic influences from inside and outside may invade together, making the illness critical. Here, “alike” means that climatic qualities such as cold, heat, warmth, and coolness are similar and in harmony; “different” means that the natures of Water, Fire, Metal, Wood, and Earth do not match.

When harmonizing medicines, if the nature of the medicine accords with the course of the illness, treatment should counter the Qi that restrains the pathogenic influence. If the medicine’s nature does not accord with the course of the illness, treatment should follow the Qi that does not restrain it. In treatment, use the corresponding flavor when you wish to tonify, and likewise use the corresponding flavor when you wish to drain. Whether the Qi is dominant or subdued, weaken any excessive tendency. Why do this? Fire by nature is restless, and the same principle applies when treating heat disorders.

The Yellow Emperor asked, “I understand using hot medicines to treat cold disorders and cold medicines to treat heat disorders, and treating in opposition when the medicine’s Qi accords with the course of the illness, but following when it does not. How, then, should the five medicinal flavors be used?”

Qibo replied, “When the Wood phase governs, drain with sour flavor and tonify with pungent flavor. The period governed by Wood begins sixty-one days before the spring equinox; it is the first of the six seasonal Qi periods.

“When the Fire phase governs, drain with sweet flavor and tonify with salty flavor. The period of sovereign Fire is the second Qi period, beginning sixty-one days after the spring equinox. Ministerial Fire governs the third Qi period, around the summer solstice. Although sovereign Fire and ministerial Fire are distinguished as two kinds, their Qi functions in the same way.

“When the Earth phase governs, drain with bitter flavor and tonify with sweet flavor. The period governed by Earth begins sixty-one days before the autumn equinox; it is the fourth Qi period.

“When the Metal phase governs, drain with pungent flavor and tonify with sour flavor. The period governed by Metal begins sixty-one days after the autumn equinox; it is the fifth Qi period.

“When the Water phase governs, drain with salty flavor and tonify with bitter flavor. The final Qi period falls around the winter solstice.”

Here, “governs” means the Five Phases Qi that directs changes in the climate during a given period. The first through final Qi periods divide the year into six intervals.

“For guest Qi of Jueyin, tonify with pungent flavor, drain with sour flavor, and moderate with sweet flavor. For guest Qi of Shaoyin, tonify with salty flavor, drain with sweet flavor, and astringe with salty flavor.”

The New Collation points out that the Treatise on the Qi of the Zang Organs in Accordance with the Seasons says that when the Heart Qi needs to be relaxed, sour flavor should promptly be used to astringe it; when the Heart Qi needs to be softened, salty flavor should promptly be used to soften it. It therefore identifies “astringe with salty flavor” here as an error.

“For guest Qi of Taiyin, tonify with sweet flavor, drain with bitter flavor, and moderate with sweet flavor. For guest Qi of Shaoyang, tonify with salty flavor, drain with sweet flavor, and soften with salty flavor. For guest Qi of Yangming, tonify with sour flavor, drain with pungent flavor, and disperse with bitter flavor. For guest Qi of Taiyang, tonify with bitter flavor and drain with salty flavor; use bitter flavor to make it firm and pungent flavor to moisten it. Pungent flavor can also open the interstices between the skin and muscles, distribute fluids, and keep the movement of Qi unobstructed.

“Guest Qi and host Qi each govern for sixty-one days. Guest Qi has no fixed position; it shifts from year to year.”

When pathogenic influences are excessive, reduce what is in excess and strengthen what is relatively deficient. When the body’s healthy Qi is excessive, reduce what is in excess, then nourish what is deficient. Whether to treat the excess and deficiency gently or forcefully should be decided according to the condition.

The Yellow Emperor said, “Well said. I would like to know why Yin and Yang are divided into three categories. How does this work?”

Qibo replied, “Yin and Yang Qi wax and wane, and their effects differ, so they are divided into the Three Yin and Three Yang. Greater Yin is the strongest of the Yin categories, and Greater Yang the strongest of the Yang categories. Next come Lesser Yin and Lesser Yang, followed by Bright Yang, and finally Terminal Yin. ‘Terminal Yin’ means that Yin Qi has reached its limit; a detailed explanation appears in the Discussion of the Cycles of the Sun and Moon in the Spiritual Pivot.”

The New Collation says: The Treatise on the Cycles of the Six Qi records that when the Yellow Emperor asked what was meant by “the amount of Qi,” Guiyuqu replied, “Yin and Yang Qi each wax and wane, so they are called the Three Yin and Three Yang.”

The Yellow Emperor asked, “What does Bright Yang mean?”

Qibo replied, “Two currents of Yang Qi meet, making the light bright and abundant. That is why it is called Bright Yang.”

The Discussion of the Cycles of the Sun and Moon in the Spiritual Pivot says that the month of Chen (the third month) corresponds to the Bright Yang channel of the left foot, while the month of Si (the fourth month) corresponds to the Bright Yang channel of the right foot. The two currents of Yang Qi meet at the front, which is why it is called Bright Yang.

The Yellow Emperor asked, “What does Terminal Yin mean?”

Qibo replied, “Two currents of Yin Qi meet and reach their limit.”

The Discussion of the Cycles of the Sun and Moon in the Spiritual Pivot says that the month of Xu (the ninth month) corresponds to the Terminal Yin channel of the right foot, while the month of Hai (the tenth month) corresponds to the Terminal Yin channel of the left foot. Yin Qi has reached its limit, which is why it is called Terminal Yin.

The Yellow Emperor then asked, “Qi waxes and wanes, and illnesses vary in severity. How should one judge the proper degree of treatment?”

The New Collation says that the Treatise on the Cycles of the Six Qi states: “The body has degrees of excess and deficiency; treatment has degrees of gentleness and urgency; and prescriptions have degrees of size.” The Yellow Emperor wished to hear the essentials of this principle.

Qibo replied, “The movement of Qi has high and low levels; illness may be near or far; patterns may be exterior or interior; and treatment may be mild or strong. Treatment should be precisely suited to the location and condition of the illness.”

The organs and bowels are situated at different heights, the Qi of the bowels travels different distances, and illnesses differ as exterior or interior patterns. Medicines, too, may be mild or strong. Adjust their dosage and the speed and force of their action so that their effects reach the site of illness. Do not use too much or too little.

The general principles for composing prescriptions are these: one chief ingredient, the medicine that provides the main therapeutic effect, with two assistant ingredients, which support it, makes an odd prescription; two chief ingredients with four assistants make an even prescription; two chief ingredients with three assistants make an odd prescription; and three chief ingredients with six assistants make an even prescription.

Here, “odd prescription” refers to an ancient single-ingredient type of formula, while “even prescription” refers to an ancient compound formula. Both single and compound formulas have small and large forms. Thus an odd prescription may have one chief ingredient and two assistants, or two chief ingredients and three assistants; an even prescription may have two chief ingredients and four assistants, or three chief ingredients and six assistants.

The overall strength of a medicine or treatment has degrees of reach, and methods of treatment vary in intensity. They should be chosen according to the specific circumstances; this is what is meant by “regulation.”

Thus, for a nearby site of illness, use an odd-numbered formula, with an odd number of ingredients or an odd dosage; for a distant site, use an even-numbered formula, with an even number of ingredients or an even dosage. Formulas for inducing sweating should not be even-numbered, and formulas for purging should not be odd-numbered. To tonify the upper body, prepare the formula so its action is gentle; to tonify the lower body, prepare it so its action is forceful and rapid. “Rapid” means the medicines have a strong flavor and nature; “gentle” means their flavor and nature are mild. Their medicinal force should reach the site of illness just as intended. This is the method described here.

Medicines for inducing sweating should not be given in even-numbered formulas because their medicinal Qi cannot disperse outward. Medicines for purging should not be given in odd-numbered formulas because their force drives out pathogenic influences; if used too strongly, they can easily cause harm. When treating or tonifying the upper body, a formula that acts too forcefully will not remain there; instead, it will drive downward into the lower body. When treating or tonifying the lower body, a formula that acts too slowly will disperse along the way, weakening its effect.

If a forceful formula is made mild in flavor and nature, its action will be no stronger than that of a gentle formula. If a gentle formula is made strong in flavor and nature, its action will be like that of a forceful formula. Then a gentle formula cannot act gently, and a forceful formula cannot act forcefully. A strong flavor lacks the power of a strong formula, while a mild flavor lacks the effect of a mild formula. The formulas’ sizes lose their proper measure, and the strength of their action has no standard. The regulation of deficiency and excess, cold and heat, and the organs and bowels will be thrown into confusion, making balance impossible. If so, how could one expect the illness to settle?

If the site of illness is distant, and the medicine takes effect before reaching it, its administration should be adjusted to the course of the illness so that its force passes beyond the intervening distance and reaches the site, without exceeding the prescribed measure.

For example, if the illness is in the kidneys and a medicine associated with the heart is administered, and that medicine is cold in nature, its action may still press urgently downward. Unless its flavor and nature are used to regulate it, the kidney medicine will overwhelm the heart Qi and further weaken it. This shows that upper and lower, near and far, each have their own distinctions.

The principle for harmonizing Qi is this: for a nearby site, whether the formula is odd-numbered or even-numbered, use a small dose and administer it frequently. For a distant site, whether the formula is odd-numbered or even-numbered, use a large dose and administer it infrequently. Large doses are given fewer times; small doses are given more times. The greater number is nine, and the lesser is two.

Decoctions and pills generally follow this principle in their dosage and frequency of administration. The near and far described here refer to the locations of the organs and bowels: the heart and lungs are relatively near, the liver and kidneys relatively far, and the spleen and stomach lie between them. The Three Yang, the womb, the intestinal tract, and the gallbladder also each have their own degrees of nearness and distance. If divided according to the body’s upper and lower regions, the upper body is near and the lower body is far.

Sometimes a physician with advanced understanding can weigh the circumstances and adapt the treatment: the formula may contain an odd number of ingredients but use even-numbered dosages, or contain an even number of ingredients but use odd-numbered dosages. For a nearby site, one may use an even-numbered formula and administer it frequently; for a distant site, one may use an odd-numbered formula and administer it infrequently. Thus the lungs are treated nine times, the heart seven times, the spleen five times, the liver three times, and the kidneys once. This is an odd-numbered method. Hence the saying: use small doses more often and large doses less often.

The New Commentary says: On close examination of the annotation, one edition reads “the Three Intestines, womb, intestinal tract, and gallbladder” where another has “the Three Yang, womb, intestinal tract, and gallbladder.” Further examination of the term “Three Yang” shows that the text below breaks off at this point.

The claim that there are “three intestines” is also incorrect. There are the large intestine and the small intestine; adding the rectum gives three kinds of intestine. But since the text has already mentioned the womb and the rectum, it cannot also speak of “three intestines.” Here, “three” should be changed to “two.”

(“Liqie” is a phonetic gloss indicating how the preceding character is pronounced.)

When a prescription with an odd number of ingredients fails to dispel the pathogenic influence, one should switch to a prescription with an even number of ingredients. This is called a “combined prescription.” If the even-numbered prescription still has no effect, one should reverse the direction of treatment and add medicines of the opposite nature as adjuncts, so as to observe and respond to the course of the illness. This means that cold, hot, warm, and cool methods should be applied in the opposite direction according to the patient’s condition.

When prescribing, it is better to use a simple, light prescription than one with too many ingredients; medicines with mild properties are preferable to those with strong effects; and smaller doses are preferable to large ones. Thus, if an odd-numbered prescription fails, use an even-numbered prescription as the main treatment. If the even-numbered prescription still does not cure the illness, adjust one of its ingredients in the opposite direction, then use an adjunct medicine to observe changes in the pathogenic Qi and achieve results in accordance with the course of the illness.

Heat opposes cold, and cold runs counter to heat. A mild heat pathogen can be subdued by cold medicines, and a mild cold pathogen can be dispersed by hot medicines. But when the cold or heat pathogen is very strong, a medicine of the opposite nature may clash with it like two armies at war. Different tones cannot harmonize, and different kinds of Qi are difficult to bring into accord. The medicine then cannot subdue the pathogen. If one attacks rashly, the pathogenic Qi and medicinal Qi will resist each other, causing cold and heat to intermingle within the body, disrupting the opening and closing of Qi, while the pathogen remains entrenched and does not recede.

Therefore, the sages use an adjunct medicine in the opposite direction. They first observe the pathogenic Qi and bring the medicinal Qi into accord with the body’s Qi. Then they gradually adjust the medicine’s cold or hot nature to the course of the illness: at first its nature resembles that of the pathogen, but in the end it turns to overcome it. Dryness and moisture balance one another and can break down what is rigid. What is strong must eventually break, while what is soft and fragile will disperse on its own.

The Yellow Emperor said, “Well said. I understand that illness arises from its root (ben). How should illnesses that arise from the exterior or the extremities (biao) be treated?”

Qibo said, “Treatment should address the root of the illness while also taking account of its manifestations. Treating according to the root provides the means to treat the manifestations.”

This passage discusses the relationship between the root and manifestation of the Qi of Shaoyin and Taiyang. In the other four kinds of Qi, root and manifestation are the same.

The Yellow Emperor said, “Well said. How can one observe the changes in illness caused by an excess of the six Qi?”

Qibo said, “Observe the conditions when the six Qi arrive. If clear Qi arrives in great abundance, Dryness is in excess and the Wind-Wood Qi is afflicted. Liver disease then arises, and the illness may further spread to the gallbladder.

“If hot Qi arrives in great abundance, Fire is in excess and Metal-Dryness Qi is afflicted. Lung disease then arises, and the illness may further spread to the ileum, that is, the large intestine. The New Collation says: the commentary’s ‘ileum and large intestine’ follows the Jia Yi Jing, according to which the ileum is the large intestine.

“If cold Qi arrives in great abundance, Water is in excess and Fire-Heat Qi is afflicted. Heart disease then arises, and the illness may further spread to the Triple Burner and small intestine.

“If damp Qi arrives in great abundance, Earth is in excess and Cold-Water Qi is afflicted. Kidney disease then arises, and the illness may further spread to the bladder.”

When the Qi of wind is flourishing, Wood Qi is in excess. Damp Earth Qi is disrupted, causing illness in the Spleen; the illness may then spread to the Stomach.

This is what is meant by becoming ill after being invaded by pathogenic Qi: the Qi at the body’s surface is obstructed, while the body’s interior also resists the pathogen. The body is unsettled both inside and out, and illness follows. This is called “contracting a pathogen.”

When the Qi of the year is weak, pathogenic Qi grows stronger. In a year when Wood Qi is deficient, external cool pathogens can readily invade; when Fire Qi is deficient, external cold pathogens can readily invade; when Earth Qi is deficient, external wind pathogens can readily invade; when Metal Qi is deficient, external heat pathogens can readily invade; and when Water Qi is deficient, external damp pathogens can readily invade. This is what is meant by a deficiency in the Qi of the year. When the year’s Qi is insufficient, external pathogens take advantage of the weakness, and their invasion is more severe.

When the seasons are out of harmony, pathogenic Qi also grows stronger. When one of the Six Qi—wind, cold, summer heat, dampness, dryness, and fire—reaches the position governing the season, it can overcome the Qi associated with that position. If the body is affected by this, illness follows. The illness also corresponds to the relationship in which the affected Qi cannot overcome another, and to the related internal organ; as a result, the pathogen grows stronger.

Pathogenic Qi also grows stronger when the moon is waning. This refers to the moon’s diminished appearance before the first quarter and after the last quarter.

Repeated exposure to pathogens makes illness critical. The Qi of the year is already insufficient, and pathogenic Qi then invades in force: this is called “double exposure.” It is also called double exposure when the year’s Qi is already insufficient, is then overcome by the Qi of the season, and the person is exposed to a pathogen as well. Weakness in the body’s internal vital Qi invites pathogens, while the Qi of the season offers no support. How could illness under these conditions fail to become critical?

Whenever one Qi is in excess, a corresponding counteracting Qi must arise to restrain it. The Qi of Heaven and Earth cannot exist with only one side prevailing. Once one Qi becomes excessive, a counteracting Qi must come to restore balance.

The Yellow Emperor asked, “What are these pulse patterns like?” Qibo replied:

When the Qi of Jueyin arrives in its season, the pulse is wiry, soft, deficient, and slippery; its shape is straight and long. This is called a “wiry” pulse. If it is full and forceful, that is illness; if it is not full but weak, that is also illness. If its shape is not straight and long, that too is illness. It is also illness if the pulse does not match the position governed by Jueyin, or if the pulse should be wiry but is not.

When the Qi of Shaoyin arrives in its season, the pulse resembles a hook. It comes with fullness and recedes with diminished force, like an inverted hook. This is called a “hook” pulse. If the pulse does not come with fullness but grows stronger as it recedes, that is illness. If it is full both as it comes and as it recedes, or is not full at either point, that is also illness. It is also illness if the pulse does not resemble an inverted hook, or if no hook pulse appears at the corresponding position.

When the Qi of Taiyin arrives in its season, the pulse is deep. A deep pulse lies farther below the surface and can be felt only by pressing down; it is one of the pulse patterns found at the various positions. If it is excessively deep, that is illness; if it is not deep, that is also illness. It is also illness if the pulse does not match the position governed by Taiyin, or if it should be deep but is not.

When the Qi of Shaoyang arrives in its season, the pulse is large and floating. “Floating” means that it lies closer to the surface; “large” means that it is somewhat larger than usual. If the pulse is excessively large and floating, that is illness. If it floats but is not large, or is large but not floating, that is also illness. If it is neither large nor floating…

Even when the pulse shows an abnormal pattern, illness may arise because it appears in a position where it should not. A pulse that is excessively floating and forceful can also cause illness.

When Yangming Qi arrives, the pulse is short and rough.

When the Qi of the pulse flows back and forth with difficulty, it is called “rough.” When it travels only a short distance, it is called “short.”

An excessively short pulse can cause illness, as can an excessively rough one. A pulse that is neither short nor rough may still cause illness if it appears in the wrong position. Illness may also arise when the pulse position fails to show the short, rough pattern.

When Taiyang Qi arrives, the pulse is large and long.

When the Qi of the pulse travels a long distance, it is called “long.” An excessively large pulse or an excessively long one can cause illness. So can a pulse that is long but not large, or large but not long. Illness may likewise arise when the pulse is not in its proper position, or when it fails to show the large, long pattern.

When the Qi of the pulse arrives in a balanced and gentle state, the pulse is normal. When it is neither too weak nor too forceful, it is called “harmonious.” If the Qi of the pulse arrives in an excessively forceful state, the pulse is pathological.

A pulse that feels like a taut bowstring is called “wiry”; one that feels like a string of connected pearls is called “slippery.” A pulse that sinks as if pressed against the bone is called “deep”; one that floats at the surface of the skin is called “floating.” One that flows sluggishly is called “rough.” One as short as a hemp seed or millet grain is called “short.” A pulse as large as a hatpin, or as long as a rope under tension, is unusually pronounced.

A pulse that runs counter to the expected pattern can also cause illness.

If a wiry pulse is expected but the pulse is instead rough; if a large pulse is expected but it is instead fine; if a deep pulse is expected but it is instead floating; if a floating pulse is expected but it is instead deep; if a short, rough pulse is expected but it is instead long and slippery; if a soft, weak pulse is expected but it is instead forceful and firm; or if a fine pulse is expected but it is instead large—each of these shows that the movement of Qi has departed from its normal course. When such patterns appear among the usual pulse signs, they indicate illness.

Illness may also arise when the Qi of the pulse should arrive but does not. This means that the seasonal node and the pulse position have reached their corresponding time, yet the Qi of the pulse does not respond as it should.

Illness may also arise when the Qi of the pulse appears before its time. According to the calendar, when a seasonal node arrives, the pulse should change in accordance with the distribution of the year’s six Qi, adapting to shifts such as the annual movements associated with north and south. If the climate and seasonal sequence have not yet changed but the pulse has already changed, this is called “arriving before its proper time,” and it can cause illness.

When Yin and Yang Qi become confused with one another, the condition becomes critical. If the pulse does not correspond to the proper season, Yin and Yang Qi become intermingled, lose their original positions, and exchange places: a Yang pulse appears in a Yin position, and a Yin pulse in a Yang position. This is called a disorder of pulse position. The two Qi become confused with each other, so the movement of Qi becomes critical.

The Newly Collated Commentary says: According to “The Treatise on the Subtle Significance of the Six Qi,” the Yellow Emperor asked, “When the Qi of the pulse arrives at its proper time, when it should arrive but does not, and when it appears before its time, what does each mean?” Qibo replied, “Arriving at its proper time is harmony; failing to arrive when it should means the incoming Qi is insufficient; appearing before its time means the incoming Qi is excessive.” The Yellow Emperor then asked, “What happens when it fails to arrive when it should, or appears before its time?” Qibo replied, “To accord with the season is to be in harmony; to go against the season is to be contrary. Going against it brings change, and change causes illness.” The original text continues beyond this point.

The Yellow Emperor asked, “How can we know what a pulse reflects?”

Qibo replied, “What the pulse reflects is the condition to which the pulse itself corresponds.”

The Yellow Emperor asked, “The rules followed by the root, manifestation, and central Qi of the Six Qi—Wind, Cold, Summer Heat, Dampness, Dryness, and Fire—are not the same. Why is this?”

Qibo replied, “Some of the Six Qi follow their root Qi, some follow both their manifestation and root Qi, and some follow neither their manifestation nor their root Qi, but instead follow their central Qi.

“Shaoyang and Taiyin follow their root Qi. Shaoyin and Taiyang follow both their root Qi and their manifestation. Yangming and Jueyin follow neither their manifestation nor their root Qi, but follow their central Qi.

“The root Qi of Shaoyang is Fire, and the root Qi of Taiyin is Dampness. Their root Qi is the same as their manifestation, so they follow their root Qi. The root Qi of Shaoyin is Heat, while its manifestation belongs to Yin; the root Qi of Taiyang is Cold, while its manifestation belongs to Yang. Their root and manifestation differ, so they follow both.

“The central Qi of Yangming is Taiyin, and the central Qi of Jueyin is Shaoyang. The root Qi, manifestation, and central Qi of Yangming and Jueyin differ, so these two follow neither manifestation nor root, but follow central Qi. Whether a pattern follows the root, the manifestation, or the central Qi, it does so because that factor governs the movement of Qi transformation.

“Thus, when a pattern follows the root Qi, the root governs Qi transformation. When it follows both manifestation and root, both take effect in Qi transformation. When it follows central Qi, the central Qi is the primary influence.

“Here, ‘transformation’ means the fundamental force that governs Qi transformation. When illness occurs, treatment with methods such as Cold or Heat should be guided by the force that governs this transformation.”

The Newly Collated Commentary adds: “The Treatise on the Six Subtle Influences states that above Shaoyang, Fire Qi governs, with Jueyin appearing in the center; above Yangming, Dryness Qi governs, with Taiyin appearing in the center; above Taiyang, Cold Qi governs, with Shaoyin appearing in the center; above Jueyin, Wind Qi governs, with Shaoyang appearing in the center; above Shaoyin, Heat Qi governs, with Taiyang appearing in the center; and above Taiyin, Dampness Qi governs, with Yangming appearing in the center. This is what is called the ‘root.’ Beneath the root Qi is where the central Qi becomes manifest; beneath the central Qi lies the ‘manifestation’ of Qi. When root Qi and manifestation differ, the resulting signs also differ. This is the meaning of the passage.”

The Yellow Emperor asked, “When the pulse seems to match the illness but the actual condition is the opposite, how should it be understood in diagnosis?”

Qibo replied, “The pulse may seem to correspond on the surface, but when pressed, it has no strength or sense of pulsation. This can occur in the pulses of all the Yang channels.

“In other words, the illness may look like Heat, and the pulse may be rapid, yet under pressure it does not move or feel forceful. This may result from Cold becoming so extreme that it blocks Yang Qi and drives it outward. It is not a true Heat pattern.”

The Yellow Emperor asked, “What is the opposite situation in the pulses of the Yin channels?”

Qibo replied, “The pulse may seem to match the illness on the surface, but when pressed, it beats vigorously and feels forceful.

“In other words, the outward symptoms may look like a Cold pattern, yet the pulse Qi feels strong and forceful beneath the fingers. This results from Heat becoming so extreme that it repels Yin Qi. It is not a true Cold pattern.”

Thus, illness may arise from the root, from the manifestation, or from the central Qi; some conditions respond to treatment directed at the root, others to treatment directed at the manifestation, and still others to treatment directed at the central Qi. Some also require attention to both root and manifestation. In treatment, some cases call for medicines used contrary to the usual method, while others call for the usual method. Treating a cold condition with cold medicines and a hot condition with hot medicines is called “treatment in opposition.” Treating with the method of counterbalancing—using medicines with opposite properties to support the main treatment so the patient’s body can accept the medicine—is called “treatment by following.” These usages relate to the earlier discussion of “treatment in opposition” and “treatment by following.”

Using cold medicines for a cold condition and hot medicines for a hot condition may seem, on the surface, to go against common sense. But when the illness truly presents in this way, the treatment accords with the condition, so it may also be said that “within opposition there is accord.” Conversely, when severe Cold evil blocks Yang Qi, continuing to use cold medicines; or when severe Heat evil blocks Yin Qi, continuing to use hot medicines, may seem to follow the nature of the illness, but in fact goes against the central Qi. Thus, a prescription may appear to accord with the condition while actually treating it in opposition.

Therefore, those who understand the relationship between manifestation and root will not err in applying it. Only by truly understanding treatment in opposition and treatment by following can one treat appropriately without being constrained. This is the principle being expressed. Without this understanding, one is not equipped to discuss diagnosis and may instead disrupt the principles of medicine. For this reason, the Essentials says: “A shallow physician thinks he has already understood. Before the patient’s Heat condition has been cured, a Cold condition arises in turn. The disease Qi seems the same, yet its manifestations differ; the result is confusion in diagnosis and disorder in the principles of medicine.” Here, “xixi” describes a feeling of satisfaction: inwardly, one believes oneself content and thinks one has thoroughly understood the Way of medicine.

When applying the principles of the Six Qi—Wind, Cold, Summer Heat, Dampness, Dryness, and Fire—shallow practitioners and genuine physicians often understand only half. For example, the shallow practitioner thinks the transformations of Jueyin Qi are Cold, when they are actually Warm; and thinks the transformations of Taiyang Qi are Hot, when they are actually Cold. Reversing these qualities leads treatment away from the right course and shows that one’s study and application of medical principles have not yet reached the level expected of a physician.

Taiyang and Shaoyin each undergo Cold transformation, but their actual relationships differ when assessing the manifestation, root, and therapeutic effects. Taiyang takes Cold as its root and Heat as its manifestation; Shaoyin takes Heat as its root and Cold as its manifestation. Medicines must be used in accordance with this principle. The central Qi of Jueyin and Yangming has a similar relationship: Jueyin’s central Qi is Hot, while Yangming’s is Damp. The qualities of these two kinds of central Qi also stand in contrast to the relationship between Taiyang and Shaoyin. However, Taiyang and Shaoyin differ from the other Six Qi in how manifestation and root relate to treatment, which is why it is said that “the disease Qi seems the same, yet its manifestations differ.”

Within a single channel, the manifestation and root already differ in their Cold and Heat qualities. To speak of the root, one must further examine its manifestation; to discuss the manifestation, one must also consider its root. If one speaks only of the nature of the Qi without fully investigating the relationship between manifestation and root, then the discussion of the condition has not yet…

Distinguishing Yin and Yang requires more than recognizing that both are forms of Qi. One must also discern what each governs and how they manifest differently, such as in coldness and warmth.

If the mind loses sight of sound principles, treatment will also violate medical principles. Such a person is called a “crude practitioner”—someone whose medical skill is coarse—and the name is truly deserved.

The principles of root and branch are concise in substance yet broad in scope: from a small point, one can infer the larger picture. Though they may appear to address only one aspect, they allow us to recognize the harms caused by many illnesses. Distinguishing “branch” from “root” makes treatment easier to grasp and prevents damage to the body’s vital Qi; examining the movement of Qi at the root and branch enables them to be brought into harmony. Understanding excess Qi and its subsequent counteraction and restoration can provide a model for all people to follow. If we can understand as much as possible about the transformations of Heaven and Earth, how could the diagnosis of a single person be called obscure and difficult to understand? Mastering the essentials of the classics and the foundations of treatment is enough to make one a teacher to physicians throughout the world. If one still dismisses these principles, how could one become a model for all people?

The Newly Revised Commentary says: The “Treatise on Branch and Root and the Transmission of Disease” records cases in which a disease is at the branch and is treated from the branch, or at the root and is treated from the root. It also describes disease at the root treated from the branch, and disease at the branch treated from the root. Thus, some illnesses are cured by treating the branch, others by treating the root; some respond to treatment that runs counter to the disease, and others to treatment that follows its course. Those who understand counteracting and following will treat without error; those who understand branch and root will diagnose and treat accurately. To be ignorant of branch and root is to treat recklessly.

The principles of following or counteracting Yin and Yang, and of branch and root, may seem small but are in fact vast: from one aspect, many illnesses can be understood. Their substance may seem limited, yet they encompass a great deal; from what is near at hand one can understand what is profound, and from the present infer what is distant. If one merely says that distinguishing branch from root is easy but cannot use that understanding to guide treatment, the treatment will go against the disease. Only when treatment is appropriate is it called treatment that follows the disease.

If illness comes first and Qi then becomes disordered, treat the root. If Qi becomes disordered first and illness follows, treat the root as well. If a person is exposed to cold before becoming ill, treat the root; if exposed to heat before becoming ill, treat the root too. If heat comes first and abdominal distension follows, treat the branch. If illness comes first and diarrhea follows, treat the root; if diarrhea comes first and another illness develops afterward, treat the root as well. First bring the diarrhea under control, then treat the other illness.

If illness comes first and abdominal distension follows, treat the branch. If abdominal distension comes first and distress in the heart follows, treat the root.

The human body has “guest Qi,” Qi that comes from outside and temporarily affects the body, and “corresponding Qi,” Qi that accords with the body’s own movement. When urination and bowel movements are obstructed, treat the branch; when they are unobstructed, treat the root. If illness occurs with signs of excess, give priority to the root while also addressing the branch: treat the root first, then the branch. If illness occurs with signs of deficiency, give priority to the branch while also addressing the root: treat the branch first—the original text breaks off here.

Next, treat the root cause of the illness, carefully observing whether the condition is mild or severe and adjusting treatment accordingly. If the illness is mild, treat both the root and the manifestation; if it is severe, treat only the manifestation. If difficulty passing urine or stool occurs first, followed by the onset of illness, then the root should be treated. This classic discusses root and manifestation in particular detail.

The Yellow Emperor asked: “When do the changes of prevailing and counteracting Qi appear—early or late?” Qibo replied: “When a given Qi prevails, illness arises as its prevailing force arrives. Once the illness has become evident and that force gradually subsides, the counteracting Qi begins to stir. At first, the unease brought on by the counteracting Qi does not last long; soon its effects become apparent.

“When does the counteracting Qi arise? Only after the prevailing force has waned does the counteracting Qi emerge. When it gains strength, the illness worsens. The prevailing force may be mild or severe, and the counteracting force may likewise be greater or lesser. When the prevailing force is moderate, the counteracting force is moderate; when the prevailing force is weak, the counteracting force is weak. This is the natural order.”

The Yellow Emperor asked: “When the prevailing and counteracting Qi arise, they sometimes do not accord with the season, or arrive later than it. Why is this? Yang Qi is said to flourish in summer, Yin Qi in winter, cool Qi in autumn, and warm Qi in spring. This is the normal pattern of the seasons. Yet the prevailing and counteracting forces act differently across the four seasons. Why?”

Qibo replied: “The arising and changing of Qi do not have the same degrees of fullness and decline. The waxing and waning of cold, heat, warmth, and coolness become manifest at the transitions between the seasons. The activity of Yang Qi begins with warmth and reaches its height in heat; the activity of Yin Qi begins with coolness and reaches its height in cold. Thus each season—spring, summer, autumn, and winter—has its own period of climatic dominance.

“The Qi of the four seasons is in fact most evident during the transitional periods between them. Judged by the seasonal calendar, spring warmth is strongest in the months of Chen and Si, summer heat in Wei and Shen, autumn coolness in Xu and Hai, and winter cold in Chou and Yin. Spring begins in mid-spring, summer in mid-summer, autumn in mid-autumn, and winter in mid-winter. Thus in the month of Chou, Yin Qi gathers and layers of solid ice form over the earth; in the month of Wei, Yang Qi blazes, with lightning flashing and thunder sounding in the sky; in the month of Xu, frost is cold and harsh, and all things grow firm; in the month of Chen, gentle breezes bring ease and the branches and leaves flourish. These clearly reveal the differences in climate during the transitions between seasons, which cannot be concealed.

“Although the arising and storing of Yin and Yang Qi generally follow the usual sequence of the seasons, the specific dates of seasonal transitions often differ from the customary calendar when we observe climatic changes and the body’s responses. It is appropriate to make judgments in accordance with these variations.

“The Essentials says: ‘The warmth of spring, when it develops into summer, becomes heat; the clear severity of autumn, when it develops into winter, becomes piercing cold.’ Carefully examine the signs at the transitions between seasons, and you can discern the beginning from the end. This is what the passage means.”

This passage speaks of the "young" and "robust" stages of qi (气). When Yang qi first arises, it appears as warmth; at its height, it appears as summer heat. When Yin qi first arises, it appears as indignation; at its height, it appears as violent rage. All of this describes the difference between qi in its "young" and "robust" stages, and serves to show that the workings of qi have both flourishing and waning phases. Once these phases of flourishing and decline are matched to the positions of the four "corners" (siwei: southeast, southwest, northeast, and northwest, the points where the seasons turn into one another), the whole course and application of Yin-Yang (阴阳) from beginning to end can be inferred.

The Yellow Emperor asked: "Is there a fixed number for the seasonal deviation of qi?" Qibo answered: "It is generally thirty 'degrees,' where a 'degree' means a 'day,' so thirty days." (The "New Revised Edition" points out that the "Great Treatise on the Six Primary Cycles" says "thirty degrees and a remainder," meaning a little over thirty days; the wording here is abbreviated.)

The Yellow Emperor asked: "How, then, does the pulse respond?" Qibo answered: "The deviation of the pulse matches the deviation of the season. By the usual rule, once the allotted days arrive, the deviation fades of its own accord. The pulse also changes in step with the deviation of the solar term, and only when the days of deviation are complete and the qi that governs the season has arrived does the pulse depart."

The Essentials of the Pulse says: if in spring the pulse is not sinking, in summer not wiry, in winter not choppy, and in autumn not rapid, this is called the "Four Blockages." It means that the qi of heaven and earth and the four seasons is obstructed and cannot move as it should.

A pulse that sinks to excess is a disease; one that is wiry to excess is a disease; one that is choppy to excess is a disease; one that is rapid to excess is a disease. A pulse is balanced only when it accords with the harmonious qi of heaven and earth. If its form is displayed too strongly, it is being produced by forced effort, and what is forced cannot last. Hence any excess is a sign of illness.

"Mixed appearance" is a disease, "recurrent appearance" is a disease, "departing before its time" is a disease, and "failing to depart when the time has passed" is a disease. "Mixed" means that the pulse signs of several qi appear jumbled together. "Recurrent" means that the pulse sign of a qi already weakened or spent appears again. "Departing" means that the qi governing the season has passed and gone. If the sun's course has not yet exceeded the range of deviation, the qi of heaven has not yet withdrawn. If the days have exceeded that range and the pulse still lingers, then the qi of heaven has gone while the pulse remains; since it no longer corresponds to the season, it is called a disease.

A pulse that runs contrary to the season signals a fatal condition. For example, a sinking pulse in summer, a rapid pulse in autumn, a slow, moderate pulse in winter, or a choppy pulse in spring is called "contrary." It defies the mandate of heaven, so how could life long endure? (The "New Revised Edition" notes that the earlier statement calls a non-rapid pulse in autumn a "blockage," while here a rapid pulse in autumn is called "contrary." The reason is that the deviation applies only to the middle month of the season; once the days of deviation are exhausted and the pulse is still rapid in the final month of autumn, it is "contrary.")

Therefore it is said that the qi of the four seasons hold one another in check, each performing its own office, like the beam and the weight of a steelyard, which must not lose their balance. The "balance" (quanheng) is the steelyard itself: in the qi of heaven and earth, cold faces heat and warmth faces coolness, each restraining the other so that an even equilibrium is maintained.

Just as when weighing an object with a balance beam, neither side should be too high or too low. The two sides must be level and equal, without encroaching on one another or disrupting their order. Then Heaven and Earth will be tranquil and settled, and the processes of generation and transformation will each find their proper place. When the Qi of Yin-Yang is tranquil, the growth and transformation of the myriad things proceed in their proper order. Once it becomes agitated and unbalanced, severe illnesses arise. This is the principle being described.

The commentary explains: “Movement” means change—the normal, mild climate shifts and becomes a calamity. “Severe” means grave. The New Collation cites the “Treatise on the Six Subtle Principles,” which says: “The success and failure of things, their concealment and manifestation, all arise from movement. If movement continues without ceasing, anomalous changes will occur.”

The Yellow Emperor asked, “What are ‘obscurity’ and ‘brightness’?” Qibo replied, “When two Yin forces meet and reach their end, this is called ‘obscurity.’ When two Yang forces come together, this is called ‘brightness.’ Obscurity and brightness correspond to the differences between cold and heat.”

The commentary explains: The meeting and completion of the two Yin forces occurs in the ninth and tenth months, Xu and Hai. The joining of the two Yang forces in brightness occurs in the third and fourth months, Chen and Si. The “Treatise on the Correspondence of the Sun and Moon” in the Lingshu says that Hai is the tenth month and corresponds to the left foot’s Jueyin, while Xu is the ninth month and corresponds to the right foot’s Jueyin. These are where the two Yin forces meet and reach their end, hence the name “Jueyin.” Chen is the third month and corresponds to the left foot’s Yangming, while Si is the fourth month and corresponds to the right foot’s Yangming. Here the two Yang forces come together in front, hence the name “Yangming.” When Yin meets, there is obscurity; when Yang joins, there is brightness. This is the source of the imagery of obscurity and brightness. Cold and heat are positioned in the southwest and northeast, while obscurity and brightness are positioned in the northwest and southeast. Thus, the positions of obscurity and brightness do indeed correspond differently to those of cold and heat. The New Collation cites the Treatise on the Primordial Celestial Record, which says: “Obscurity and brightness each have their own position, and cold and heat accordingly wax and wane, expand and contract.”

The Yellow Emperor asked, “What are ‘division’ and ‘culmination’?” Qibo replied, “When Qi reaches its utmost point, this is called ‘culmination’; when Qi divides in two, this is called ‘division.’ At a culmination, the Qi before and after is the same; at a division, the Qi before and after differs. This is the normal order governing Heaven and Earth.”

The commentary explains: This principle follows from the question about obscurity and brightness. The winter and summer solstices are the two “culminations”: they are the times when the Qi of Heaven and Earth governs the year and reaches its appointed position. The spring and autumn equinoxes are the two “divisions”: at these times, the first and second, and the fourth and fifth, of the intervening Qi—those that alternate on either side of the principal Qi—each share in administering the Qi that governs the year. Hence the saying, “At a culmination, the Qi is the same; at a division, the Qi differs.” The correspondence of the Qi at the two solstices and two equinoxes is the normal order of the Qi of Heaven and Earth.

The Yellow Emperor said, “You have said that the Qi of spring and autumn begins in front, while the Qi of winter and summer begins behind. I understand this now. But the Six Qi alternate as they come and go, and their governance of the annual cycle is not fixed. How, then, should one tonify and drain?”

The commentary explains: When the positions of the Six Qi are determined by the divisions and culminations, the first and fourth Qi begin at the solar terms Beginning of Spring and Beginning of Autumn.

The fifteen days before the Spring Equinox and the Beginning of Autumn mark the rule for determining the sequence of the Three Qi and Six Qi. The fifteen days after the Beginning of Summer and the Beginning of Winter serve the same purpose. These divisions around the four seasonal nodes correspond precisely to key points in the movement of the Three Qi and Six Qi: the winter and summer solstices. Thus, the Qi of spring and autumn begins before its seasonal node, while the Qi of winter and summer begins after it.

A year has 365 days, and the climate changes after each interval of time. When the old year passes, its climate also gives way to a new one; when the new climate arrives, the old climate recedes. The right time to use medicines varies with the climate in each place. Prescriptions for draining pathogenic influences and supplementing deficiency must also follow the proper order. The Yellow Emperor therefore asked about this again.

Qibo said: “Treat the climates governed by the upper and lower divisions by following the directions that benefit them; choosing the appropriate medicinal flavors is the key. The same principle applies to the left and right sides. In general, for illnesses governed by Shaoyang, use sweet flavors first, then salty ones; for illnesses governed by Yangming, use pungent flavors first, then sour ones; for illnesses governed by Taiyang, use salty flavors first, then bitter ones; for illnesses governed by Jueyin, use sour flavors first, then pungent ones; for illnesses governed by Shaoyin, use sweet flavors first, then salty ones; and for illnesses governed by Taiyin, use bitter flavors first, then sweet ones. Add medicines that benefit the condition, and support the patient with medicines that nourish the body. This is called following the nature of the Qi that governs it.

“‘Governing’ means taking charge of the climate for the year. ‘Attaining’ means grasping and applying its nature and effects. Once you understand these qualities and functions, the expansion and contraction of Qi can be regulated by human action. If you fail to understand them, the movement of Qi will run counter to its proper course and fall into disorder. How, then, could you expect to drive out pathogenic influences? You would instead damage the innate, refined Qi. The order of medicinal flavors described here applies to illness: first drain, then supplement.”

The Yellow Emperor said: “Well said. The onset of every illness is caused by the normal functions and abnormal changes of the Six Qi: wind, cold, summer heat, dampness, dryness, and fire.”

Wind, cold, summer heat, dampness, dryness, and fire are the six Qi of nature. Their calm operation in accordance with the natural order is called “transformation”; when they become turbulent and abnormal, this is called “change.” Thus, illness arises from changes in the Six Qi.

The scripture says that when pathogenic Qi is excessive, drain it; when upright Qi is deficient, supplement it. Although I have given physicians methods for treating illness, they still do not use them with complete success. I hope these essential principles of the medical Way can certainly be put into practice, producing a response as immediate as an echo following a drumbeat and results like removing a thorn or washing away grime. Can you explain this skill, so subtle and wondrous?

Acupuncture is called “skillful,” while the use of medicines is called “sacred.” The New Corrected Edition says: The Difficult Classic holds that diagnosing illness by observing the complexion is called “spiritual”; diagnosing it by listening to the voice is called “sacred”; diagnosing it by asking about the symptoms is called “skillful”; and diagnosing it by feeling the pulse is called “subtle.” Understanding illness from outward signs is called “sacred,” while understanding it from inward signs such as the pulse is called “spiritual.”

Qibo said: “Examine the mechanisms of illness carefully, and do not violate the principles suited to the climate and the patient’s condition. This is what I mean.”

Once the key principles are understood, small actions can achieve great results: little effort can bring far-reaching effects.

The Yellow Emperor asked, “I would like to hear about the principles underlying disease.” Qibo replied:

All tremors and dizziness caused by wind disorders are related to the liver. Wind is characterized by movement, and the liver corresponds to Wood; their natures are alike.

All tightening and spasms caused by cold disorders are related to the kidneys. “Tightening” means contraction, and “drawing” means spasm. Cold makes things contract, and the kidneys correspond to Water; their natures are alike.

All rapid breathing and obstructed Qi caused by Qi disorders are related to the lungs. In autumn, the air turns cool and mist gathers like smoke. When coolness arrives, breathing changes; if the chill grows excessive, Qi becomes depleted. The correspondence can be seen in natural phenomena. “Fullness” means distension, and “obstruction” means that the movement of Qi is blocked. The action of Qi corresponds to the nature of Metal, to which the lungs belong.

All swelling and abdominal fullness caused by dampness are related to the spleen. Where the soil is thin, the water is shallow; where the soil is thick, the water is deep. Flat, dry land lies low, while higher ground is more prone to dampness. Dampness corresponds to the nature of Earth, to which the spleen belongs.

All clouding of consciousness and convulsions caused by heat disorders are related to Fire. They display the characteristics of fire.

All pain, itching, and sores are related to the heart. When the mind is calm, pain is less severe; when it is agitated, pain worsens. All changes arise through the activity of the mind, so pain, itching, and sores are related to the heart.

All counterflow of Qi, blockage, and diarrhea are related to the Lower Burner, the functional region of the organs in the lower part of the body. Here, “lower” refers to the Qi of the liver and kidneys in the Lower Burner. Kidney Qi secures and contains, while liver Qi regulates the opening and closing, controlling what enters and leaves. These disorders are therefore related to the Lower Burner. “Reversal” means counterflow of Qi; “securing” means blockage. Counterflow surging upward, blockage that prevents passage, irregular movement in and out, and unstable changes between dryness and dampness are all related to the governing function of the Lower Burner.

All weakness and wasting, panting, and vomiting are related to the Upper Burner, the functional region of the organs in the upper part of the body. Here, “upper” refers to the Qi of the heart and lungs in the Upper Burner. Heat injures the Qi of the heart, while the lungs receive and transform the heat. When heat accumulates and affects the Upper Burner, these disorders are attributed to it.

The New Corrected Edition says: “On closer examination, the disorder called wasting does not seem to belong entirely to the Upper Burner. Wang Bing’s commentary does not explain why it is attributed to the Upper Burner, and later readers have therefore raised questions. The present account follows the ‘Treatise on Wasting’: all five organs can give rise to wasting disorders. When the lungs become hot, their lobes dry out, leading to wasting paralysis—weakness of the limbs and inability to walk. This is why wasting is said to be related to the Upper Burner. Wasting is also called lung atrophy.”

All jaw clenching, chattering teeth, shivering, and symptoms that seem to arise when the spirit has lost its hold are related to Fire. They result from heat pathogens flaring up inside the body.

All spasms and stiffness of the neck are related to dampness. This occurs when dampness injures the Taiyang channel, a name for a channel in the body.

All counterflow of Qi surging upward is related to Fire, because fire rises.

All abdominal distension is related to heat.

When heat and pathogenic influences accumulate in the body, they can cause distension of the lungs.

All disorders involving agitation, frenzy, or abnormal behavior belong to Fire.

Excess heat in the stomach and the extremities can also give rise to these disorders.

All sudden stiffening of the body and rigidity of the sinews and vessels belong to Wind.

When Yang Qi is obstructed within the body, Yin Qi moves to the body’s surface.

All disorders that produce sounds during an attack, or feel like a drum when pressed, belong to Heat. This refers to sounds heard during the illness.

All disorders involving swelling, pain, soreness, or fright belong to Fire, because they contain an abundance of heat.

All disorders involving twisting of the sinews and vessels, arching of the body, or cloudy urine belong to Heat. Here, “reversing and twisting” refers to the sinews and vessels tightening and spasming; “fluids” refers to urine.

All disorders in which the fluids discharged are clear and cold belong to Cold. “Discharged” here includes emissions from the upper and lower openings, as well as vomit and urine.

All disorders involving vomiting, bringing up sour fluid, sudden diarrhea, or an urgent, uncontrollable need to defecate belong to Heat. “Sour” here refers to sour fluid and foam.

Thus, the essential principle of medicine is to examine the mechanisms of illness carefully and determine the causes to which different disorders belong. When a sign appears, investigate its cause; when a sign does not appear, investigate that, too. If the illness is excessive, seek the source of the excess; if the body’s vital Qi is weak, seek the source of the deficiency. One must also first distinguish the relationships of control among the Five Phases, then unblock Qi and blood so they can move in harmony and flow freely, ultimately restoring balance. This is the principle being described.

The Sage’s words are profound, and rightly so. The saying, “Investigate what is present and what is absent; trace both deficiency and excess,” means that the cause of the illness must be made clear.

For example, if severe Cold is treated with warming methods but warmth still does not return, there is no Fire within the body. If heat comes and goes, appears by day and lies dormant at night, or flares at night and stops by day, or changes with the seasons, this also indicates that there is no Fire within the body. The Heart Qi should be supported.

Likewise, if intense Fire-Heat is treated with cooling methods but coolness still does not take hold, there is no Water within the body. If the heat flares and then stops, comes and goes suddenly, or appears and subsides intermittently, this also indicates that there is no Water within the body. The Kidney Qi should be supported.

When pathogenic Qi is obstructed inside, causing vomiting and preventing food from being swallowed, there is Fire within the body. If illness causes vomiting and food that has been eaten is brought back up, there is no Fire within the body.

If diarrhea comes on suddenly and passes quickly, before the food has had time to digest, there is no Water within the body. If the stool is loose and watery, the illness lasts a long time, and its episodes begin and stop irregularly, this also indicates that there is no Water within the body.

Therefore, an excess of Heart Qi produces heat, while an excess of Kidney Qi produces Cold. When the Kidneys are deficient, Cold moves within the body; when the Heart is deficient, heat draws inward. If a Heat condition is not relieved by cooling treatment, there is no Fire within the body; if a Cold condition is not relieved by warming treatment, there is no Water within the body.

When a Cold condition cannot be warmed, investigate whether there is no Water; when a Heat condition cannot be cleared, investigate whether there is no Fire. When heat cannot persist, investigate whether the Heart Qi is deficient; when Cold cannot persist, investigate whether the Kidney Qi is insufficient. What is excessive should be drained; what is lacking should be replenished. Deficiency should be tonified, and excess should be drained. When a condition lies between the two…

When the Qi between the upper and lower parts of the body flows without obstruction, Qi and blood circulate freely. Cold and heat then naturally come into balance, and Yin-Yang can work together in harmony. Thus, in some illnesses, cold medicines are used to treat heat: although the signs of heat subside, the patient can no longer take water or food. In other illnesses, hot medicines are used to drive out cold: although the signs of cold disappear, the patient becomes dull and agitated. This happens because the movement of Qi has not been opened up but has instead become congested. From the changes of Water and Fire, one can also infer other conditions. Therefore, when a disease shows excess, seek the cause of the excess; when it shows deficiency, seek the cause of the deficiency. When Qi is forceful, investigate why it is forceful; when Qi is weak, investigate why it is weak as well. The subtle art of treatment lies in making the movement of Qi free and balanced. “The Five Phases overcoming one another” refers to their mutual restraint. One should first use the pattern of mutual overcoming among the Five Phases to examine the interactions of cold, heat, warmth, coolness, and dampness, as well as sour, salty, sweet, pungent, and bitter flavors.

The Yellow Emperor said, “Well said. How do the Five Flavors act in relation to Yin-Yang?”

Qibo said, “Pungent and sweet flavors disperse Qi outward and belong to Yang. Sour and bitter flavors make Qi rise or move downward and outward, and belong to Yin. Salty flavor makes Qi rise or move outward, and belongs to Yin. Bland flavor promotes the seepage and discharge of fluids and belongs to Yang. Each of these six flavors has its own action: some are astringent, some dispersing, some moderating, some hasten the movement of Qi, some dry, some moisten, some soften substances, and some make them firm. Use them according to what the illness requires, so that the movement of Qi is regulated and restored to balance.”

“Rising” means inducing vomiting; “discharging” means promoting passage and elimination. “Seeping and discharging” means promoting urination. Clear fluid separates from the ileum, the final section of the small intestine, seeps into the bladder, and through the transformative action of the Qi of the bladder becomes urine, which is then expelled from the body. The New Collation adds: The Treatise on the Organs’ Qi and the Seasons records that pungent flavor disperses, sour flavor astringes, sweet flavor moderates, bitter flavor firms, and salty flavor softens. It also says that each of the pungent, sour, sweet, bitter, and salty flavors has its proper use: some disperse, astringe, or moderate; others hasten the movement of Qi, firm substances, or soften them. Disorders of the four seasons and the Five Zang organs should be treated with the flavors suited to each.

The Yellow Emperor said, “If a disease cannot be cured by regulating the movement of Qi, how should it be treated? When should toxic medicines be used, and when should non-toxic medicines be used? Please explain the principles.”

Qibo said, “Diseases arise in four broad ways. First, a change in the movement of Qi gives rise to disease inside the body. Second, a change in the movement of Qi gives rise to disease on the body’s surface. Third, disease arises inside the body without being caused by a change in the movement of Qi. Fourth, disease arises on the body’s surface without being caused by a change in the movement of Qi.

“Diseases arising inside the body from changes in the movement of Qi include accumulations and gatherings (masses within the body), abdominal lumps, tumor-like Qi, goiter (enlargement of the neck), nodules (localized lumps), epilepsy, and similar conditions. Diseases arising on the body’s surface from changes in the movement of Qi include abscesses and sores, scabs and scabies, deep ulcers, hemorrhoids, twitching or spasms of the limbs, edema, red eyes, eruptions of red skin rashes, swelling, and conditions such as pain and itching.

“Diseases arising inside the body without being caused by changes in the movement of Qi include retained fluid (water and fluid that linger without transforming), food stagnation, irregular hunger and fullness, injury from overwork, undigested food retained in the stomach, cholera, and emotional distress such as grief and fear…”

Illnesses arising from within include such things as anger and joy, longing and attachment, and grief and melancholy. Illnesses coming from outside include miasma.

Demons and spirits, insects and snakes, gu poison, flying corpses (malevolent spirits that people in antiquity believed could harm the living), ghost strikes (sudden assaults on the body by demonic forces, as people in antiquity understood them), as well as collisions, falls, wind-cold, summer heat, dampness, cutting and chopping, arrows, stabbing and slicing, blows, and tumbles are all external causes of illness.

Of these four categories of causes, some illnesses can be cured by treating only the internal cause, while others require treating both internal and external causes. Some can be cured by treating only the external cause, while others require treatment of both. In some cases, treating the internal cause first and the external cause afterward brings a cure; in others, the external cause must be treated first, followed by the internal one. Some conditions call for a forceful attack with toxic medicines, while others require gentle regulation and guidance with nontoxic medicines. Accordingly, treatments may be mild or strong, gradual or urgent; they may astringe or disperse, moisten or dry, soften or firm. Physicians who prescribe and administer medicines each have their own views and often follow their customary practices, which do not necessarily accord with the principles of the Suwen. So I ask you again for guidance.

Qibo replied: “Whether to use toxic or nontoxic medicines depends on the illness being treated; the dosage depends on the patient’s condition. If the treatment clears stagnation, cures the illness, resolves a crisis, and saves someone near death, it is a good prescription. One cannot say that using a toxic medicine first is always right and using one later is always wrong, nor that nontoxic medicines are always unsuitable and toxic ones always suitable. The key is to assess the severity and extent of the illness, then decide which medicine to use and in what dose.”

The Yellow Emperor said, “Please explain the proportions of medicines.” Qibo said, “One chief ingredient and two assistant ingredients make a small formula; one chief ingredient, three assistant ingredients, and five supporting ingredients make a medium formula; one chief ingredient, three assistant ingredients, and nine supporting ingredients make a large formula.” Cold conditions are treated with warm or hot medicines, and hot conditions with cold medicines. For mild illness, treat it with an opposing method; when the illness is severe, follow its course and use a corresponding method.

A mild illness is like an ordinary fire: it catches when it meets grass and burns more fiercely when it meets wood, but dampness can suppress it and water can put it out. So one should oppose the course of the illness, restraining and attacking it with the contrary method.

A condition at its most severe is like dragon fire: when it meets dampness, its flames grow stronger; even when it meets water, it burns. Anyone who does not understand its nature and tries to suppress it with water or dampness will only send its flames surging skyward; they will stop only when there is nothing left to burn. Those who understand its nature treat it contrary to ordinary expectations: they use fire to drive it away, and the flames then subside of their own accord and go out. “Opposing treatment” here means using cold medicines to attack heat and hot medicines to attack cold. “Following treatment” means treating with cold or hot methods that accord with the illness’s course. Yet even when treatment follows the illness’s course, the same method is not always used. Thus the text below says, “Opposing treatment is direct treatment; following treatment is reverse treatment. Whether following treatment should be used sparingly or extensively must be judged according to the circumstances.” Is this what that means?

○ New Editorial Note (a supplementary note by later editors): In the Shennong, the medicines are recorded as having chief…

The chief, deputy, and assistant medicines—which respectively treat the main condition, support the treatment, and guide its effects—work together to harmonize their medicinal properties and coordinate their actions. A prescription may contain one chief, two deputies, three assistants, and five guides; or one chief, two deputies, and nine assistants and guides.

Hard, stubborn pathogens should be eliminated with medicine; external pathogens should be expelled. Illness caused by overexertion should be treated with warming methods; what is knotted and congested should be dispersed; what lingers should be attacked; dryness should be moistened; urgency should be moderated; what is scattered should be gathered; deficiency should be supplemented; obstruction and stagnation should be set in motion; and fright should be calmed. For illness in the upper body, treatment may guide it downward. One may also use massage, bathing, or gentle, forceful, opening, and dispersing methods. The key is to choose the method that suits the condition.

The appropriate method should be selected with care according to the illness and its signs and symptoms.

The Yellow Emperor asked, “What are contrary treatment and treatment that follows the symptoms?” Qibo replied, “Contrary treatment is regular treatment; treatment that follows the symptoms is reverse treatment. In treatment that follows the symptoms, the medicine may be used in a smaller or larger amount, depending on the specific condition.”

Contrary treatment, or regular treatment, means responding to the nature of the pathogen with an opposing method: for example, using cooling medicines to treat heat patterns and warming medicines to treat cold patterns. Treatment that follows the symptoms, or reverse treatment, appears on the surface to follow the pattern’s presentation, but its aim is still to treat the illness. “Using less” means that, among three treatment methods, one is the same and two are different; “using more” means that two are the same and one is different. Here, “different” means adjusting the method according to the condition.

The Yellow Emperor asked, “What is reverse treatment?” Qibo replied, “For a heat pattern, use cold-natured medicine but administer it in a warm way; for a cold pattern, use warm-natured medicine but administer it in a cool way. When a pathogen is closed in, use a method that appears to close or supplement; when a pathogen is congested, use a method that appears to open and free the flow. The essential thing is to grasp the main cause of the illness and first address what gives rise to the pattern. In this way, the treatment may initially seem to match the pattern, yet ultimately produces the opposite effect. When applied appropriately, it can disperse accumulations, break through hard knots, harmonize the movement of Qi, and bring the illness to resolution.”

For example, when cold pathogens are lodged deep inside and congeal into accumulations, forming shan jia (abdominal masses and related conditions), attacking them with hot medicines may cause the cold pathogen to reject the heat. The medicine then cannot reach its target, and the condition may worsen; continued attack can make the patient’s pain more severe. The treatment is therefore to begin with honey-boiled aconite, followed by warm honey, using a relatively large amount of honey. After taking it, the condition subsides. This is what Master Zhang called “using heat through cold”: treating a cold pattern with hot medicine while using a cool or gentle way to make it possible to take.

There is another situation: a burst of fire and heat is underway, and the patient has taken too much cold medicine. The cold has obstructed the heat pathogen, so the body instead becomes cold, with vomiting, hiccups, a dry throat, a bitter taste in the mouth, and aversion to hot things alongside a preference for cold ones. Everyone regards this as a heat pattern and agrees that cold medicine should be used, but that would make the condition worse. What should be done? If the patient’s preference is disregarded, the medicine may be rejected; if it is followed, the condition may worsen. At this point, cold and heat should be harmonized: use hot medicine, but cool it before giving it. Once swallowed, the medicine’s coldness dissipates and its hot medicinal nature takes effect; the pathological Qi then improves, and the vomiting and hiccups subside. This approach neither goes against the patient’s sensations nor fails to bring good results. Drinking chilled strong wine follows a similar principle. This is “using heat through cold.”

“Aversion to heat” refers to the residual Qi of various foods and is chiefly related to the generation of life…

A commentary in the collation notes that the word “govern” here may be mistaken, since symptoms such as vomiting have already been discussed.

In some heat patterns, cold medicines used directly cannot penetrate. The patient may be averse to cold, and the cold does not suppress the heat; instead, it becomes difficult to dispel. Using medicine that follows the heat pattern may worsen the heat, while cold medicine given directly cannot take effect. So cold medicines such as fermented soybeans are soaked in wine, or warmed slightly before being taken. Wine is warm, while the medicine is cold; together, they do not work against each other. By the time the wine’s warmth has dissipated, the cold medicine has already taken effect, and the heat then subsides. This is “using cold to treat heat”: administering cold medicine by a warm method.

Cold foods can also be combined with warming foods, mixed evenly and then taken or eaten to ease the heat. This, too, is “using cold to treat heat.” For example, when a patient with a heat pattern eats pork, rice noodles, sunflower greens, or dairy foods, these can be balanced with warming ingredients such as Sichuan pepper, ginger, and tangerine peel. This is the same kind of method.

There is another situation in which a similar approach can be used: heat pathogens lodged in the Lower Burner, the region of the organs in the lower part of the body. For example, Qi may be deficient in the Lower Burner while Qi movement is obstructed in the Middle Burner, causing severe distension and fullness in the chest and flanks. Eating makes the distension and fullness worse. Inexperienced doctors often find this hard to assess. They want to relieve the distension but fear damaging the Lower Burner; tonifying the Lower Burner makes the distension in the Middle Burner worse; dispersing the Qi stagnation leaves the Lower Burner even more deficient; and treating that deficiency makes the distension in the Middle Burner more severe. The doctors discuss the case repeatedly and agree on an approach, yet still fail to resolve the deficiency, focusing only on attacking the distension. After the medicine is taken, the distension eases for a time; once its effect wears off, the condition returns. As a result, the distension in the Middle Burner and the deficiency in the Lower Burner persist.

The proper method is to free the flow of Qi in the Middle Burner while strongly tonifying the Lower Burner. A small dose of medicine can easily worsen the obstruction; a sufficient dose, by contrast, can restore the flow of Qi. With this treatment, the distension in the Middle Burner subsides on its own, and the deficiency in the Lower Burner is also replenished. This is “using obstruction to treat obstruction”: treating obstructive distension with methods that tonify and replenish.

Another example: intense heat pathogens accumulate in the body, causing persistent diarrhea. Heat patterns should normally be treated with cold medicines. Once the accumulation has dispersed, purgation with cold medicines can clear the heat bind, and the diarrhea will stop. This is “using free flow to treat free flow”: treating diarrhea, a symptom of excessive flow, with a method that purges.

Similarly, intense heat may congeal inside the body, causing loose stools and diarrhea over a long period. The condition may improve for a time, then recur, continuing for years. In this case, purging with hot medicines removes the cold pathogen, and the diarrhea stops. This, too, belongs to the same kind of method.

To treat a heat pattern with cold medicine, use a warm method to carry the medicine through the body; to treat a cold pattern with hot medicine, use a cool method to carry it through. The initial medicinal properties and the final effects may seem opposed. This is “contrary treatment.” There are many similar cases; here, only the main points have been briefly presented.

The New Collation adds that the Treatise on the Five Phases in Their Regular Cycles also says: “Treat heat with cold, and administer it warmly; treat cold with heat, and administer it coolly.” This likewise explains the principles of “using cold to treat heat” and “using heat to treat cold.”

The Yellow Emperor asked, “How should Qi be regulated so that the body can return to normal?” Qibo replied, “Sometimes one must follow the course of the illness; sometimes one must oppose it. One may also follow it first and oppose it later, or oppose it first and follow it later. The key is to free the flow of Qi and restore its balance. This is the principle of treatment.”

“Counteracting treatment” means treating the illness with a proper method opposite to the pathogenic influence. “Following treatment” means treating it by going along with how the illness presents, using a method that seems to run counter to it. Counteract the pathogenic influence with the proper method, and it will return to harmony; follow the course of the illness with treatment that turns it in the opposite direction, and it too can be brought into harmony. This is why the methods are called “counteracting and following.”

If the pathogenic influence is not dispersed and the pathways through which Qi circulates are not opened, Qi will change when it encounters cold or heat, giving rise to various disorders.

The Yellow Emperor asked: When a disorder involves both the inside and the outside of the body, how should it be treated?

Qibo replied: If an illness develops from the inside outward, regulate the interior. If it develops from the outside inward, treat the exterior. In either case, cut off the root of the illness.

If an illness develops from the inside outward and the exterior symptoms are more severe, regulate the interior first, then treat the exterior. If it develops from the outside inward and the interior symptoms are more severe, treat the exterior first, then regulate the interior. In both cases, remove the root first, then address the branches.

If disorders of the interior and exterior are unrelated, treat only the more important one. By “unrelated” we mean that each has developed into a distinct illness.

The Yellow Emperor said: Good. After a fever, a person may become chilled; the cold and heat alternate like malaria, sometimes occurring once a day and sometimes only after several days. Why is this?

Qibo replied: This happens because the forces of “dominance and recurrence”—the mutual restraint, waxing and waning, and alternating response of Yin and Yang—meet at different times. When Yin is abundant and Yang is weak, the interval between attacks is longer. When Yang is abundant and Yin is weak, the interval is shorter. This follows the pattern by which the forces of dominance and recurrence interact and wax and wane; malaria follows the same pattern.

When Yin and Yang are evenly matched, cold and heat each occupy half the day. When Yang is abundant and Yin is weak, an attack occurs once a day, with fever but no chills. When Yang is weak and Yin is abundant, an attack occurs every other day, beginning with chills and followed by fever.

Even when the forces of dominance and recurrence are at work, if their influence is weak, an attack may occur once and then not return for six or seven days. The illness may seem to have passed, only to recur later. Sometimes attacks occur for three days in a row and then stop for six or seven days; sometimes they recur after ten days and continue for four or five days before stopping. All these patterns depend on how much Qi is present and whether the forces of dominance and recurrence happen to meet.

Those with shallow understanding do not know these principles and say that sudden illness is caused by ghosts and spirits. They pray and seek refuge for a long time, waiting for the illness to pass, while the patient may die in the meantime. When the patient dies, they still believe fate was to blame. As a result, the wronged dead seem to fill the roads, and those who die young lie across the wilderness. How could a compassionate person see this and not feel grief? This custom has lasted a long time and is difficult to change at once. Yet if it remains unchanged, that too is truly beyond remedy. How tragic, how tragic!

The Yellow Emperor said: Medical writings say that cold disorders should be treated with heat, and heat disorders with cold, but practitioners of the arts are unable to…

If the guiding principles are abandoned and the method of treatment changed, one will fall into difficulty: when a heat illness is treated with cold medicines, the patient may become even hotter; when a cold illness is treated with hot medicines, the patient may become even colder. What should be done in these two situations?

These situations refer to cases in which treatment does not ease the illness but instead brings on new symptoms of cold or heat through the medicines’ cold or hot effects. The new illness may sometimes pause for a while and then return; sometimes the symptoms disappear while the medicine is being taken, only to recur after it is stopped; in other cases, they persist without letup. If physicians abandon the principles of treatment, they have no method to follow. Yet if they treat according to the usual principles, the illness does not recede; and if they set those principles aside, they go against common sense. Treatment continues, but the medicines seem to have no effect. The physician is left confused, unable to understand the situation or know what method to rely on. The new illness caused by the medicine and the original illness become intermingled. How, then, can the patient be cured?

Qibo said, “When heat arises after cold medicine has been used, begin treatment from the Yin aspect. When cold arises after hot medicine has been used, begin treatment from the Yang aspect. This is called ‘seeking what it belongs to’—that is, finding the underlying Yin or Yang to which the symptoms belong.”

In other words, strengthen the source of Fire to dispel the obscuring influence of Yin cold; strengthen the root of Water to restrain excessive Yang. This is what “seeking what it belongs to” means.

Physicians with crude technique and shallow learning often fail to study deeply. They use hot medicines to attack cold and cold medicines to treat heat. Before the heat illness is cured, a cold illness has already arisen; if they attack the cold too forcefully, the heat illness grows worse. When heat flares up, cold remains within the body; when cold appears, signs of heat on the body’s surface have not yet faded. The physician wants to attack the cold but fears worsening the heat and does not dare proceed; wants to treat the heat but worries about the cold within and can only stop. Thus, caught between two courses of action that restrain one another, the illness becomes dangerous. Who would have thought that each of the organs has its own root and its own governing Qi of cold, heat, warmth, and coolness?

Treating a problem of the heart does not necessarily require hot medicine, and treating a problem of the kidneys does not necessarily require cold medicine. If Heart Yang is strengthened, Qi can circulate even when cold is present; if Kidney Yin is strengthened, heat can subside. From this we can see that sometimes heat can be treated with hot medicine, and cold with cold medicine. Only by grasping the principle can treatment often prove effective. Who could have imagined that the wisdom and principles of prescribing could be explored to such depths! Alas, is a person’s death truly determined by fate? Could it not instead result from a physician’s shallow learning and mistaken treatment?

The Yellow Emperor asked, “Why does heat arise after taking cold medicine, and cold arise after taking hot medicine?”

Qibo replied, “This is because the treatment has violated the Qi that was dominant at the time, so the illness has changed in the opposite direction.”

All things have qualities of cold and heat, and Qi is divided into Yin and Yang. If the Qi dominant at the time is violated, its influence will be strengthened. Liver Qi is mild and warm; Heart Qi is hot; Lung Qi is cool; Kidney Qi is cold. The Spleen, meanwhile, has the combined role of harmonizing and coordinating them. This is why the Qi of the organs has different qualities. In spring, one should use cooling methods to regulate the Liver…

If, in summer, one uses medicines that are somewhat cooling to treat the Heart, the result may be that the Heart becomes hotter. If, in autumn, one uses somewhat warming medicines to treat the Lung, the result may be that the Lung becomes colder. If, in winter, one uses very hot medicines to treat the Kidney, the result may be that the Kidney becomes colder. This is probably because the Qi of a particular organ has been supplemented too excessively. When supplementation goes too far, the organ’s cold or hot Qi may become excessive on its own.

The Yellow Emperor asked, “If no particular organ is being supplemented, why does this happen?”

Qibo replied, “That is a very thorough question. The reason is that people have not paid attention to how each of the Five Flavors—the sour, bitter, sweet, pungent, and salty tastes of foods and medicines—has its own destination. After entering the Stomach, each flavor tends toward the organ associated with it: sour first enters the Liver, bitter first enters the Heart, sweet first enters the Spleen, pungent first enters the Lung, and salty first enters the Kidney.”

The Newly Revised Commentary says: “In the Treatise on the Five Qi Revealed, the destinations of the Five Flavors are given as follows: sour enters the Liver, pungent enters the Lung, bitter enters the Heart, salty enters the Kidney, and sweet enters the Spleen. This is what is meant by the ‘five entries.’”

Taking medicines with a particular flavor over a long period increases the corresponding Qi; this is a general principle of how things change. But when Qi continues to increase over time, it can also become a cause of shortened life. When the Five Flavors enter the Liver, they make Liver Qi somewhat warm; entering the Heart makes Heart Qi somewhat hot; entering the Lung makes Lung Qi somewhat cool; entering the Kidney makes Kidney Qi somewhat cold; and entering the Spleen forms the Qi of Great Yin, which also encompasses the cold and hot Qi of the four seasons. The Five Flavors all increase their corresponding Qi, so each acts on the Qi of its associated organ.

Thus, prolonged use of bitter medicines such as huanglian and kushen may, paradoxically, lead to a condition of excessive heat. This is one example. The same applies to medicines of the other flavors, but people often overlook this and fail to observe carefully what changes follow their use. So it is a general principle that prolonged use increases Qi; as Qi continues to increase over many years, it may cause an organ’s Qi to become excessive. When Qi becomes excessive in this way, some of it may become depleted. Once an organ’s Qi is cut off, sudden premature death may follow. This is why the long-term increase of Qi is one cause of premature death.

Therefore, when examining medicines and methods of taking them according to the Collection on Correct Principles for Observing Transformation through Medicines, one should bear in mind that if a medicine does not include all Five Flavors and the Four Qi—cold, hot, warm, and cool—prolonged use may, even if it brings temporary results, eventually lead to sudden premature death. This is what is meant here. Some people give up grain and take only medicinal foods without dying suddenly. Why is that? Because the flavors of the Five Grains are not there to support the body. If they later resume eating grain, that too may lead to premature death.

The Yellow Emperor said, “Well said. What do the terms ‘ruler’ and ‘minister’ mean in a prescription?”

Qibo replied, “A medicine that treats the disease is called the ruler; one that assists the ruler is called the minister; and one that works together with the minister is called the envoy. These terms do not refer to the three grades of medicines: upper, middle, and lower.”

When superior-grade medicines serve as ruler, middle-grade medicines as minister, and inferior-grade medicines as assistants and envoys, the distinction is based on the quality and grade of the medicines. Methods of taking medicines to nourish life should follow this classification. Methods for treating disease do not necessarily do so: the medicine that treats the disease serves as ruler, and the medicine that assists it serves as minister…”

(The original text ends here; no further passage was provided.)

The medicines used as assistant drugs—those that help the principal medicines take effect—serve to support the efficacy of the prescription.

The Yellow Emperor asked, “What does ‘three grades’ mean?” Qibo replied, “It refers to the differences among medicines in their beneficial and harmful effects, their properties, and their functions.”

The “three grades” are the upper, middle, and lower grades, reflecting the different properties and uses of medicines. The New Correction says that, according to the Shennong’s Classic of Materia Medica, upper-grade medicines are rulers and chiefly nourish life, corresponding to Heaven; middle-grade medicines are ministers and chiefly nourish one’s nature, corresponding to humanity; and lower-grade medicines are assistants and envoys, chiefly used to treat illness, corresponding to Earth.

The Yellow Emperor said, “Good. When illness is classified as internal or external, how should it be treated?”

The earlier question about internal and external illness concerned methods for regulating the movement of Qi. The discussion was left unfinished, so the Yellow Emperor asks again here. This exchange should follow the earlier phrase “seek where it belongs”; the chapter order in the ancient editions is disarranged.

Qibo said, “To regulate the movement of Qi, one must distinguish Yin and Yang and determine whether the illness lies within or without, then treat it according to the corresponding location and method. If the illness is internal, treat it from within; if it is external, treat it from without. If the condition is mild, harmonize it; if it is somewhat more severe, bring it back to balance; if it is intense, diminish it. One may use methods such as inducing sweat or purging, or lessen the illness according to the properties of cold, heat, warmth, or coolness. Then determine where the illness belongs and choose an appropriate treatment.”

Illness may be internal or external, and treatment likewise distinguishes interior from exterior. If the illness is internal, harmonize it with internal treatment; if it is external, harmonize it with external treatment. If the movement of Qi is only slightly disturbed, regulate it gently. If the illness is severe and does not recede with treatment, weaken its force and make it subside.

For example, if signs of cold are mild, harmonize them with warming methods; if they are more pronounced, treat them with heat; if the cold is extreme, use purging to drive it out. If purging does not work, counteract it with the opposite method. If it still has not been eliminated, seek the affected organ, channel, or network vessel to make the illness subside. If signs of heat are mild, harmonize them with cooling methods; if they are more pronounced, treat them with cold; if the heat is extreme, induce sweating to expel the pathogenic influence. If sweating does not eliminate it, counteract it with the opposite method. If that still does not work, seek where the illness belongs and make it subside. Thus, one uses methods such as inducing sweat, purging, and applying cold, heat, warmth, or coolness according to the condition, so that the illness diminishes; one then identifies where it belongs and chooses a treatment suited to it. “You” means “place” or “where.”

By carefully following the principles, treatment can be made thorough and appropriate. When Qi and blood are harmonized, one can preserve the lifespan bestowed by Heaven for a long time. Treating in accordance with the medical Way allows each measure to fit the condition. A physician can therefore use medicines from plants, minerals, and other sources, as well as command spirits and harmonize Yin and Yang, dispelling all kinds of illness and keeping Qi and blood balanced so that one’s innate Qi is not depleted. This is possible because the physician can adjust the timing and degree of treatment at will and decide whether pathogenic influences should be retained or expelled. In this way, the spirit remains within the body and life is prolonged.

The Yellow Emperor said, “Good.”

Supplementary Notes and Explanatory Text on the Plain Questions of the Inner Classic of the Yellow Emperor, Volume 48