《黃帝內經素問補註釋文》Vol. 49

The Yellow Emperor sat in the Bright Hall (the ancient imperial court for proclaiming governance) and summoned Thunder Duke, asking: "Do you comprehend the principles of medical arts?" The Bright Hall was the palace where ancient rulers issued decrees, with eight windows and four gates, round above and square below, situated south of the capital. The Yellow Emperor, concerned with the people's suffering and sympathetic to their hidden hardships, demonstrated the compassionate heart of a sage by summoning Thunder Duke to inquire about methods for healing all beings.

Thunder Duke replied: "Though I can recite medical texts, my understanding remains superficial; though I can comprehend, I still cannot discern subtle distinctions; though I can differentiate, my grasp remains incomplete; though I have insight, I cannot yet fully elucidate." This indicates Thunder Duke's understanding of medicine remained at a surface level, unable to penetrate its profound subtleties. Yang Shangshan once said there are five stages in studying medical Dao: first recitation, second comprehension, third discernment, fourth clarity, and fifth manifestation.

Thunder Duke continued: "My current medical skill is only sufficient to treat ordinary officials, not yet qualified to heal feudal lords." He dared not boast of exceptional medical ability, recognizing the vast difference between treating commoners and attending to nobility.

Thunder Duke entreated the Yellow Emperor to impart the "measurements of heaven's canopy" (referring to the boundless principles of medical Dao), teaching him how to harmonize with the Yin-Yang transformations of the four seasons and distinguish the patterns of celestial bodies and luminaries, thereby illuminating medical Dao for the benefit of future generations. "Measurements of heaven's canopy" metaphorically describes the profound depth of medical Dao; "harmonizing with the four seasons' Yin-Yang" refers to aligning with natural rhythms; while "distinguishing stars from sun and moon" means discerning variations in celestial phenomena.

Thunder Duke hoped to integrate the Yellow Emperor's medical principles with Shennong's medical knowledge, allowing posterity to regard this as a medical system jointly established by both sage-emperors. The Yellow Emperor praised him: "Excellent! Do not omit these essentials. These all represent the corresponding relationships between Yin-Yang, exterior-interior, above-below, and feminine-masculine. A truly accomplished physician must understand astronomy above, comprehend geography below, and grasp human affairs in between—only then can one practice medicine enduringly and instruct others without causing doubt. These medical theories may be transmitted to posterity as precious treasures."

This dialogue reveals the transmission method of ancient medical Dao, emphasizing the physician's need for comprehensive mastery of natural laws and human affairs, embodying the core TCM concept of "harmony between heaven and humanity."

Leigong asked, “Please allow me to learn this teaching and recite and explain it.”

Here, “recite” can also mean to make something clear. “Reciting and explaining” means comparing one thing with something similar so that it is easier to understand.

The Yellow Emperor said, “Have you not heard of the Treatise on Yin and Yang?” Leigong replied, “No.” The Yellow Emperor said, “The Three Yang have Heaven as their proper domain.”

“The Three Yang have Heaven as their domain” means that the Three Yang Qi circulate in the upper part of the human body. The Treatise on Yin and Yang was an ancient text. In one version, the phrase “Heaven is their domain” appears instead as “Heaven makes them great.”

Their movement between above and below has no regular pattern. When they converge, illness arises, and Yin and Yang become unbalanced.

“Above and below have no regular pattern” means that Qi moves abnormally and has no fixed location, rising and falling unpredictably. “They converge and illness arises” means that the Qi of the Three Yang channels of the hands and feet come together and cause illness. When Yang Qi gathers in one place, Jing Qi (essence energy) declines, and the functions of Yin and Yang become unbalanced.

Leigong asked, “When the Qi of the Three Yang gather together, they are hard to withstand. Please explain the principle behind this.”

“Hard to withstand” means that when Qi gathers in one place, its force becomes strong and difficult to bear.

The Yellow Emperor said, “When the Three Yang act on their own, the Qi of the Three Yang channels of the hands and feet gather together, like wind and rain, without a fixed pattern. If the illness is in the upper part of the body, it becomes a disorder at the crown of the head; if it is in the lower part, it becomes a disorder involving leakage.”

“Gather together” here refers to the Qi of the Three Yang channels of the hands and feet joining. The Foot Taiyang channel begins at the inner corner of the eye, ascends to the forehead, and meets at the crown of the head. Its collateral branch runs from the crown to the upper corner of the ear. Its main pathway enters the brain from the crown, then branches downward through the nape and shoulders, follows the spine to the lower back, and enters and connects with the kidneys before joining the bladder. The Hand Taiyang channel begins at the hand and ascends along the arm, passes over the shoulder, enters the supraclavicular hollow (the depression above the collarbone), connects with the heart, descends along the throat, passes through the diaphragm to the stomach, and joins the small intestine. Thus, when the Qi of the Three Yang gather together, illness in the upper part may appear as a disorder at the crown of the head, while illness in the lower part may appear as a disorder involving leakage. “Leakage” can manifest as bleeding or the discharge of pus. Yang Shangshan, however, explains it as the bladder’s inability to retain fluid, causing frequent urination and defecation that cannot be controlled.

“Like wind and rain” means that the onset has no fixed pattern. The text therefore continues: …

There are no outward signs by which to predict the condition, and no fixed pattern within the body. The changes in the illness do not follow the regular course of the channels. On examination, the affected area has no fixed position above or below; only by recording the findings and distinguishing among them can one determine the condition.

This means that when the Qi of the Three Yang gather together, their position above or below follows no regular pattern. There are no predictable changes in complexion or other outward signs, and within the body the channels follow no fixed course. When the illness arises, it often departs from the established order of channel circulation, and symptoms have no fixed location above or below. The condition must therefore be recorded, weighed, and analyzed before it can be distinguished.

Leigong said, “Few of the patients I treat recover. Please explain the deeper principle behind this…”

Once this is understood, the doubts in the heart cease. In other words, after hearing the explanation, suspicion is dispelled.

The Yellow Emperor said, “The Three Yang are the most abundant of the Yang qi.”

The qi of the six Yang channels gathers together; hence they are called “Yang at its utmost abundance.” When Yang qi accumulates and flourishes, it can make a person frightened and cause sudden illness. The onset is swift, like a fierce wind that suddenly strikes, and the body stiffens and collapses. All nine orifices may also become blocked.

When Yang qi is excessive and overflows outward, the throat becomes dry and constricted. “Accumulation” means gathering layer upon layer. The qi of the six Yang channels converges in successive layers, growing vast and forceful, difficult to restrain. Yang qi becomes bound up; when it grows excessive, it overflows without limit, and the nine orifices become blocked.

When Yang qi enters the Yin aspect—that is, the organs—it may cause illness that shifts unpredictably between the upper and lower parts of the body. Pathogenic qi presses close to the intestines and may even lead to intestinal dysentery, a disorder of the intestines commonly marked by diarrhea or bloody, mucus-filled stools. Here, “Yin” refers to the organs. When pathogenic Yang presses upon the organs and causes illness, it may also produce symptoms that vary between the upper and lower parts of the body. On examination, if the illness is in the lower part, frequent bowel movements and reddish or whitish mucus in the stool are often seen.

This describes illness of the Three Yang: the patient is restless and unable to sit still, suddenly wants to lie down, and feels heavy in the body. The Foot Taiyang channel runs down from the shoulder to the waist, so the patient finds it difficult to rise from sitting and feels heavy when lying down. The reason is that when the patient rises, Yang qi grows more abundant and surges, making the patient want to lie down again. After lying down, the channel qi becomes more harmonious, and the body feels settled. The New Collation says that the Jia Yi Jing reads “the body feels heavy” where the text has “the body feels whole.”

The Yellow Emperor then said, “How can this account enable us to understand the myriad things under Heaven, distinguish Yin and Yang, follow the seasons, and correspond with the Five Phases? What you have said is not yet complete.”

Lei Gong said, “The principles of Yin and Yang have not yet been clearly distinguished, and their explanation is still unclear. Please let me continue to receive your instruction, so that I may understand the utmost Dao.”

The New Collation points out that, from this passage to the end of the chapter, the Quan Yuanqi edition presents the material as a separate chapter titled ‘The Flourishing and Decline of Forms.’

Earlier, the Yellow Emperor had not agreed that Lei Gong deeply understood these principles, so Lei Gong asked again for instruction. The Yellow Emperor said, “If you receive instruction but do not know how to bring what you have learned into accord with the utmost Dao, you will confuse the teachings handed down by your master. I will tell you the essential points of the utmost Dao.”

Without understanding the essentials, what one has learned will scatter into endless disorder. Later generations have copied one another, long after the time of the sages; each learner has come to regard their own method as correct, and so the teachings handed down by their masters have been confused.

When illness has already damaged the five organs, sinews, and bones, leaving a person increasingly emaciated, and the principles you have described are still unclear and obscure, then the medical Dao studied by the rulers of the world may well be lost as a result. If an illness this severe cannot be distinguished, how could a milder illness be diagnosed and cured? In that case, one cannot gain a broad understanding of changes in illness or grasp how to teach rulers to study the medical Dao. The world’s medical learning will then decline.

“When Kidney qi is about to become depleted, the heart is anxious and fearful; even toward evening, the person remains slow and unresponsive, unable to manage everyday affairs.” Of the signs shown by the organs, these signs of the Kidney are relatively easy to recognize. But when the Kidney pulse is about to cease, the spirit will…

By evening, the muscles, sinews and bones, and channels may feel sore, weak, and hollow. If the Qi of the five zang organs is only somewhat deficient and has not been completely depleted, a person will seem weak in spirit and physical strength, unable to regain their former fullness and vigor. This condition is due to insufficient Kidney Qi, not to an injury.

[The New Collation says: In the Taishu, this passage reads, “The Kidney is about to be exhausted; death may come at dawn or dusk.” The character rendered here as “wan” is pronounced “wu guan.”]

Discussion of Calm and Careful Inquiry

[The New Collation says: In the Quan Yuanqi edition, this chapter is titled “Calmly Distinguishing Black from White.”]

The Yellow Emperor sat at ease, summoned Leigong, and asked, “You have studied medicine and recited medical texts. If you can examine a wide range of learning, compare and organize it, and bring its principles together, then tell me what you know best: the five zang organs and six fu organs; the gallbladder, stomach, large intestine, small intestine, spleen, uterus, bladder, brain, and marrow; and the pathways by which nasal discharge, saliva, weeping, grief, and fluids move. These are all areas of human physiology and treatment where mistakes can easily occur.”

Distinguishing the Five Zang Organs

The Yellow Emperor asked, “I have heard that some practitioners regard the brain and marrow as zang organs, while others regard the intestines and stomach as zang organs. Some people classify these as fu organs instead. Their accounts differ, yet each group believes itself to be right. I do not understand the principle behind this, and would like to hear your explanation.”

Qibo replied, “The brain, marrow, bones, vessels, gallbladder, and the female womb—these six arise from Earth Qi and are like the earth in their nature. They can store Yin essence without discharging it, so they are called the ‘extraordinary fu organs.’ The stomach, large intestine, small intestine, Triple Burner, and bladder arise from Heavenly Qi and are like the heavens in their nature. They transport and discharge, but do not store essence and Qi. They receive turbid Qi passed on by the five zang organs, so they are called the ‘transforming and transmitting fu organs.’ Physicians of old regarded the distinctions and functions of these zang and fu organs as matters that must be understood clearly and handled without error in diagnosis and treatment.”

The Yellow Emperor said, “You must work hard to understand these principles; only then can diagnosis and treatment be carried out with complete accuracy. If you fail to understand them, you will invite blame from others. Acting rashly without knowing these principles may even harm a life. That is why people often lay blame when they hear discussions of medical theory.”

Leigong said, “Although I have recited many sections of the upper and lower volumes of the Mai Jing, and have tried to distinguish what is alike and what differs, and to compare and classify them, I still cannot achieve complete understanding. How, then, could I be qualified to explain their principles?”

[The meaning is that Leigong says he has read many volumes and sections of the Mai Jing. Although he has tried to distinguish similarities and differences, and to compare and classify them, he cannot rely on this alone to bring the principles fully together, much less grasp their highest truths. “An” means “where” or “how.”]

The Yellow Emperor said, “You may try to explain separately the changes in the five zang organs, the imbalances of the six fu organs, mistakes that may arise in treatment with acupuncture and stone lancets, and the circumstances in which poisonous medicines, decoctions, and the flavors of food are appropriate. Describe all these matters in detail…”

According to the context, this passage says that the Yellow Emperor believed Lei Gong had not directly answered his question about the key points of examination. Instead, Lei Gong had discussed treatments for patterns of deficiency in the liver, kidneys, and spleen. The Yellow Emperor therefore rebuked him for answering a different question. The passage goes on to say that the pulse signs of several organs can sometimes look very similar, making them easy to confuse. The examiner must remain calm and compare them carefully.

The Yellow Emperor said, “You have used this to answer my question, and I do not know how to understand it.”

Here, “error” means a mistake: failing to examine the pulse in the customary way and consequently treating the illness incorrectly. Toxic medicines, acupuncture, moxibustion, stone lancets, and decoctions can all be used to attack pathogenic influences; the flavors of food are used to nourish the body. Lei Gong was asking why these methods sometimes work for this kind of illness and sometimes do not.

The New Critical Edition notes that, according to the Taishu, the character shi here is written as cheng.

Lei Gong said, “Deficiency of the liver, kidneys, or spleen can all make a person’s body feel heavy and the mind feel oppressed. In such cases, sometimes the illness is cured by administering toxic medicines, or by acupuncture, moxibustion, stone lancets, or decoctions; sometimes it does not improve. I would like to ask about the reason.”

Lei Gong thought that the Yellow Emperor’s earlier question concerned treating illness with toxic medicines, decoctions, and the flavors of food, so he spoke about illnesses and treatments of this kind.

The Yellow Emperor said, “You are already so old. Why are you still asking such a question? I must have asked it poorly myself, and so brought on an answer that misses the point.”

The Yellow Emperor meant that Lei Gong’s answer did not correspond to what he had asked. He therefore said that his own question must indeed have been poorly framed, causing this mistaken response.

The Yellow Emperor continued, “I asked you about what is deep, subtle, and hard to see, but you answered with material from the upper and lower chapters. Why?”

“Subtle obscurity” refers to conditions that cannot be seen on the surface, such as internal changes in the body, Qi, nutritive Qi, and defensive Qi. In the “Treatise on the Eight Correct Signs and the Spiritual Illumination,” Qibo tells the Yellow Emperor that “observing what is obscure” means observing changes in bodily form and Qi, and in nutritive and defensive Qi, that do not show themselves on the body’s surface and can be detected only by a physician. The physician must assess the illness by bringing together changes in the warmth and cold of the day, the waxing and waning of the moon, and the rising and sinking of the Qi of the four seasons. These changes should be detected before they become visible outwardly. This is why the Yellow Emperor says he was asking about matters that are “subtle and obscure.”

Lei Gong, however, spoke about deficiency of the liver, kidneys, and spleen, topics discussed in the upper and lower chapters. That is why the Yellow Emperor asked why he had answered with material from those chapters.

When the spleen is deficient, its pulse may sometimes be floating, like the lung pulse. The kidney pulse may sometimes be faintly floating, like the spleen pulse. The liver pulse may sometimes be rapid, deep, and scattered, like the kidney pulse. These are cases in which the pulses are easy to confuse during examination. One should nevertheless examine them calmly and distinguish them by comparing them one by one.

When the spleen is deficient, its pulse may be floating and resemble the lung pulse; the kidney pulse may be faintly floating and resemble the spleen pulse; and the liver pulse may be rapid, deep, and scattered, resembling the kidney pulse. Why does this happen? Because the relationships among the organs are close, their pulse signs can differ in subtle ways yet resemble one another, confusing the physician and leading to incorrect treatment. Even so, one should observe calmly and steadily, carefully comparing the pulse signs of each organ.

More specifically, a floating and moderate pulse belongs to the spleen; a floating and short pulse belongs to the lungs; a faintly floating and slippery pulse belongs to the heart; a rapid, tense, and scattered pulse belongs to the liver; and a pounding, deep, and slippery pulse belongs to the kidneys. If these distinctions are not made through careful comparison, doubt and confusion will only grow.

As for the Spleen, Liver, and Kidneys, each corresponds to Earth, Wood, and Water. Even a child knows this—why ask?

The Spleen belongs to Earth, the Liver to Wood, and the Kidneys to Water. All three organs lie below the diaphragm, close to one another.

Lei Gong said, “A person has a headache, tight tendons and vessels, heavy bones, a timid expression, and shortness of breath. He also often hiccups, belches, and feels bloated in the abdomen. He is frequently frightened and does not like to sleep. Which organ is ill? His pulse is floating and wiry; when pressed, it feels as hard as stone. I do not understand the reason, so I am asking again about the three organs in order to clarify how they may be compared.”

The reference to “asking about the three organs” means that, given the pulse’s qualities—floating, wiry, and hard as stone—he wants to compare and distinguish the causes of the illness.

The Yellow Emperor said, “This is called careful discernment: reasoning by analogy.

“In the elderly, examine the six bowels, which correspond to the five viscera. In the young, examine the channels and vessels. In people in their prime, examine the five viscera. The elderly often take in too many rich flavors; the young are often harmed by physical labor; and people in their prime are prone to excessive sexual activity. Excessive sexual activity depletes Jing and Qi. Too much labor allows wind evils to enter the channels and vessels. Too many rich flavors damage the six bowels. Therefore, the focus of examination differs in each case.

“What you have said does not get to the heart of the matter. The Eight Winds, or wind evils that invade the body from different directions, accumulate; the five viscera are damaged, and the pathogenic Qi changes and affects them in turn. A floating, wiry pulse indicates that Kidney Qi is deficient.

“A floating pulse indicates deficiency; a wiry pulse reflects Liver Qi. The pulse is therefore floating and wiry because Kidney Qi is deficient.

“A deep pulse as hard as stone means that Kidney Qi is congested within the body. ‘Stone’ means hardness; ‘lodged within’ means that Kidney Qi has become knotted inside and cannot flow freely.

“A timid expression and shortness of breath indicate that the water pathways are obstructed, while the body and breath grow weaker day by day. When Kidney Qi is deficient, fluids do not circulate freely. The Lungs are also struck, so the body’s form and Qi gradually disperse and decline.

“Coughing and oppressive discomfort indicate that Kidney Qi is moving upward in reverse. It is congested within and rises to the organ that corresponds to it as its mother.

“A person’s illness has its root in one organ. To say that three organs are ill at the same time would go against medical principles.”

The classics do not say this.

Lei Gong said, “A person has limp, weak limbs, panting and coughing, and blood in the stool. After examining him, I concluded that the Lungs were injured. His pulse felt floating, large, and tight, so I did not dare treat him. Later, a physician with limited skill used a stone lancet—a stone instrument used in ancient times for needling—to let blood. The patient bled even more, but once the bleeding stopped, his body felt lighter. Why?”

The Yellow Emperor said, “You are indeed skilled at treating many illnesses, but you have judged this one incorrectly.”

To believe that this is an injury to the lungs, yet not dare to treat it, is a sign of reckless understanding and faulty judgment.

The method of treatment with stone needles requires careful thought. A wild goose may happen to fly high in the sky, but can it really do so by relying on its wings alone? A careless physician who uses stone needles is much the same: occasionally curing an illness does not mean that he has mastered the correct method.

When the sages treat illness, they follow rules and standards. They compare the particular case with similar ones, then examine its changes in depth, carefully observing the condition from top to bottom. Why cling to just one account of the channels? Here, “channels” refers to the meridians, not to rules for treating illness in general.

When the pulse is floating, large, and vacuous, it means the Spleen Qi cannot remain contained. The Spleen’s Qi disperses beyond the Stomach and turns toward Yangming (the Stomach channel). A branch of the Foot Taiyin Spleen channel enters the intestines and Stomach. Thus, when the Spleen Qi cannot remain contained, it cannot reach the Stomach and instead turns toward Yangming.

The Qi of the two Yang organs is not strong enough to overcome that of the three Yin organs, so the pulse becomes disordered and irregular. The “two Yang” here refers to the Heart and Lungs; the “three Yin” refers to the Liver, Spleen, and Kidneys. The Heart and Lungs lie above the diaphragm, while the Liver, Spleen, and Kidneys lie below it. When the Qi of the three Yin organs rises and becomes predominant, it exceeds that of the two Yang organs. Yang Qi cannot overcome Yin Qi, and the pulse therefore becomes disordered and irregular.

Loose, weak limbs indicate that Spleen essence is not being distributed. The Spleen governs the limbs; when Spleen essence cannot be transformed and conveyed, this condition arises.

Panting and coughing occur when water Qi combines with Yangming. Kidney Qi counterflows upward into the Stomach, causing water Qi to gather in Yangming.

Blood leaking outward indicates that the Qi in the vessels is urgent and that blood has lost its normal course. “Leak” here means that blood flows out. When the Qi in the vessels rushes, blood overflows within them and cannot enter the channels to circulate normally, so bleeding occurs. Because the vessel Qi surges and blood spills outward, it is said that the blood has nowhere to flow.

To diagnose these symptoms as an injury to the Lungs is an error caused by reckless understanding and faulty judgment. It shows a failure to compare them with similar conditions, and thus a failure of discernment.

“Failure of discernment” means being unable to distinguish conditions by comparison, and therefore mistaking these symptoms for an injury to the Lungs.

When the Lungs are injured, the Spleen Qi cannot remain contained, the Stomach Qi becomes unclear, and the channel Qi governed by the Lungs cannot circulate normally. The true Qi of the five organs is damaged, some channels are severed, and the Qi of the five organs leaks outward. In severe cases, nosebleeds or vomiting may occur. These signs differ from the symptoms described earlier.

When Lung Qi is injured, Spleen Qi disperses outward; that is why it is said that the Spleen Qi cannot remain contained. When the Lungs are damaged, Qi can no longer circulate. When Qi does not circulate, the Stomach becomes congested; that is why it is said that the Stomach Qi becomes unclear. The Lungs govern the movement of nutritive and defensive Qi and the harmonizing of Yin and Yang. When the Lungs are injured, the channels can no longer…

To practice medicine, one must base treatment on the true condition of the lung. Here, “true organ” means the lung itself. If the lung is damaged, its membrane ruptures, and the associated channels are injured and can no longer circulate normally, the Qi of the five viscera will surge upward and spill outward. If blood does not then flow from the nose, it will be brought up by vomiting.

Why does this happen? The lung connects with the nose, while the stomach corresponds to the mouth; the mouth and nose are both gateways through which breath enters and leaves. Now that the lung is damaged, the stomach Qi is also unsettled. If the blood does not flow out through the nose, it will descend into the stomach. Thus, if there is no bleeding from the nose, blood will be vomited from the mouth.

However, bleeding caused by injury to the lung differs from bleeding caused by injury to the spleen in both its symptoms and the place from which the blood emerges. The causes also belong to different categories, so the two conditions must not be confused.

This is like saying that Heaven has no fixed form and Earth no fixed pattern, and that black and white are far apart. It means that the signs and manifestations of lung injury and spleen injury are completely different, just as Heaven and Earth are separated and black differs from white.

“This was my fault.” Now that you understand, I will say no more.

That is exactly what happened: the Yellow Emperor said, “Lei Gong, your understanding of this condition is still quite rudimentary. This is because I did not teach you how to reason by analogy, so I admit that it was my fault.”

If one can clearly cite similar signs and manifestations, compare them, and reason from one case to another, one can examine illness with composure. This method is therefore called “Zhenqing.” The New Collation notes that the Taishu writes “jing” in place of “qing.”

This is the highest principle. By clearly citing signs and manifestations and weighing and comparing different categories, one will not misjudge even subtle, mild conditions. Why is this possible? Because the Great Dao is subtle and profound, making this possible.

“Congrong” is also the title of a chapter in an ancient medical classic. In the “Treatise on the Categories of Yin and Yang,” Lei Gong says, “I have devoted myself fully to learning the channels. I must also learn the principles of Congrong, so that I can bring myself into accord with Congrong.” This shows that an ancient text did indeed contain a chapter called “Congrong.”

Treatise on the Five Errors (the New Collation notes that the Quan Yuanqi edition gives the title as “Treatise on Errors”)

The Yellow Emperor said, “Ah, how profound this principle is! Its subtle workings are inexhaustible. It is like looking down into an abyss or gazing up at drifting clouds: an abyss can still be measured, but floating clouds are unsettled, and their limits cannot be seen.”

The Yellow Emperor marvels at the boundlessness of the Great Dao. “Its subtle workings are inexhaustible” means that its applications and transformations have no end. Deep water is clear and can be seen through, so it can still be measured. Floating clouds drift without settling and have no fixed boundaries, so their limits cannot be known. The New Collation points out that this passage repeats material from the “Treatise on the Six Subtle Principles.”

The medical art of the sage establishes standards for the people. When discussing illness and judging a patient’s intentions and emotional state, one must have methods and follow the corresponding principles…

Doctors who follow the rules of examination and make their rounds taking patients’ pulses are people who help the common people. In diagnosing illness, then, there are the “Five Failings”—five kinds of error in medical practice—and the “Four Virtues,” the four virtues doctors should follow. Do you know what they are?

By taking care to avoid the Five Failings, one can honor and follow the De of the four seasons. De is the working of the Dao and the master of life, so it must be honored and followed. The “Treatise on the Heavenly Truth of High Antiquity” says that people of old could all live beyond a hundred years without their movements declining because their virtue was complete and undamaged. The Ling Shu Jing says that what Heaven endows in human beings is De. From this we know that Heaven bestows De, on which people depend for life; the Qi of life sustains the spirit and connects with Heaven. The “Treatise on the Vital Qi Connecting with Heaven” says that, since ancient times, humanity’s connection with Heaven has been the root of life. This is what it means.

The New Collation says, “‘To assist’ means to help.” Yang Shangshan also says, “‘To supplement’ means to help.”

Lei Gong rose from his seat and bowed twice. “I am young and have little experience. I am troubled and do not know what the Five Failings and Four Virtues are. I do not understand how to relate them to the body and to names, nor how to cite the scriptures. I have no answer in my heart. The classics have not been taught to me by a teacher, and I am not someone who understands things by nature. My learning is shallow.” In this way, he humbly declared his inadequacy.

The Yellow Emperor said, “Whenever a patient has not yet been examined, the doctor must first ask whether the patient was once prominent but later fell into poverty. If so, illness may arise from within even without exposure to external pathogens. This illness is called ‘Losing One’s Glory.’”

This is because the spirit has been damaged. A person who was once honored and prosperous but later suffers humiliation and disappointment remains attached to the past, with aspirations blocked and the heart burdened by grief and fear. Thus, even without exposure to external pathogens, illness may arise from within, and the blood vessels gradually weaken and diminish. That is why it is called “Losing One’s Glory.”

The illness of someone who was once wealthy but later became poor is called “Loss of Essence.” The Qi of the Five Viscera stagnates, allowing pathogenic influences to gather. In wealth, the person indulged their desires; after falling into poverty, they lost their wealth. Their heart became burdened with grief, while their circumstances brought overwhelming sorrow. Their mind then sank into memories and longing, and their spirit was depleted by thoughts of gain and loss. The movement of nutritive Qi and defensive Qi was obstructed, slowed, and brought to a standstill; Qi and blood could no longer flow freely, and over time they congealed and formed an illness.

The doctor examines the patient, but cannot tell which organ is affected, and the patient’s outward appearance has not changed. After the examination, the doctor is puzzled and does not know the name of the illness.

This describes the illness in its early stages. It is caused by longing and attachment, so it has not yet penetrated the organs. The effects of thoughts and emotions are unusual, while the body’s outward appearance has not yet changed. A doctor who does not understand this will be puzzled during the examination.

The body grows thinner day by day, and Qi becomes too weak to transform and generate essence.

This describes the illness as it progresses. Qi and blood constrain one another, and the body’s flesh and muscles gradually waste away. The “Treatise on the Correspondence of Yin and Yang” says, “Qi returns to essence, and essence depends on Qi for nourishment.” Now the original Qi is weak and cannot transform and generate essence, so essence is left without nourishment. As a result, the body grows thinner day by day.

As the illness worsens, the breath grows weak. The person often feels uncomfortably cold and may sometimes become frightened and restless.

Evil influences penetrate deeply when they become lodged within and Grain Qi—the vital energy derived from food—has been depleted. Yang Qi is then pressed inward, causing aversion to cold, fear and agitation, and chills throughout the body.

Evil influences penetrate deeply when they deplete defensive Qi, which protects the body, on the outside, while damaging nutritive Qi, which flows through the vessels and nourishes the body, within. Worry wears down Blood and Qi, while grief further weakens Qi. Thus defensive Qi is depleted externally and nutritive Qi is damaged internally.

Question: Why does the deep penetration of evil influences cause this depletion and damage? Answer: The reason lies here. The New Collation Commentary, an annotation by an ancient editor of medical texts, says that according to the Taishu, the phrase “illness is deep because of this” should read “illness is deep and severe,” meaning that the illness has penetrated deeply and worsened.

Even a skilled physician can make mistakes. Failing to understand how an illness began is one such error in diagnosis and treatment. “Failure” here means not asking when the illness began or what caused it.

Whenever examining a patient, one should first ask about their diet and living environment. People in different regions have different diets and living conditions, so these matters must be clarified. The “Treatise on Different Methods and Appropriate Regions” says: The East is where all things under Heaven and Earth begin to grow. Close to the sea and waterways, it produces abundant fish and salt. People there eat fish, enjoy salty foods, and are content with their homes, finding the local food delicious. The West is rich in metal and jade, and its terrain has much sand and stone; it is where Heaven and Earth gather things in. The people live on hills and ridges, where winds are frequent and the soil and water are harsh. They wear coarse cloth, sleep on grass mats, eat plentifully, and tend to have more body fat. The North is where Heaven and Earth store things away. Its terrain is high, and people live on hills and ridges amid frequent winds, cold, ice, and snow. They prefer to dwell in open country and eat dairy products. The South is where Heaven and Earth bring forth and nourish life. Yang Qi is abundant, the terrain is low, the soil and water are soft, and mists and dew gather there. People enjoy sour flavors and eat fu, a food commonly found in the region. The central region is flat and damp, where Heaven and Earth nurture all things and produce is abundant. The people there eat a varied diet and do little hard labor. This shows why one should ask about these circumstances before diagnosing an illness. The sages combined the various methods of examination, applying each as appropriate to different circumstances; this is what the passage means.

Sudden great joy or grief, or joy followed by suffering, can damage Jing Qi. The New Collation Commentary says that according to the Taishu, “beginning with joy” here should read “beginning with suffering.” Joy makes Qi flow freely, while grief diminishes it. Grief that festers within exhausts Jing Qi and harms life. When Jing Qi is exhausted, the body is also damaged and the spirit becomes dispirited.

Sudden anger damages Yin Qi, while sudden joy damages Yang Qi. Anger makes Qi move upward against its proper course, thereby harming Yin; joy makes Qi flow freely, thereby harming Yang.

Rebellious Qi surges upward and fills the meridians, causing the spirit to become startled and scattered, and to leave the body.

An incompetent physician does not know when to tonify and when to drain, nor does he understand the illness. As a result, the body’s Jing and Qi are continually depleted, allowing pathogenic Qi to invade when it finds an opening. This is the second error in treating disease.

If a physician does not distinguish among a patient’s different emotions—joy, anger, sorrow, and pleasure—and applies tonification or draining indiscriminately, the Jing and Qi of the five organs will gradually be depleted. Pathogenic influences will then erode the body and go on to disturb its upright Qi.

A physician skilled in pulse diagnosis must compare different pulse patterns, distinguish abnormalities from normal states, and examine them carefully in order to become a good doctor. If one does not understand these principles, such a diagnosis is not worth much attention. This is the third error in treating disease.

“Qiheng” refers to abnormal climates or conditions that differ from the norm. “Congrong” means distinguishing whether the Qi of the organs is deficient or replete and recognizing changes in the pulse’s strength and depth, even when different patterns seem similar. The Treatise on Distinguishing with Composure says that when the pulse of a deficient Spleen floats, it resembles the Lung pulse; when the Kidney pulse floats slightly, it resembles the Spleen pulse; and when the Liver pulse is rapid, deep, and scattered, it resembles the Kidney pulse. These are patterns that physicians can easily confuse, but careful examination makes it possible to tell them apart.

There are three standard considerations in examining an illness. First, one must ask about the patient’s social status, whether they have suffered a change in status, and whether they are fixated on becoming a lord or noble. Nobles often live at ease and feel pleased, while people of low status labor physically and suffer emotionally. Since their circumstances of hardship and ease differ, these matters should be clarified before diagnosis. “A lord whose position has fallen into ruin” refers to a titled lord whose status has declined, for example, one demoted from the rank of a high minister. “Aspiring to be a lord or king” means fixating on a prestigious position, making endless demands and never being satisfied. (The New Collation notes that in The Great Simplicity, the word “aspiring” in “aspiring to be a lord or king” is written as “duke.”)

When a noble loses his power, even without being attacked by external pathogens, his body may decline because his spirit has been injured. Worry, fear, anguish, and pent-up distress are the causes.

Someone who was once wealthy and later becomes poor may, even without external pathogenic injury, develop dry, withered skin and contracted sinews and vessels; they may even become weak and unable to walk, with their sinews and vessels drawn into spasms. This happens because the Qi of the five organs becomes stagnant and knotted, and pathogenic influences gather in one place.

If a physician cannot firmly admonish the patient and secure their compliance with medical instructions, or cannot rally their spirit; if the physician is weak and yielding, allowing the illness to disrupt what is normal without being able to change its course, then the physician’s treatment cannot take effect. This is the fourth error in treating disease.

“To admonish” means to warn and restrain the patient, stopping improper behavior and securing compliance with medical instructions. “Rallying the spirit” means invigorating the patient’s spirit. “Outwardly yielding” means that the physician gives in and goes along with the patient. If admonition cannot stop improper behavior, encouragement cannot secure compliance, and the physician merely yields and lets matters take their course, allowing normal order to be disrupted and the illness to remain unchanged, how can this be called practicing medicine?

Whenever an illness is examined, one must understand its course from beginning to end. One must also gather the relevant information, feel the pulse, ask what the illness is called, and take the distinction between men and women into account in making a judgment.

Here, “beginning and end” refers to complexion and appearance. The Treatise on the Subtleties of the Pulse says that to understand outward signs, one should trace them from end to beginning—that is, carefully observe changes in the Five Colors and the Qi, and understand how they cycle and recur.

This passage describes signs left behind when illness takes hold. “Cutting” means pressing the pulse with the fingers; “asking the name” means asking what the illness is called. Men generally have stronger Yang Qi, so a larger pulse on the left is commonly a favorable sign; women generally have stronger Yin Qi, so a larger pulse on the right is commonly a favorable sign. Pulse findings should therefore first be compared with these usual patterns.

The eight emotional disturbances—“separation, severance, pent-up thought, resentment, grief, fear, joy, and anger”—can leave the Five Zang organs empty and cause Qi and blood to lose their ability to remain contained. If a physician does not understand the reasons behind them, how can they know what treatment to use?

“Separation” means being parted from someone dear; “severance” means cutting off thoughts one has held close; “pent-up thought” means worries accumulating and becoming oppressive; “resentment” means old grievances knotting up and remaining unresolved. Separation from someone dear unsettles the hun and shen; cutting off one’s attachments depresses the thoughts; accumulated worries wear down the Shen Qi; unresolved grievances torment the will. Grief obstructs the movement of Qi; fear shakes the mind and spirit, making them unable to remain settled; great anger causes confusion and prevents self-regulation; excessive joy scatters the mind and spirit, so they cannot remain within. Through these eight emotional disturbances, the Five Zang organs become empty, and Qi and blood lose their ability to remain contained. If the physician does not think carefully and determine the causes, what can they say?

The revised edition notes that in the phrase “scattered and shaken, and unable to remain contained,” the words “scattered and shaken” appear in the Jia Yi Jing as “unable to gather and shaken”; “shaken” is read as “dan.”

People whose sinews and vessels were severed through excessive injury may recover their ability to move, yet their fluids can no longer continue nourishing the body. “Severing the sinews and cutting off the vessels” refers to injury to the sinews and vessels caused by excessive damage. Although the body has returned to normal, fluids still cannot be generated because Jing Qi has been depleted. “Moisture” here means bodily fluids.

Thus, Qi in the injured sinews and vessels, along with blood, congeals inside the body and remains lodged there. When it presses against the Yang vessels—the channels and collaterals of the Yang meridians—and the six Fu organs, it turns into pus. If it accumulates in the abdomen over a long period, it manifests outwardly as alternating chills and fever. “Jiong” means heat.

A physician of crude skill does not know that the chills and fever are caused by accumulated pus. Mistaking them for an ordinary fever, the physician treats the patient as usual and repeatedly needles the Yin and Yang meridians, further depleting Qi and blood and worsening the illness. The body then becomes weak and limp as if coming apart; the limbs can no longer move, and spasms develop in the sinews. Death is near. Is this really fate? Was it not caused by the physician?

If a physician cannot clarify the illness or ask where it began, and simply tells the patient what day they will die, that too is crude practice. This is the fifth of the errors in treating illness. “Crude physician” here does not necessarily mean someone whose learning is incomplete. Even someone who studies medicine and has read the medical texts of the Three Dynasties…

The principles of medicine do not provide a complete account of what must be examined; treatment goes against established methods, and other clues to the cause of illness are not pursued. If these five kinds of error are never investigated, there is no need to ask how such a person cultivates himself: it is already clear that he is merely a physician of limited skill.

All five errors arise because people have studied medicine without understanding human affairs or grasping how things work. In other words, although they have learned the rudiments of medicine, they have not yet grasped its subtle principles and remain ignorant of the ways of the world.

Therefore, when the sage treats illness, he must understand the patterns of Heaven and Earth and Yin-Yang, the cycles of the four seasons, the functions of the five zang organs and six fu organs, and relationships such as female and male, exterior and interior. He must also know which illnesses are suited to acupuncture, moxibustion, stone therapy, or medicinal poisons. The sage calmly observes human affairs and, through this, understands the principles of the channels and vessels. People differ in social standing and wealth, and their physical constitutions differ as well. The sage must ask the patient’s age, distinguish the young from the old and the courageous from the timid, examine the location of the illness closely, and learn where it began. Only then can examination of the Eight Correct Influences—the changes in vital energy associated with the seasons and directions—and the Nine Indicators—a method of examining the pulse and the body’s condition—yield conclusions that accord with the illness.

Such is the knowledge the sage possesses. Physicians should strive to learn it.

The key to treating illness lies in taking the body’s internal Qi as the essential guide and following it to investigate the underlying disorder. If the cause cannot be found, the problem lies in the relationship between the interior and the exterior.

This means that, in treating illness, one must look within the body for abnormalities in its form, Qi, and blood. To identify these abnormalities is to grasp the sage’s method of treatment. If they still cannot be found, one must examine further the Qi of the organs and the relationships of Yin-Yang and interior and exterior. The New Collation states that, according to the Quan Yuanqi edition and the Taishō, this passage reads, “Qi within is substantial.” Yang Shangshan explains that the Qi between Heaven and Earth is external Qi, while the Qi within the human body is internal Qi. External Qi gives rise to the myriad things, so it is called “external substance”; internal Qi nourishes the channels and sustains life, so it is called “internal substance.” In treating illness, investigating the principles of internal Qi is the key.

Follow the rules of diagnosis and treatment, and treat according to the illness; then you will not violate the principles of the shu points—the sites where the Qi of the channels flows and gathers, and where therapeutic effects are concentrated. Master and apply this method, and you will remain free from danger throughout your life.

“Follow the rules” means to understand the measures that govern the quantity of Qi and blood and the depth of needling. “Treat according to the illness” means to use each shu point according to the conditions it treats. If both are done, the principles of treatment through the shu points will not be violated. “Danger” is the meaning of “peril.”

If the principles of the shu points are not understood, pathogenic heat will accumulate in the five zang organs and spread into the six fu organs. As heat accumulates in the organs, Yin and Yang Qi contend and bind together; wherever the heat passes, abscesses and swellings will form.

Diagnosing an illness without sufficient care is called violating the established method; in other words, it means failing to follow the proper procedures for diagnosis and treatment.

Carefully observe these principles of treatment, and make diagnosis and treatment accord with the classics. This refers to what was said earlier: begin with the body’s internal Qi and investigate the principles governing the shu points and the places where the channels converge.

The Upper Classic, the Lower Classic, the Measures and Standards, Yin-Yang, the Extraordinary and Constant, and the Five Centers must all be judged and examined on the basis of the Bright Hall…

The Upper Classic explains how Qi communicates with Heaven, while the Lower Classic describes the many changes of illness. The two classics mentioned here are used to infer the movement of Yin-Yang Qi and to distinguish ordinary and unusual signs of disease in the five viscera. These judgments are made according to the different regions of the Bright Hall, the area where complexion was observed and illness assessed in ancient times.

“Estimating and Measuring” means inferring how deeply a disease has taken hold; “the Unusual and the Constant” concerns abnormal illnesses; and “the Five Centers” refers to the colors that appear on the face as Qi from the five viscera shows itself. The Bright Hall allows one to observe the myriad things, distinguish black from white, and judge length and shortness. That is why judgments are made according to it.

“Examining beginnings and endings” means carefully observing the waxing and waning of the Five Phases’ colors—their states of being constrained or flourishing—and watching how they cycle and recur. Applying diagnostic methods according to these principles makes it possible to respond to inexhaustible situations. When examining illness, one can see every part of an ox laid out before one and take in the whole picture; by extending what one knows from one case to another, one can judge accurately in every circumstance. Mastering this method leads to a far-reaching understanding, allowing one to apply it flexibly and respond with composure in the world.