Huangdi Neijing

Kong, Y.C.

Published by The Chinese University of Hong Kong Press

Kong, Y.C.
Huangdi Neijing: A Synopsis with Commentaries.
The Chinese University of Hong Kong Press, 2010.
Project MUSE.muse.jhu.edu/book/24634.

For additional information about this book

https://muse.jhu.edu/book/24634

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 8 Morbid Manifestations
(Bing Tai 病能)

Exegesis

This is by far the most substantial chapter in NJZY; it takes up 40% of the
text. There are quotes from 24 chapters of Suwen and 10 chapters of
Lingshu. While all quotations in previous chapters concern theories, prin-
ciples and guidelines, this chapter discusses various diseases, their symp-
toms, their pathogenesis, presentation and prognosis. With rare
exceptions, there are no suggestions as to treatment. This is exactly what
the chapter title implies: bingtai 病 能, “morbidity” (reading 能 as tai 態), it
covers topics of disease and its causes, presentation and location, as laid
out in Qin Bo-wei’s table in the previous chapter. It is interesting to note
how the concept of “disease” (bing 病) substantiates itself as Suwen leads
the reader onwards from the first line. The word “disease” appears as
early as the second paragraph of Suwen Chapter 1. The ancient sages
taught us to remain “calm and free of desires, then the genuine qi will flow
through. When the mind remains unperturbed, how can disease ever
occur (bing an cong lai 病 安 從 來) ?” In Chapter 2, the sages “do not treat
a full-blown disease, they [would rather] treat the disease before it
emerges.” In Chapter 3, the reasoning is that when “a disease sets on its
course, it tends to transmute and transform.” Chapter 4 goes on to discuss
the location of diseases due to climatic and geographic factors. Then in
Chapter 5, a yin-yang imbalance is ascribed to be the principal cause of
all kinds of diseases, their course of development (shiqi 始 起), their
genesis and whether or not they are in accordance with natural events
(nicong 逆 從) and their presentation (xingtai 形 能). The last term is of

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 248 Neijing Zhiyao Yigu 內經知要譯詁

particular interest. Suwen Chapter 5 actually uses the term “xingtai”. The
character 能 neng is widely accepted to be a homonym of tai 態 (state,
form, appearance, attitude). Indeed the term xingtai 形態 (outward appear-
ance, shape, form) remains in current use today, as in xingtai xue 形 態 學
(morphology). The original text quotes Qibo as saying that “The change in
alternating dominance of yin or yang is manifested as the outward appear-
ance of the disease.” (bing zhi xingtai 病 之 形 能, “the presentation of the
disease”, hence bingtai 病態, “morbidity”).1
In Suwen Chapter 45, in describing the morbid presentation of qi
when obstructed in the six conduits, the term used is bingtai. Huangdi
wishes to be enlightened about the morbid manifestations due to obstruc-
tion of qi in the six cardinal conduits.2 This is followed immediately by
Suwen Chapter 46: On Morbid Manifestations (Bingtai Lun 病 能 論), which
is devoted entirely to this subject. It is explained, through several concrete
examples, how the cause behind a principal symptom should be investi-
gated, and appropriate treatment is discussed. However, the term bingtai
never appears in the text. The new term appears earlier, in Suwen
Chapter 42, which is on “wind” as an evil qi. Huangdi asks: “The presenta-
tions of the wind evil qi affecting the five zang-organs are different; how
about their diagnosis and morbid manifestations?” Here, “morbid manifes-
tation” is again bingtai.3 Later, in Chapter 45 on qi obstruction, Huangdi
raises the same question concerning the morbid presentation of qi
obstruction in the six cardinal conduits. Finally, in Chapter 80 on the ten
parameters of pulse diagnosis, the importance of matching them to the
morbid signs (he zhi bing tai 合 之 病 能) is stressed. That said, the char-
acter 能 neng could stand by itself without being a homonym of tai 態;
terms such as jineng 機 能 (mechanism), gongneng 功 能 (function), and
qianneng 潛 能 (potential) could be associated with disease to mean the
dynamics of the disease, i.e. pathogenesis. According to the philosopher
Xunzi, “The ears, eyes, nose and mouth each serve a function but they
are different from each other; this is natural design.” 4 Here, the first

1
《素問．治陰陽應象大論》：「陰陽更勝之變，此病之形能也。」
2
《素問．厥論》
：「六經脉之厥狀病能。」
3
《素問．風論》
：「願聞其診及病能。」
4
《荀子．天論》
：「耳目鼻口形能各有接而不相能也，夫是之謂天官。」

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 Morbid Manifestations 249

occurrence of 能 is read tai, the second is read neng. Hu Shu subscribed

to this argument (ref. 24).
Quotations from the early chapters of Suwen read in sequence gradu-
ally reveal the Chinese approach to disease management:

1. May there be no problem by keeping calm and non-desirous (bing

an cong lai 病安從來).
2. It is preferable to treat a disease before it emerges (zhi wei bing
治未病).
3. Disease tends to change in the course of its development (bing
jiu ze chuan hua 病久則傳化).
4. Climatic factors may affect specific individual zang-organs (wu
zang ying si shi 五臟應四時).
5. Seek the ultimate cause of a disease (zhi bing bi qiu zhu ben 治
病必求諸本).

The imbalance of yin-yang (yin yang fan zuo 陰 陽 反 作) falling out of

synchrony with the body function (bing zhi ni cong 病 之 逆 從) gives rise to
morbid manifestations (bing zhi xing neng 病 之 形 能) that mark the onset
of a disease (bing zhi shi qi 病之始起).
The idea of not having a problem, so that there is no case to answer,
comes from Zhuangzi, who preached absolute nihility, the total abandon-
ment of wisdom and intellect.5 This is a somewhat negative attitude that is
not in keeping with the positive attitude of Chinese medicine in conservating
health. The latter advocates striking a balance with the changes in the
natural and social enviroment. A compromise approach is to limit the
damage due to disease, hence the proverb “Reduce a serious disease to
a minor ailment and eliminate a minor ailment to become healthy again.”6
However, there are many kinds of disease.7 Chapter 8 of NJZY puts
together a large number of diseases current at that time. While the chap-
ters quoted are spread fairly evenly throughout Suwen and Lingshu, it is
easy to see that two “clusters” of disease patterns are distinguishable.

5
《莊子．盜跖》，〈胠篋〉：「絕聖棄智。」
6
大病化小，小病化無。
7
《莊子．人間世》：「醫門多疾。」

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 250 Neijing Zhiyao Yigu 內經知要譯詁

These are Suwen Volume 9 on febrile diseases (Chapters 31–34) and

Suwen Volume 12 on special kinds of disease such as paralysis and
atrophy (Chapters 42–45). For NJZY as a whole, there are also three
thematic “clusters”, viz. Sections 8.18–21 on tympanites, Sections
8.25–27 on sleep and dreams and Sections 8.29–35 on unfavourable
prognosis. The totality of information quoted in this chapter can be
regrouped under the following headings:

111 Classification of diseases (Section 8.1, hereunder only the

figures of each section is shown).
222 Pathogenesis: seasonal climatic conditions (8.2), internal injury
(8.3) deficiency in yang (8.6), deficiency in genuine qi (8.11) and
clinical picture of the principal conduits affected (8.4).
333 Diet and life-style: food bias (8.2), food habits and fatigue (8.7).
444 Deficiency and excess: deficiency in yang (8.2), deficiency and
excess (8.5), deficiency and excess in terms of yin-yang (8.6),
five types of deficiency and five types of excess (8.8).
555 Special topics: wind (8.10), malaria (8.15), tussis (8.16), numb-
ness (paralysis) (8.23), atrophy (8.24), boils (8.28).
666 Febrile disease: cold limbs (8.12), visual manifestations of zang-
organ fever (8.13).
777 Tympanites: tympanites (8.18 and 8.19), tympanite-like swellings
(8.20), oedema and jaundice (8.21).
888 Transmutation: cold-induced fever and its transmutation (8.14)
and terminal transmutation (8.32).
999 Pain: pain (8.9) and cold-induced pain (8.22).
1111 Sleep, dreams and fear: fear and the damage it causes (8.17),
sleep with dyspnea (8.25) and dreams (8.26 and 8.27).
1111 Unfavourable prognosis: unfavourable prognosis in different time
frames (8.29–35)

NJZY Chapter 8 puts together the most relevant clinical observations

in Neijing. These observations, albeit superficial, were no doubt genuine
and detailed. The authors have even tried to relate these observable
symptoms and signs to the function or malfunction of the visceral organs,
especially in terms of the five physiological systems as represented by the
five zang-organs. However, when a rationale behind these symptoms is
sought, the answer does not always accord with medical knowledge

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 Morbid Manifestations 251

today, or in other cases, the cause and effects are reversed. Such misin-
terpretations were, of course, inevitable at a time when medical experts
lacked the knowledge available to doctors today, but it is important to note
that our ancestors devoted huge efforts to understanding the problems of
health and disease, and out of the substantial body of medical knowledge
which they acquired, some basic principles of prevention and treatment of
diseases evolved that are still valid today. The terms “alternative” or
“complementary” medicine is often regarded as derogatory for ethnomedi-
cine. However, Chinese medicine as presented here by Neijing, could
inspire a useful alternative or complementary approach to disease
management, armed with the mighty store of medical knowledge that we
enjoy today.

[Section 8.1] Suwen Chapter 74: On Basic Approaches to

Disease Management

《素問．至真要大論》曰：諸風掉眩，皆屬於肝；諸寒收引，皆屬於腎；諸
氣膹鬱，皆屬於肺；諸濕腫滿，皆屬於脾；諸熱瞀瘛，皆屬於火；諸痛癢
瘡，皆屬於心；諸厥固泄，皆屬於下；諸痿喘嘔，皆屬於上；諸禁鼓慄，
如喪神守，皆屬於火；諸痙項強，皆屬於濕；諸逆沖上，皆屬於火；諸腹
脹 大，皆 屬 於 熱；諸 躁 狂 越，皆 屬 於 火；諸 暴 強 直，皆 屬 於 風；諸 病 有
聲，鼓之如鼓，皆屬於熱；諸病胕腫，疼酸驚駭，皆屬於火；諸轉反戾，
水液渾濁，皆屬於火；諸病水液澄澈清冷，皆屬於寒；諸嘔吐酸，暴注下
迫，皆屬於熱。

All kinds of wind-induced tremor and dizziness [1] belong to [2] the liver.
Coldness-induced contraction and spasm [3] belong to the kidney. Panting
and dyspnea [4] caused by qi disturbance belong to the lung. Wetness-induced
swelling and bloating belong to the spleen [5]. Fever-induced clouded mind
and convulsions are due to fire [6]. All kinds of pain, boils and pruritus belong
to the heart [7]. Constipation and dysuria, or incontinence, caused by qi
obstruction are related to the lower burner [8]. [Pulmonary] dystrophy, asth-
matic breathing and retching belong to the upper burner [9]. Lockjaw
[trismus], biting hard and shuddering [10] as if losing integrity of mind [loss
of consciousness] are due to fire. Muscle spasms and stiff neck belong to

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 252 Neijing Zhiyao Yigu 內經知要譯詁

wetness [11]. [Symptoms caused by] upward reflux of the flow of qi [12]
belong to fire. All kinds of abdominal bloating [13] belong to heat. Irascibility
and mania [14] belong to fire [15]. Sudden fits of spasticity and stiff neck
belong to wind [16]. Tympanites with sonorous signs like beating a drum
belong to heat [17]. Oedematous swellings and soreness in limbs as well as
fright belong to fire [18]. Cramps and arched back [opisthotonos] as well as
turbid urine belong to fire [19]. All symptoms with clear stream urine [20]
belong to coldness. Vomiting, acid regurgitation and torrential diarrhoea
belong to heat [21].

Explanatory Notes
As a paradigm of nosology in Chinese medicine, this paragraph follows a
strict pattern. Each sentence is structured in the following way: All kinds of
(zhu 諸) diseases/symptoms belong to (jie shu yu 皆 屬 於) organ/disease state/
location, where the bold type represents constants and the italic type repre-
sents blanks that can be filled in: they can vary, but always keep to the same
rhythm, in a pair of two four-word phrases (諸 x x x, 皆屬於 x). In four cases,
an additional four-word sentence is added to describe the principal symptom,
or a collateral symptom. In only one case does the leading sentence exceed
four words (it contains eight words). The rigid format underlines the effort to
categorise. It operates at two levels:

1. Disease/symptom
In order of appearance in the text, these are: wind, coldness, qi conges-
tion, wetness, heat (fever), pain/pruritis, qi obstruction, pulmonary dystrophy/
retching, lockjaw, muscle spasms, qi upsurge, abdominal bloating, irascibility,
spasticity, sonorous tympanites, oedema/soreness/fright, cramps/arched back/
turbid urine, clear urine, vomiting/retching/diarrhoea. (19 cases)

2. Signature symptoms
These can be grouped according to the signature symptom. There will be
more than 19 cases, since one type of pathomechanism may exhibit more than
one signature symptom, and a particular symptom can be counted in more
than one category. Why these apparently unrelated symptoms are listed under
the same pathomechanism is not clear (e.g. cramps and chyluria).

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 Morbid Manifestations 253

climatic factors—wind, coldness, wetness, heat. (4 cases)

qi disturbance—congestion, obstruction, upsurge (3 cases), paraesthesia
—pain/pruritus, soreness. (2 cases)
muscle spasms—lockjaw, muscle spasms, cramps, catalepsy. (4 cases)
tympanites—bloating, sonorous tympanites. (2 cases)
micturation—turbid urine, clear stream. (2 cases)
agitation—irascibility, mania, fright, convulsions, clouded mind. (5 cases)
tissue fluid—swelling, oedema. (2 cases)
gastro-intestinal upset—constipation/dysuria or incontinence, vomiting/
retching, diarrhoea. (3 cases)

In Chinese medicine, these 19 types of pathomechanism can be

regrouped as follows, according to where they are seen as “belonging”:

Group 1: The five zang-organs, i.e. five physiological systems. (5 cases).

Group 2: The two locations, i.e., upper and lower burners. (2 cases)
Group 3: The six climatic factors, e.g. fire (6 cases), heat (3 cases), wind,
coldness, wetness. (1 case each).

While the zang-organs are representative of the main physiological

systems, the two locations regarded as linked to the burners actually refer to
two centres/levels of autonomic regulation (above and below the diaphragm).
As to climatic factors, this is only a figurative way of speaking, as fire may
indicate hyperactivity, or wind may indicate sudden onset. In any case, the
repeated appearance of fire and heat tacitly imply that they they mean
different things each time they appear. This inconsistency in categorisation
reflects an inherent weakness in Chinese medicine, which was not, at the time
of Neijing, entirely based on a structure—function relationship. Even now,
however, with all our modern medical knowledge, many of these climatic
factors can still be identified with a particular anatomical structure, e.g. the
“fire” of mania is actually an over-excited state of mind.
Wang Bing, in his annotation to this passage, allocated the pathomecha-
nisms to two principal groups, viz. with or without “fire” and no “water”.
There was also a collateral group related to qi obstruction. Wang’s annotation
reads as follows: “In case of extreme cold, [if] hot drugs fail to have a warming
effect, it is because there is no fire [thermogenesis?]; it is appropriate to
strengthen the heart. In case of high fever, [if] cold drugs fail to have a cooling
effect, it is because there is no water [humoral regulatory factor?]. Relapsing

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 254 Neijing Zhiyao Yigu 內經知要譯詁

fever, in recurrent cycles of remission and relapse is due to a lack of water

[autonomic control of thermostasis]; it is appropriate to strengthen the
kidney. Internal resistance to food ingestion in terms of vomiting and regurgi-
tation is due to the presence of fire [enteritis?]. Nausea and vomiting as a
result of ingested food being unable to stay down are due to a lack of fire
[dyspepsia?]. Rapid gut passage of food, only partially digested, is due to a lack
of water [digestive enzymes?]. Loose stool and unpredictable polyuria are due
to a lack of water [failed water retention?]. Therefore, when the heart is hyper-
active, there will be fever. When the kidney is hyperactive, there will be chills.
A dysfunctional kidney will generate internal coldness. A dysfunctional heart
entraps heat. Furthermore, fever that cannot be cooled down with cold drugs
is due to a lack of water [destruction of pyrogens?]. Chills that cannot be
warmed up are due to a lack of fire [failed response to thermogenesis?] [If]
cold drugs fail to cool down a fever, the problem lies with the absence of water.
[If] hot drugs fail to warm up the body, the problem lies with the absence of
fire. When a hot drug cannot sustain its warming effect, there is little support
from the heart. When a cold drug cannot sustain its cooling effect, there is
little contribution from the kidney. There are prescriptions of a cold nature
used to tackle fever, but as the febrifugal effect shows itself, the patient cannot
ingest cooked food. By the same token, when using hot drugs to tackle chills,
the patient becomes unconscious or irascible. This [paradoxical] outcome is
due to qi congestion; it cannot flow through.”
Li Zhong-zi was full of admiration for these comments and was
convinced that Wang Bing had grasped the quintessence of clinical Chinese
medicine (see also Section 7.3, Explanatory Notes). Later, in the Yuan dynasty,
Liu Wan-su 劉 完 素,8 founder of the Anti-Phlogistic School (Hanliang pai 寒
涼 派), championed the use of cold drugs to combat the “fire” pathogen. He
made a thorough study of these 19 pathomechanisms and produced a mono-
graph entitled The Ultimate Mechanism of Disease Patterns Inspired by Suwen.9

8
劉完素 (also known as Hejian 河間, ca. 1120–1200) drew all his medical ideas from
Suwen, on which he wrote several books. Of these, The Ultimate Mechanism (Suwen
xuanji yuanbingshi 素問玄機原病式), was based on the 176 characters excerpted in
this Section. He expanded it by a hundred characters to 277, but had actually
written another 27,000 characters to underscore his interpretation.
9
See recent reprint by Renmin weisheng chubanshe (2006).

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 Morbid Manifestations 255

There he added “aridity” (zao 燥) as an additional causative factor, probably

prompted by the wide spread use of aromatic drugs (xiangyao 香 藥), a vogue
introduced and maintained by Arab traders.
The term bingji appears in the introduction to this important excerpt, but
it is not quoted by Li Zhong-zi. It appears again after this excerpt and is
quoted erroneously in Section 7.1 in connection with the ultimate cause of all
diseases, i.e. imbalance between yin and yang.

Footnotes

[1] tremor and dizziness: The “wind” disease may refer to its sudden onset, its
migratory nature, or involuntary tremor, as in seizures. These are features of
wind movement. When it means wind-borne factors, it is called the “wind
evil qi” (fengxie 風 邪 ). Here it means tremor or dizziness that arises
suddenly. Diao 掉 refers to involuntary movement of the arms (asterixis), as
if casually throwing something away. All wind diseases are ascribable to
the liver, but not many can be explained in terms of modern medicine.
[2] belong to: Diseases which belong to the liver category, i.e. systemic physi-
ology of the liver, are of course due to liver malfunction. But in Chinese
medical parlance, this means the disease belongs to the liver conduit (ganjing
肝 經), and symptoms may appear anywhere along this conduit. See Section
6.1 for the itinerary and Section 8.4 for the symptoms.
[3] contraction and spasm: Cold-induced spasm in the limbs is due to obstruc-
tion in the flow of qi and reduced circulation to the limbs, leading to cold
extremities. Cold-induced cramps and spasm in the limbs are now best
described in Raynaud’s phenomenon. The clinical manifestation of
Raynaud’s phenomenon is a change in colour of the fingers or toes through
white and blue to red, which is secondary to spasm of the arterioles after
exposure to cold. Raynaud’s phenomenon can be primary, or in association
with rheumatoid arthritis, scleroderma, systemic lupus erythematosus,
hypothyroidism, frostbite or medication (e.g. ergotamine, beta-blockers).
How these symptoms are related to a malfunction of the kidney or the
adrenals is not clear.
[4] panting and dyspnea: The Chinese term 膹 鬱 fenyu describes a shortness of
breath because of difficulty in breathing, having air trapped in the lungs, and
being unable to breathe out. Fen means “gasping for air”. Yu refers to air
congestion in the lungs; the character actually describes frustration in the
face of an insoluble situation.

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 256 Neijing Zhiyao Yigu 內經知要譯詁

[5] spleen: These first four cases are ascribable to a physiological system, repre-
sented by a zang-organ. The fifth case, the heart, follows. The “spleen” in
Chinese medicine is a very broad concept. While it includes the spleen
itself, it is more involved with digestive function (the spleen and stomach),
and in this case, refers to the pancreas. Spleen function in Chinese medicine
involves the immuno-defence capacity as well as drainage of body fluid.
Spleen malfunction leads to accumulation of body fluid, as described in this
case.
[6] clouded mind and convulsions: The Chinese term 瞀 瘛 maoqi describes the
loss of consciousness and spasm that can accompany a high fever. Mao
means “smouldering with hot air” (mao 冒). Qi 瘛 is a short spasm (as in qi
chong 瘛 瘲). This description fits well with febrile seizure. Chinese medicine
would treat it with rhinoceros horn, cow bezoar or gypsum, depending on
the circumstances. A popular over-the-counter preparation, the cow bezoar
bolus (angong niuhuang wan 安 宮 牛 黃 丸), is specially indicated for this
situation. Here, gong 宮, “the palace”, refers to the central nervous system.
The bolus contains a number of rarely used drugs like cow bezoar, rhinoc-
eros horn, realgar, cinnabar, pearl and gold foil. It is amazing how Chinese
medicine can make use of exotic items before the advent of modern
medicine, which tends to make Chinese medicine look primitive and
rudimentary.
[7] heart: This is the fifth instance of disease categorisation by zang-organ. Why
heart malfunction should be related to pain, boils and pruritus is very
unclear. This “heart” may actually mean the brain, that tolerates these nocic-
eptive inputs depending on the pain threshold of the person. In Chinese
medicine, hot and flaring boils, swellings and pruritus are seen as being due
to hyperactivity of the heart (xinhuo sheng 心 火 盛, “heart fire flaring”). It
may refer to an accumulation of pyrogens in the blood.
[8] lower burner: This is a disease categorised by location. Since the three
burners are not based on anatomical structures, this is a reference to organs/
functions regarded as being controlled by the lower burner, which is involved
with fluid drainage and discharge from the lower end of the body (xia jiao ru
du 下 焦 如 瀆, “lower burner is like a gutter”). The text mentions only xia 下
(“low, below, under”), so it can simply mean “below” the diaphragm. Because
it describes constipation/anuria and diarrhoea, it is logical to believe that xia
is an abbreviation of xiajiao, the lower burner. The character jue 厥 means
“reflux” or “reverse flow”, thus causing obstruction of the normal flow of qi

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 Morbid Manifestations 257

(i.e. orthodromic propagation of the nerve impulse). Li Zhong-zi interprets

this character as hanjue 寒厥 or rejue 熱厥, in either case a loss of autonomic
control of the bowels, which seems to make sense here.
[9] upper burner: The same reasoning as above can be applied. However, the
character wei 痿 means “dystrophy”; it occurs in the term weibi 痿 躄 (see
Section 8.24). Because the lobes of the lung are hot and scorched, the legs are
weakened so that the sufferer cannot walk (paraparesis). Since the lung is
controlled by the upper burner, here shang 上 must refer to the upper burner.
Paraparesis as a result of lung malfunction may be due to chronic obstructive
pulmonary disease caused by environmental factors such as inhaling tobacco,
asbestos or particulate air pollutants. These solid deposits gradually destroy
lung function so that the patient becomes physically intolerant. The other
two symptoms mentioned are not related to the lung, but to the upper
compartment, the thoracic cavity. While vomiting is generally described as
outu 嘔 吐, ou is in fact “retching”, not the vomiting up (tu 吐) of anything
substantial.
[10] lockjaw and shuddering: Here are three related symptoms: lockjaw (jin 禁,
“prohibits”, signifies jin 噤, “unable to speak”), bulging cheeks (gu 鼓,
“drum”) because of biting hard, and shuddering (li 慄, “trembling”, as in
jianli 戰 慄, “trembling with fear”). The common cause of these symptoms is
hypothermic shock or fear. This would seem to argue against placing them in
the “fire” category, but here “fire” is not a pathogen, it may actually mean “lack
of fire”, where “fire” is the physiological compensation needed to meet an
environmental or emotional challenge. In modern medical terms, it may
refer to the “chill” phase prior to the onset of fever, e.g. in malaria. The addi-
tional sentence “like losing integrity of mind [loss of consciousness]” fits the
description of delirium tremens, a confusional state of mind characterised
by visual hallucinations of a horrific nature, and involuntary hyperactivity of
the skeletal muscles. Delirum tremens can be observed in patients with high
fever, or acute infection, acute alcoholism, excessive mental or physical stim-
ulation, and last but not least, drug withdrawal.
[11] wetness: Here, this is wetness as the signature symptom; it is different from
wetness as a causative factor, as with the spleen. But “wetness” due to accu-
mulation of tissue fluid may mean rheumatism (fengshi 風 濕), a degenera-
tive disease involving connective tissues.
[12] flow of qi: Upward reflux of the flow of qi (qi ni chong shang 氣 逆 沖 上) can
be as simple as burping and belching, but it can also describe tachycardia

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 258 Neijing Zhiyao Yigu 內經知要譯詁

and arrhythmia. There was a disease in ancient times called bin tuan 奔／賁
 (running pig) because it was characterised by panting.
[13] abdominal bloating: Bloating can be caused by a number of factors, e.g.
ascites, food fermentation in the bowel, helminthiasis, liver cirrhosis. Heat as
a category may refer to the latent or incubation period of an infectious
disease, often accompanied by mild fever.
[14] irascibility and mania: Here are three principal symptoms: irascibility (zao
躁), mania (kuang 狂) and “abnormal” behaviour (yue 越). The last requires
some explanation. The character yue means “over the limit”. As a disease,
kuangyue 狂 越 means abnormal behaviour involving climbing high to yell
or sing, hence yue. This resembles closely the mania phase of bipolar depres-
sion. This is marked by increased physical and mental activity, inflated self-
esteem (delusions of grandeur), loss of discretion and judgement causing
self-mutilation or bodily harm. This much we can read into kuang yue. There
is a question posed in The Analects of Confucius: “Must it be an eccentric/
radical [person]?”10 Here kuang juan, “anti-conformist”, is a mild form of
kuangyue, “social rebel”. Confucius, failing to find friends of moderate views,
would rather befriend eccentric or radical persons who had progressive views
and would not lower themselves to behave meanly.
[15] fire: This second appearance of “fire” in the text is apparently describing an
over-excited state of mind, like the active phase of bipolar disorder. Suwen
Chapter 49 carries a vivid description of bipolar disorder. “What is called
shutting oneself behind closed doors is a result of yin and yang confronting
each other. In this confrontation, if yangqi [the excitatory phase] is exhausted
and yinqi [the inhibitory phase] becomes dominant, one prefers to be left
alone behind closed doors. What is called an episode is when one rises to an
elevated position to sing, or disrobes while running amok. [In this case], yin
and yang renew their confrontation, and yangqi is forced out to the surface;
that is why one sheds one’s clothing while running.”
[16] spasticity and stiff neck: Sudden fits of spasticity come like a gust of wind
and can disappear without treatment. While the sudden onset (bao 暴) can
be a seizure of any kind, a stiff neck may be the major symptom in cataleptic
rigidity involving part or whole of the body that will last longer. This condi-
tion can be precipitated by severe emotional trauma, or in symptoms of

10
《論語．子路》
：「必也狂狷乎？」(bi ye kuang juan hu?)

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 Morbid Manifestations 259

schizophrenia, depression, epilepsy or, in the modern context, cocaine with-

drawal. Whole body rigidity is also a symptom of Parkinsonism; here the
rigidity persists and does not go away like a draught of wind.
[17] heat: Sonorous signs are associated with a number of diseases, e.g. asthma
(wheezing) or borborygmus (gas in the intestine). But to have a sonorous
tympanites must be a reference to the abdomen. Why these symptoms are
ascribed to “heat”, a febrile situation, is not clear. Auscultation is one of the
four basic methods of diagnosis.
[18] fire: The Chinese term 胕 腫 fuzhong describes a soft oedema, i.e. a depres-
sion appears where it is pressed with a thumb, and will last a long time. But it
is not clear in what way oedema is related to soreness and fright. Oedema is
fluid retention, and is subject to the action of glucocorticoids and mineralo-
corticoids. Muscle tone is also influenced by glucocorticoids, hence soreness.
Glucocorticoids in turn influence behaviour and emotional disorder can be a
result of either excess or deficiency of cortisol. The adrenal function is often
considered a renal “fire” element, like the renal yang element (shenyang
腎 陽), or the ministerial fire (xianghuo 相 火). Then this “fire” is related to
the permissive and supportive action of the adrenals in many physiological
functions.
[19] cramps and turbid urine: This is apparently a description of tetany. In severe
cases of tetany, there is arched back (jue gong fan zhang 角 弓 反 張, opisthot-
onos) and twisted mouth (koujiao waixie 口 角 喎 斜, paralysis of the facial
muscles), both of which are often described in Chinese medicine. Chinese
medicine routinely deals with tetany by using a standing spasmolytic
prescription muyusan 木 萸 散, again containing some rare animal drugs like
scorpion, fungi-infected silkworm and cicada exudate. (See [6] above.) While
hypocalcaemia causes muscle spasm, it is not clear how this preparation can
redress the calcium balance. Turbid urine suggests that it can be the result of
urethritis or cystitis. This fits with the concept of “fire”. “Fire” in the end
merely describes a state of excitability.
[20] clear stream urine: Long clear streams of urine, and passing water as soon as
one drinks, is indicative of extreme debility, a “cold” situation (xuhan 虛寒).
[21] heat: This may mean signs of inflammation rather than fever. Enteritis,
inflammation of the digestive tract, can cause excessive or reverse peristalsis.
It is described as huoluan 霍 亂 (“sudden violent disturbance”), in Lingshu:
Five Disturbances (Wu luan 五 亂). Nowadays, it is used exclusively to mean
cholera (huoluan zhuanjin 霍 亂 轉 筋). But cholera does not produce fever

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 260 Neijing Zhiyao Yigu 內經知要譯詁

due to inflammation of the digestive tract; it is simply reverse osmosis caused

by enterotoxins. On the other hand, late-stage typhoid fever and bacillary
dysentery (e.g. shigellosis) present with fever and diarrhoea. “Traveller’s
disease” with stomach upset and diarrhoea also fits this description.

[Section 8.2] Suwen Chapter 3: On Harmony between Yinqi

and Yangqi

《素問．生氣通天論》曰：因於寒，欲如運樞，起居如驚，神氣乃浮；因於
暑，汗，煩則喘喝，靜則多言，體若燔炭，汗出而散；因於濕，首如裹，
濕熱不攘，大筋緛短，小筋弛長。緛短為拘，弛長為痿；因於氣，為腫。
四維相代，陽氣乃竭。
陽氣者，煩勞則張。精絕。辟積於夏，使人煎厥。大怒則形氣絕，而
血菀於上，使人薄厥。有傷於筋，縱，其若不容。
汗出偏沮，使人偏枯；汗出見濕，乃生痤疿。高梁之變，足生大疔，
受如持虛。勞汗當風，寒薄為查皮，鬱乃痤。
開闔不得，寒氣從之，乃生大僂。陷脈為瘻，留連肉腠，俞氣化薄，
傳為善畏，及為驚駭。營氣不從，逆於肉理，乃生癰腫。魄汗未盡，形弱
而氣鑠，穴俞已（以）閉，發為風瘧。
春傷於風，邪氣留連，乃為洞泄；夏傷於暑，秋為痎瘧；秋傷於濕，
上逆而咳，發為痿厥；冬傷於寒，春必溫病。
味過於酸，肝氣以津，脾氣乃絕；味過於咸，大骨氣勞，短肌，心氣
抑；味過於甘，心氣喘滿，色黑，腎氣不衡；味過於苦，脾氣不濡，胃氣
乃厚；味過於辛，筋脈沮弛，精神乃央。

Exposure to cold will make one feel like a door swinging by its hinge [but it is
unable to do so]; [1] one lives in constant apprehension and lacks concentra-
tion of mind. [2] Exposure to summer heat will cause profuse sweating,
dysphoria, asthmatic breathing with a gurgling sound, [3] loquaciousness
when sedentary, and intense fever like glowing charcoal, with the body hot to
the touch. [4] These symptoms will disappear after sweating. Exposure to
wetness will make one feel [as if] one’s head is under wraps. [5] Bothered by
unalienable wetness and heat, the large muscles are tense and get shorter while
the small muscles [6] are lax and grow longer. Shortening is due to muscular

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 Morbid Manifestations 261

contracture. [7] Relaxing is a result of muscular dystrophy. Exposure to

draughts [8] will cause swelling. Alternate exposure to these four elements in
turn will sap the yangqi until exhaustion. [9]
It is the nature of yangqi to expand when mentally disturbed or stressed
[excitation]. This is extremely detrimental to the [yin] essence. [10] After
recurrent episodes in [spring], the cumulative effect in summer will make one
highly irascible. [11] Raging anger provokes a dissociation of body and mind,
blood congealed in the upper part of the body leading to a stroke [12]. The
ligaments are harmed; they are flaccid and do not respond to command [13].
When sweating occurs on one side only, this is the result of hemiplegia.
[14] Wet skin [not cleansed] after sweating will give rise to heat rash and acne.
[15] Rich foods are conducive to changes, such as ulcerated feet. One feels
famished in spite of being loaded with food. [16] When sweating after exercise
and caught in draughts, a sudden chill will give rise to hard-tipped pimples.
[17] In chronic cases, there will be [pustular] acne. [18]
When the subcutaneous striae (couli) do not loosen or tighten in time [19]
and cold evil qi creeps in, the back will be hunched and the legs bent. [20]
When the conduits are attacked, fistulas will form. [21] Cold evil qi lingering
among the muscles and subcutaneous striae will further penetrate through the
acupoints and attack the visceral organs. Then one will become timorous and
easily frightened. When there is inadequate nutritive support because it is
blocked among the muscles [obstructed local circulation], swellings and boils
will develop. [22] Unending spontaneous hidrosis [23] saps the qi and
weakens the body. [Eventually], if the acupoints are closed, the body will erupt
into paroxysmal fever.
When the wind evil qi strikes in spring, and it is loitering around for
some time, there will be torrential diarrhoea [24]. When summer heat strikes,
malaria [25] will appear in autumn. When the wet evil qi strikes in autumn, qi
circulation turns upwards [through the lung] leading to tussis; it will develop
into dystrophy of the limbs [due to qi obstruction]. When cold evil qi strikes
in winter, “warm” disease [26] will inevitably occur in spring.
With over-indulgence in sour tastes [27], the liver qi swells up [hyperactive
liver function]; as a result the spleen is exhausted. [28] With over-indulgence
in salty tastes, the large bones [29] are worn out [exhausted qi], and there will
be muscle weakening and difficulty in breathing. Over-indulgence in sweet
tastes [30] [should be replaced by bitter] will cause tachycardia and acceler-
ated breathing with chest congestion, leading to an unbalanced kidney

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 262 Neijing Zhiyao Yigu 內經知要譯詁

function and a dark complexion. [31] With over-indulgence in bitter taste

[should be replaced by sweet] [30], the spleen will be soggy [32] [stagnant
secretion], and the stomach will be bloated due to food stasis. [33] When there
is over-indulgence in pungent tastes, the sinews and conduits [ligaments and
blood vessels] are lax [the strong element metal overpowers wood]. [34]

Explanatory Notes
This section includes nearly all the essential statements from Suwen Chapter 3:
On Harmony between Yinqi and Yangqi (Shengqi tongtian lun 生 氣 通 天 論
literal translation of the title actually means “vitality” (sheng qi 生 氣) depends
on obeying natural forces (tong tian 通 天), where natural forces are seen as a
fine adjustment of yin and yang. There are so many key sentences in this
chapter, each of them axiomatic, that excerpting from it risks taking these
quotes out of context.
In an effort to illustrate the correspondence between the activities of life
and nature, emphasis is laid on the harmony between yinqi and yangqi. Yinqi
refers to the stock of essence, which forms the material basis of the activities
of life, while yangqi refers to the integrity of physiological compensation
offsetting any perturbation to the normal rhythm of life. The roles of yin and
yang are defined by Qibo in the middle of this chapter but not excerpted: “The
yin element represents the stock of essence that supports the yang. The yang
element serves to defend against noxious external factors and consolidate the
basis of wellbeing.”11 While attention is directed to the integrity of yangqi, it is
the harmony (equilibrium) between yinqi and yangqi that counts. The famous
quotation “yin ping yang mi” is found here.12 (See Section 2.3). It is the ideal
state of life with harmony between yinqi and yangqi; when yinqi is calm and
yangqi is securely stored, the spirit (mental state) is in order. Li Zhong-zi
placed this section immediately after the previous one in an attempt to high-
light the fact that the emergence of disease was mainly due to perturbation of
yangqi. Section 8.1 from Suwen Chapter 74 on nosology was of course a fitting
opening to provide an overview of disease. But it is now widely accepted that

11
陰者藏精而起亟，陽者衛外而固本 (yin zhe cang jing er qi ji, yang zhe wei wai er
gu ben).
12
陰平陽秘，精神乃治 (yin ping yang mi, jingshen nai zhi).

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 Morbid Manifestations 263

Chapter 74, together with the previous six chapters, the so-called “seven major
discussions” (qi da lun 七大論) were added and commented on by Wang Bing.
He probably drew this information from various sources, which were not
substantial enough to form a monograph in their own right. Thus Suwen
Chapter 74 is long (it is second in length only to Chapter 71, on climatic peri-
odicity) and heterogeneous in content. The section on nosology comes at the
end of this long chapter, as an extension of the statement “all diseases stem
from wind, cold, summer heat, wetness, aridity and fire”. Li Zhong-zi might
have felt it necessary to substantiate the idea of the emergence of disease by
following it with a more pertinent chapter from Suwen. Thus, following the
remarks in this section about wind-induced paroxysmal fever, the author
further generalises that this causative factor is the primary cause of all
diseases.13 It is also widely accepted that the first four chapters in Suwen
Volume 1, which are steeped in Daoism, were intentionally placed there by
Wang Bing, who saw medical practice as an extrapolation of Daoism; he
declared himself to have been a fervent adherent of Daoism since his youth.
The last paragraph of this section needs some important re-arrangement
before it shows some kind of uniformity. This involves changing the three
characters in the squares.

味過於酸，肝氣以津，脾氣乃絕；（木旺乘土）
味過於咸，大骨氣勞，短肌，心氣抑；（水旺乘火）
味過於苦，心氣喘滿；色黑，腎氣不衡（火旺侮水）
味過於甘，脾氣乃濡，胃氣乃厚；（土旺？ ）
味過於辛，筋脈沮弛，精神乃央。（金旺乘木）

This is a version re-arranged according to the “inhibitive” mode of the “five

elements” theory, the explanations for which are in the brackets. It is assumed
that the author of this paragraph in Neijing had the genuine intention of
establishing an “inhibitive” relationship, as is evident with the sour, salty and
pungent tastes. The changes are in the squares. The major changes concern the
sweet and bitter tastes. Zhang Deng-ben (ref. 1) switched these two tastes
around, a move in conformity with the “five elements” format that seems

13
故風者，百病之始也 (gu fengzhe, bai bing zhi shi ye).

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 264 Neijing Zhiyao Yigu 內經知要譯詁

quite acceptable. When there is too much bitter taste (acting on the heart),
there will be tachycardia accompanied by accelerated breathing and fullness in
the chest. Consequently, kidney (adrenal) function is tipped into imbalance;
when the kidney malfunctions, the complexion is dark. This is a “reverse inhi-
bition” mode (xiangwu 相侮), in keeping with the “inhibitive” mode, and both
are distortions of the normal “five elements” relationship. When too much
sweet taste (is acting on the spleen), the spleen (secretion) becomes soggy and
digestion (stomach qi) is sluggish (thick).
This translation is based on the change of “not soggy” to “soggy”. Zhang
Deng-ben considered, seemingly arbitrarily, that the character 不 bu (“not”)
is a redundant (yanwen 衍 文) and omitted it from the translation. Actually,
the reverse is true. Firstly, no respectable version of Suwen deletes the char-
acter bu. If the word ru 濡 still means “soggy” (as in ruzhi 濡 滯, “not forth-
coming” or “not free-flowing”), or the soggy pulse pattern (rumai 濡 脉), then
it only makes sense when too much sweet food will exhaust the spleenic (i.e.
pancreatic) secretion. Then the sentence would read as it does when
re-arranged (pi qi nai ru 脾 氣 乃 濡). This would be consonant with the idea
that “the spleen qi is exhausted” (pi qi nai jue 脾 氣 乃 絕) by the sour taste.
When the digestive juice (spleen qi) is insufficient, digestion becomes sluggish
and food stasis gives rise to abdominal bloating. The re-arrangement makes
sense except for the fact that a sweet taste, spleen and stomach all fall into the
“earth” category. While the sentence about the sweet taste is complete in itself
in a physiological sense, it is icomplete according to the “five elements” theory.
After all, this paragraph was meant to avoid food bias, it cannot be held
accountable for all the active players in digestive physiology. The five elements
theory is merely an attempt to derive a certain logic from this complicated
picture; it is not physiology per se.
It is true that different forms of misprint may appear during transcription
of ancient texts, but it is unwise to make any re-arrangements today unless
there are valid reasons to do so. However, Zhang Can-jia (ref. 15) has recom-
mended a further rearrangement as follows:

陽氣者，曰天與日 …… 是故陽因而上，衛外者也。欲如運樞，起居如
驚，神氣乃浮。
因於｛寒｝，體若燔炭，汗出而散。
因於｛暑｝，汗，煩則喘喝，靜則多言。

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 Morbid Manifestations 265

因於｛濕｝，首如裹，濕熱不攘，大筋緛短，小筋弛長。緛短為拘，弛
長為痿。
因於｛氣｝，為腫。
四維相代，陽氣乃竭。

This is a bold but sensible re-arrangement, if we believe that there was a

particular regular format in the original text. It highlights climatic factors (in
brackets) as a cause of disease and at the same time, by moving a triplet of
four characters to the front of this block of four climatic factors, it reinforces
the role of yangqi. By the same token, the following passages are re-arranged,
for obvious reasons:

1. 汗出偏沮，使人偏枯；汗出見濕，乃生｛痤疿｝。勞汗當風，寒薄
為〔查皮〕，鬱乃｛痤｝。
2. 高梁之變，足生大｛疔｝，受如持虛。營氣不從，逆於肉理，乃生
｛癰腫｝。
3. 開闔不得，寒氣從之，乃生大｛僂｝。
4. 陷脈為｛瘻｝，留連肉腠。
5. 俞氣化薄，傳為｛善畏｝，及為｛驚駭｝。
6. 魄汗未盡，形弱而氣鑠，穴俞已閉，發為｛風瘧｝。

The pathological terms bracketed show that these passages are actually
describing these six groups of disease, viz.

111 skin lesions

222 boils due to malnutrition (diabetic foot ulcer)
333 postural deformity
444 fistula in muscles and connective tissues
555 emotional disturbance such as fear and apprehension
666 paroxysmal fever

The word order in the translation, however, follows that of the ancient
text.

Footnotes

[1] hinge: The Chinese character 樞 shu originally meant the turning axis of the

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 266 Neijing Zhiyao Yigu 內經知要譯詁

door of which two protrusions, upper and lower, on the turning side are
fitted into a stone depression, like a pestle and mortar joint. It is extended
here to mean an interchange (shuniu 樞紐,《莊子．道樞》) or central secre-
tariat (shumi 樞密). The sentence has a positive meaning, “wish to turn like a
door hinge” because woodworm cannot attack a moving door hinge (hu shu
bu du 戶 樞 不 蠹). But here it means “wish (but fail) to move like a door
swinging freely on its hinges”.
[2] concentration of mind: Shenqi 神 氣 is “alertness, awareness”; it requires a
high concentration of the mind. When shenqi is said to be “floating”, one
loses one’s grasp of the facts or the situation, and lacks concentration. A
person full of self-assurance is described as being “radiant with shenqi” (shenqi
huoxian 神氣活現).
[3] a gurgling sound: Noisy breathing with wheezing or crackling, added sounds
in auscultation.
[4] glowing charcoal: This is a description of imminent sunstroke. Very often,
there is no sweating in sunstroke, hence skin is hot.
[5] head under wraps: The yang conduits converge towards the head, where
yangqi seeps out naturally like a nimbus of healthiness, indicating its positive
balance. When the head is under wraps, this positive balance of yangqi is
hampered and excessive yangqi is penned up inside the body. However,
having the head wrapped may not be seen as undesirable in some other
cultures, like the Sikhs and Pashtuns who wear sizable turbans..
[6] large and small muscles: Literally the sinews (jin 筋), this means both
muscles and ligaments.
[7] muscular contracture: The ligament may contract, as in rheumatoid arthritis,
and this is perceived as muscular contracture. Wetness is one of the two
principal causative factors of rheumatism (the other one being wind, hence
the Chinese name for it, fengshi 風 濕 ). But why large muscles should
contract while small muscles become lax is not clear. Cirrhosis of the liver
may lead to gnarled fingers, vindicating the relationship between the liver
and the ligaments, which is claimed in Chinese medicine.
[8] draughts: The Chinese commonly makes use of decorative screens to protect
against draughts. It is thought that draughts should be avoided in post-
partum recovery, to prevent bacterial infections like pueperal fever. By the
same token, after castration, the victim is shut into a room known as the
“silkworm room” (canshi 蠶 室). In sericulture, the silkworm room is one
which is hermetically sealed, especially during the hatching of the larvae.

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 Morbid Manifestations 267

Hence, “going down to the silkworm room” is a euphemism for castration (see
Si-Ma Qian).
[9] yangqi exhaustion: Alternating attacks by these four climatic factors sap the
body of its ability to compensate. These four principal climatic factors, the
four dimensions (siwei 四 維), each undermine one important body func-
tion, and exhaust different aspects of yangqi. In terms of morality, the four
dimensions are civility, loyalty, modesty and a sense of shame (li yi lian chi
禮 義 廉 恥), which are traditionally considered the four cornerstones that
hold the nation together (guo zhi si wei 國 之 四 維). Thus when one is
“complimented” for being full of civility, loyalty and modesty, the underlying
meaning is that one is shameless (wuchi 無恥, “without shame”).
[10] yin essence: When the body is under constant stress, the neural response
enters a refractory period, due to the depletion of neurotransmitters, and a
state of depression ensues.
[11] highly irascible: In Neijing, jianjue 煎 厥 is a well defined disease in which the
body suffers an unrelenting noxious stimulus. The body is under constant
stress, as if being stirring in a frying pan. This situation is described again in
Suwen Chapter 49.
[12] stroke: Thromboembolism, described as bojue 薄厥, “imminent [qi] obstruc-
tion”. Bo means “pressing”, “imminent”, or “approaching at close range”, as in
the phrase ri bo xi shan 日 薄 西 山 (the sun setting over the western hills).
Like jianjue 煎 厥, both bo 薄 and jian 煎 describe an acute state of fainting
due to qi obstruction. Bojue describes an imminent stroke as a result of
intense emotional upset, with the pre-condition of blood stasis (xueyu 血 菀/
鬱) in the head, whereas jianjue describes a patient suffering (jian 煎, “fry in
shallow oil”) a syncopic condition for some time.
[13] not respond to command: It means paresis, the result of a stroke.
[14] hemiplegia: When sweating occurs on one side only, it is because the para-
lysed side is not sweating. Because the cause was not known, the effect
became seen as the cause.
[15] rashes: Heat rash (feizi 痱子, miliaria) and acne (cuo 痤).
[16] loading of food: This cannot but be a description of advanced type II
diabetes with diabetic foot ulcers. However, many annotators have preferred
not to commit themselves and have given vague descriptions, or changed the
wording (from 足 to 是) to avoid a firm interpretation. Here gaoliang 高 梁
does not refer to the cereal sorghum. The character 高 gao is generally
accepted as an alternative form of gao 膏, “fat, grease, blubber” (as in gaozhi

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 268 Neijing Zhiyao Yigu 內經知要譯詁

膏 脂) and, by association, meat. It may also mean glutinous millet with a

texture like fat. According to Mengzi, only people reaching seventy years of
age can eat meat,14 thus easy access to rich food triggered late onset diabetes.
The phrase “With the hands full but feeling empty” (shou chi ru xu 受持如虛)
exactly describes “a state of poverty amid affluence”. This is a textbook
description of the inability to utilise the nutrients in circulation because of a
lack of insulin.
[17] hard-tipped pimples: Zha 查皮, “hard-tipped sebaceous glands, black heads”,
also called fenci 粉刺. Homonym of 皻, or 齇 (zha), the drunkard’s nose. It is
relevant to food loading.
[18] acne: cuo 痤, usually the pustular type, known now as cuochuang 痤瘡.
[19] loosening and tightening: This is referring to the subcutaneous striae. Not an
anatomical term in the modern context, the subcutaenous striae are an
imaginary structure consisting of the dermis and the hypodermis, with all
the vasculature, sweat and sebaceous glands and nerve-endings. Chinese
medicine recognises skin as an organ that controls thermoregulation and
serves as the first line of defence against exogenous evil qi. It is hard to
imagine how this can cause hunchback. Maybe it is suggesting rheumatism
after exposure to cold living conditions.
[20] hunched back: Lu 僂 means “hunchback”, kyphosis. Da lu 大 僂 may mean
hunchback with bow legs. Zhuangzi described a skilful cicada catcher in spite
of his hunchback. (《莊子．達生》「痀僂承蜩」 : , ju lu cheng tiao).
[21] fistula: Lou , “fistula”. This refers to the pustular exudate of swollen lymph
nodes (carbuncle), often at the neck. Tuberculosis is the most likely cause of
cervical lymphoadenitis. It is possible to make a connection between hunch-
back (lu 僂) and fistula (lou), for both are likely to be caused by tuberculosis.
[22] swellings and boils: a mixture of causative factors bring out a mixture of
symptoms. The common causes are derangements of subcutaneous striae,
blocked local circulation, lack of nutritive support and an apprehensive
mind.
[23] spontaneous hidrosis: Spontaneous sweating is a sign of debility due to loss
of autonomic control. As a result, yangqi seeps out of the body. This may
describe a consumptive disease like tuberculosis, although this should be

14
《孟子．梁惠王》︰「七十者可以食肉矣。」

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 Morbid Manifestations 269

tidal fever, rather than wind-induced paroxysmal fever. Pohan 魄 汗, literally

“sweating from the corporeal soul”, which resides in the lung (the sentient
soul in the liver). How can a lung sweat, even though it is affiliated with the
skin and body hair? The answer may lie in the corporeal soul (po 魄). The
corporeal soul is responsible for such mental faculties as courage, stamina
and integrity of mind, will-power and determination. Lacking such qualities,
one will be easily frightened, and through the autonomic reflex, will sweat-
even in the absence of a rising ambient temperature or physical exercise. This
is the “cold sweat” (lenghan 冷 汗). Lenghan is the same thing as pohan. A
highly neurotic person is highly susceptible to physical shock (heat or cold)
or emotional stress, and would react with the exaggerated responses of
sweating or chills.
[24] torrential diarrhoea: Dongxie 洞 泄, “diarrhoea like draining through a hole”,
or rapid gut passage with undigested grains, the latter known as xunxie 飧泄,
“stomach dumping”.
[25] malaria: Jie 痎 is a generic term for all kinds of malaria. Nüe 瘧 is the
unpleasant symptom of alternate cycles of chills and fever, not the disease
itself. Today, the compound nüeji 瘧 疾 refers specifically to parasitic malaria
but not other kinds of nüe. Here fengnüe 風 瘧 (“malaria” induced by wind)
may refer to sudden chills due to a fragile sympathetic control.
[26] warm disease: this is not the febrile disease in Shanghanlun. It was not until
the end of the Ming/early Qing dynasty that the clinical masters (among
them Ye Tian-shi 葉 天 士 , 1667–1746 and Wu Tang 吳 塘, 1758–1836.)
formulated the concept of wenbing 溫 病 (literally “warm disease”), which
often refers to seasonal viral infections with a latent period (fuqi 伏 氣). In
the late Qing dynasty, Lei Shao-yi 雷少逸 (also known as Feng 丰) wrote On
Seasonal Disease (Shibing lun 時病論). (See ref. 53, Section 5.1.2, Epidemics).
[27] taste: Taste (wei 味) can refer to both food and medicine.. Here it means
food, eating too much sour-tasting food.
[28] spleen is exhausted: A strong wood element (sour-liver-wood) will over-
power the earth element: this is the inhibitive mode among the five elements
interaction. Wood inhibits earth, but too strong a wood element will smother
the action of earth. In physiological terms, gastric acidity is under the dual
control of gastrin (more acidic) and somatostatin (less acidic). Whatever
acidity is carried into the duodenum stimulates secretin release, which in
turn stimulates pancreatic bicarbonate secretion. Bile secretion from the liver
also plays a part in neutralising duodenal acidity by rounding up the

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 270 Neijing Zhiyao Yigu 內經知要譯詁

triglycerides. These interactions between gastro-intestinal hormones coordi-

nate the early stage of digestion, involving the stomach, liver and spleen.
Neijing seems to to take note of this relationship without any knowledge of
the regulatory mechanism.
[29] large bones: these are the long bones and joints like the shoulder, pelvis, knee
and the vertebrae but not the short bones of the hands and feet. “The large
bones are worn out” may mean that movement is difficult due to oste-
oporosis. The electrolyte balance is precisely regulated in the body through
the interaction of a number of hormones. Hypernatraemia can cause thirst
and a suppression of anti-diuretic hormone and aldosterone, leading to
hypervolemia, which in turn causes extra cardiac loading, and hence hyper-
tension. Muscle weakening and difficulty in breathing (congestive heart
failure) could be complications of hypertension.
[30] sweet taste: This sentence only makes sense when “bitter” replaces “sweet”.
In the “inhibitive” mode (xiangcheng 相 乘), a strong fire element (bitter,
heart) will inhibit the water element (kidney malfunction and dark
complexion).
[31] unbalanced kidney function: When the heart is under stress, the adrenals are
stimulated and the renin-angiotensin system will become taxed. A dark
complexion is considered a sign of weak kidney function (dark is in the
water category). Over-production of adrenocorticotrophic hormone
(ACTH), including the melanocyte stimulating hormone (MSH) compo-
nent, compounded by cyanosis due to reduced renal perfusion, will give a
dark complexion.
[32] soggy: This is allowing for a misprint of nai 乃 as bu 不, in conformity with
the literary style of this passage (nai jue nai hou 乃 絕 乃 厚). Ru means “wet,
humid” (in Section 8.23: han chu er ru 汗出而濡, “skin is wet with perspira-
tion”), or steeped in liquid (in Section 8.33: gu bu ru 骨 不 濡, “the bone is
not supplied with blood” and in Section 6.3: ru mu 濡 目, “nourish the eye”).
In this case, nai ru 乃 濡 (becoming wet) means “stagnant secretion” (ruzhi
濡 滯). Zhuangzi said: “Two fish stranded in a drying pool were trying to
mosten each other with their saliva. Would it not be better for them to roam
the high seas and forget about each other?” (See Zhuangzi: Dazhongshi 莊
子．大宗師：「相咰以濕，相濡以沫，不如相忘於江湖」).
[33] food stasis: Carbohydrate loading causes indigestion, hence food stasis and
abdominal bloating. For indigestion (mainly due to carbohydrates), Chinese
hawthorn and malted barley are used. Sometimes, the leaves of Microcos

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 Morbid Manifestations 271

paniculata (buzhaye 布渣葉) are added for extra potency.

[34] sinews and conduits are lax: The relationships sour-liver (wood), salty-
kidney (water) bitter-heart (fire) and pungent-lung (metal) concern the
overpowering “inhibitive” mode of five elements interaction. While the wood
element inhibits the earth element naturally, too strong an inhibition will
smother the activity of the earth element. This is the xiangcheng 相 乘 mode
of inhibition.

[Section 8.3] Suwen Chapter 7: On Yin and Yang Types of

Disease

《素問．陰陽別論》曰：二陽之病發心脾，有不得隱曲，女子不月。其傳為
風消、其傳為息賁者，死不治。
三陽為病，發寒熱，下為癰腫，及為痿厥月耑。其傳為索澤，其傳為
頹疝。
一陽發病，少氣、善咳、善泄。其傳為心掣，其傳為隔。
二陽一陰發病，主驚駭、背痛、善噫、善欠，名曰風厥。
二陰一陽發病，善脹，心滿，善氣。
三陽三陰發病，為偏枯、痿易、四肢不舉。
所 謂 生 陽、死 陰 者，肝 之 心，謂 之 生 陽；心 之 肺，謂 之 死 陰；肺 之
腎，謂之重陰；腎之脾，謂之辟陰，死不治。
結陽者，腫四肢；結陰者，便血一升，再結二升，三結三升。陰陽結
斜（邪），多 陰 少 陽，曰 石 水，少 腹 腫；二 陽 結，謂 之 消；三 陽 結，謂 之
隔；三陰 結，謂之水；一陰一陽結，謂之喉痺。

When the double yang conduits [1] [i.e. the yang-ming conduits that govern
the large intestine and stomach, respectively] are sick and the disease spreads
to [2] the heart and the spleen, one may suffer from impotence [in males] [3]
and amenorrhoea in females. When the disease transforms [in due course]
into [symptoms of] emaciation [4] or tachypnoea, it becomes incurable.
When the triple yang conduits [5] [i.e. the tai-yang conduits that govern
the small intestine and the urinary bladder, respectively] are sick with symp-
toms of chills and fever, oedematous legs, cold and weak knees and soreness in
the shin and calf [6], it will transform [in due course] into symptoms of blood

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 272 Neijing Zhiyao Yigu 內經知要譯詁

and essence exhaustion and lack-lustre skin [7], or scrotal hernia. [8]
When the single yang conduits [9] [i.e. the shao-yang conduits that
govern the gall bladder and the three burners, respectively] are sick, the prin-
cipal symptoms are shortness of breath, coughing and diarrhoea. It will trans-
form [in due course] into symptoms of palpitation [10] or intestinal
obstruction. [11]
When both the double yang conduits (i.e. the yang-ming conduits, see
above) and single yin conduits [12] (i.e. the jue-yin conduits that govern the
liver and the pericardium respectively) are sick, the principal symptoms are
apprehension [fright], back pain, frequent belching [burping] [13] and
yawning. This is a disease of wind obstruction. [14]
When both the double yin conduits [15] [i.e. the shao-yin conduits that
govern the heart and the kidney respectively] and the single yang conduits (i.e.
the shao-yang conduits, see above) are sick, there will be abdominal bloating
and heart congestion, with frequent sighing.
When both the triple yang conduits [i.e. the tai-yang conduits, see above]
and the triple yin conduits [16] [i.e. the tai-yin conduits that govern the
spleen and the lung respectively] are sick, there will be hemiplegia, quadri-
plegia [17] and immovable limbs.
There are so-called “curable yang diseases” and “incurable yin diseases”
[18]. When disease of the liver progresses to the heart and transmutes [wood
to fire], it falls into the category of “curable yang disease”. When disease of
the heart progresses to the lung and transmutes [fire to metal], it falls into
the category of “incurable yin disease”. In the case of transmutation from
lung to kidney, this is the category of “aggravated yin”. [19] In the case of
transmutation from the kidney to the spleen, this is the category of “expanded
yin”. [20]
With entanglement of [qi flow in] the yang conduits, [21] the limbs
become swollen. With entanglement of [qi flow in] the yin conduits, there will
be haematochezia, losing one sheng (Chinese litre, equal to 200 ml) of blood.
When it relapses again, there will be two sheng. When it ocurrs for the third
time, there will be three sheng. If both the yang and yin conduits suffer from
entanglement [of qi flow], this is a disease of ascites with palpable solid
concretion [22] and a swollen lower belly. If the double yang conduits [i.e. the
yang-ming conduits, see above] suffer from entanglement, there will be
wasting symptoms. [23] Entanglement of the triple yang conduits will lead to
paralytic ileus. Entanglement of the triple yin conduits will cause oedema.

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 Morbid Manifestations 273

Entanglement in both the single yang and yin conduits will lead to inflamma-
tion of the pharynx. [24]

Explanatory Notes
This section is excerpted from an important part of Suwen Chapter 7, the
third of three chapters that constitute Volume 2 and are dedicated to the
discussion of yin and yang, the core of Chinese medical thinking. The main
substance concerning the yin-yang perspective of body function and disease is
presented in Chapter 5; this long and complex discussion on yin and yang is
quoted five times in NJZY, making it the most quoted of all the chapters.
Chapter 6 defines the reciprocal relationship between yin and yang in their
three-fold categorisation. Chapter 7 is an overall discussion of the yin (genuine
zang-organ, systemic physiological function) and yang (stomach, nourish-
ment, hence energy metabolism) components of pulse patterns (see Section
4.12). An assessment of their relative importance can provide a prognosis
when disease occurs in a particular physiological system (a conduit designated
by its yin or yang category) and its transmutation to another. A short passage
of prognosis in fatal systemic organ failure was quoted in Section 4.12, in
connection with diagnosis by pulse-taking. A short sentence on the unique
pulse pattern of pregnancy was also quoted in Section 4.13. Because these
discussions of a wide range of subjects are extrapolations of the yin-yang
concept onto pulse patterns, their categorisation, signature symptoms, prog-
nosis and transmutation, the title of the chapter is literally “Alternate Discus-
sion of Yin and Yang.”
Gao Shi-zong (ref. 14) preferred to interpret bie 別 as “different”, a
different kind of yin or yang. Conventionally, there is always a yin component
in a yang state and vice versa. However, if there is a yin state without yang, e.g.
in the absence of gastric yang (indigestion, lack of energy supply), the genuine
zangqi (zang-organ function, i.e. yin) will reveal itself, and this is called “a
different kind of yin” (bieyin 別 陰). This is not the normal yin-yang complex
where yin is always balanced with yang, and vice versa. A person’s normal yin-
yang balance is healthy. If the balance is disturbed, one becomes sick. In the
worst case scenario, yin without yang or yang without yin will result in incur-
able disease. In modern terms, when body function is in overdrive and goes
beyond the limit of physiological compensation, morbid signs appear; this
could be fatal.

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 274 Neijing Zhiyao Yigu 內經知要譯詁

The three-fold classification of yin and yang is a virtual concept without a

concrete unit. However, it does indicate the relative importance of the degree
of yin or yang. In Suwen Chapter 74, Huangdi asks : “What is the three-fold
classification of yin and yang?” To this Qibo does not give a direct answer.
When Huangdi asks more specifically “What is yang-ming?” Qibo says : “It is
the combined [i.e. average] brilliance of the two yang [tai-yang and shao-
yang]”(liang yang he ming 兩 陽 合 明). This statement de facto locates yang-
ming (luminous yang) as the double yang with respect to the triple yang
(tai-yang, brilliant yang) and single yang (shao-yang, lesser yang). Similarly,
Qibo says “Jue-yin is the termination of the two yin” (liang yin jiao jin 兩 陰 交
盡). In Suwen Chapter 79, there are more qualitative descriptions of yin and
yang. But in what concerns yang-ming and shao-yang, it states unequivocally
that “yang-ming is double yang” (er yang zhe, yang ming ye 二 陽 者，陽 明 也)
and “shao-yang is single yang” (yi yang zhe, shao yang ye 一 陽 者，少 陽 也),
again without a unit given. There is no similar quantitative definition of yin.
From Suwen Chapter 6, the quotations:
太 陽 為 開，陽 明 為 闔，少 陽 為 樞 (tai-yang wei kai, yang-ming wei he,
shao-yang wei shu) and
太陰為開，厥陰為闔，少陰為樞 (tai-yin wei kai, jue-yin wei he, shao-
yin wei shu)
seem to treat jue-yin as the double yin, corresponding to yang-ming, which is
well defined quantitatively as double yang. The argument lies in whether to
put jue-yin as the closure (he 闔) or the hinge (shu 樞). Liang Yun-tong (ref.
18) favoured the hinge theory, which sees jue-yin as single yin. (See Unschuld
on the three-fold categorisation of yin and yang.) In the text quoted here,
shao-yin is double yin, i.e. the heart and the kidney conduits, whereas jue-yin
is single yin, i.e. the liver and pericardium conduits.
While the quantification of jue-yin/shao-yin remains a moot question, we
have to take a more eclectic view of the three-fold yin-yang categorisation of
symptoms and disease patterns. The three-fold categorisation is as good, and
as artificial, as the “five elements” theory, with which the ancient sages tried to
put the complexity of natural events into what seemed to them a reasonable
framework. It may not be true in every aspect, but it did help them to project
a complicated situation onto a set of basic coordinates.15 This is a kind of
Cartesianism in a Chinese context.

15
以簡御繁 (yi jian yu fan) “using simplicity to control complexity.”

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 Morbid Manifestations 275

Footnotes

[1] double yang conduits: This passage describes the diseases occurring in the
large intestine and stomach (yang-ming conduits) having transmuted to the
heart and spleen. These four conduits lie in sequence, according to the
normal flow of qi, i.e. large intestine → stomach → spleen → heart. This is
the only case in this section in which the origin and destination of transmu-
tation are indicated. All other cases merely indicate transmutation, presum-
ably to another conduit further down the sequence, but without specifying
which.
   Disease in a certain conduit can be a disease of the nominal organ (zhong
zang 中 臟, literally, “the evil qi striking the organ”), or it can occur along the
itinerary of the conduit (zhong jing 中經, “the evil qi striking the conduit and
spreading along its itinerary”), or even a side branch of the principal conduit
(zhong luo 中 絡, “the evil qi striking a side branch of the principal conduit
and remaining in the region”). Disease in the morbid organ may spread to
regions that are connected with this organ by innervation or vascularisation,
i.e. in a particular physiological system. Disease in the relevant side branch
may lie in a region governed by local circulation or innervation. Suwen 63
elaborates on disease at all levels of the side branches.
   The majority of the principal conduits are indicative of symptoms perti-
nent to the nominal organs. In some cases, like the stomachic conduit, it is
indicative of disease in blood. The large intestine conduit is indicative of
disease concerning all body fluids (jinye 津 液). The stomachic conduit
concerning blood may include its nutritive components. In this case, malnu-
trition can cause impotence/sterility (hypogonadism) due to malfunctioning
of the heart (blood circulation) and spleen (intermediary metabolism). But
in the other cases that follow, only the symptoms are mentioned.
[2] disease spreads to: The disease spreads from one physiological system to
another, in this case indicated by its nominal organ. In most cases, the trans-
mutation is described in the three-fold yin-yang categorisation. Transmuta-
tion along the six cardinal conduits forms the core subject-matter of
Shanghanlun by Zhang Zhong-jing.
[3] impotence [in males]: The Chinese text reads simply “the unspeakable” (yin
qu 隱 曲, literally “the hidden and the crooked”), which is generally accepted
to mean impotence in males.
[4] emaciation: The Chinese text has fengxiao 風 消, “emaciation by wind”. The
pathogenic wind is often related to liver disease, but not in this case. When

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 276 Neijing Zhiyao Yigu 內經知要譯詁

the disease spreads to the spleen, which is involved with digestion and
absorption of nutrients, emaciation occurs. It is further argued that with
malnutrition, the blood dries up and a desiccated body becomes feverish.
Fever in a weakened body will precipitate the appearance of other unex-
pected symptoms and the rapid onset of these symptoms is described as a
“wind” (sudden or unexpected) disease. It can be taken to mean a consump-
tive wasting disease with a persistent low fever.
[5] triple yang conduits: This refers to the small intestine and urinary bladder
conduits that govern diseases of the viscous body fluids (ye 液) and the
sinews, respectively.
[6] shin and calf: The Chinese text says specifically the calf (shuan [月耑]) feels
sore (yuan 㾓). Because this term is preceded by “weakness in knee and leg”
(weijue 痿 厥, “paraparesis”), it is more likely that that both the shin and the
calf feel sore.
[7] lack-lustre skin: The Chinese text uses the specific term suo ze 索澤, meaning
“dissipation” (xiaosuo 消索) of the “radiance” (guang ze 光澤, runze 潤澤); it
describes a lack-lustre complexion, due to the lack of fat in the skin, or astea-
tosis. The ensemble of symptoms described in [6] and [7] are consistent with
a syndrome related to chronic renal failure. It bears no direct relation to the
hernia described below.
[8] scrotal hernia: The Chinese term 頹 疝 tui shan describes a type of painless
hernia with a huge swollen scrotum. (See seven types of hernia, ibid. 6-2-4).
[9] single yang conduits: This refers to the three burners and the gall bladder
conduits that govern the dynamics of qi flow and the bones, respectively.
These diverse symptoms may relate to infection with the enteroviruses, a
genus of the family Picornaviridae. Different serotypes of the enteroviruses
can cause diseases ranging from upper respiratory tract infections, pneu-
monia, pleurodynia, myocarditis, pericarditis, and asceptic meningitis to
gastroenteritis. Some members of the group can also cause hand-foot and
mouth disease, myositis and hepatitis.
[10] palpitation: The Chinese term xinche 心 掣 (che, not zhi) describes a condi-
tion whereby the heart feels as if it is tugged and responds by beating quickly.
Here, che should not be interpreted as “stop, restrain or withhold”. Palpita-
tions occur when the heart is pumping more quickly and/or more strongly
in order to maintain high blood pressure. It is the result of physical stress or,
more likely, organic derangements such as valve incompetence or arrythmia.
[11] intestinal obstruction: The Chinese term 隔 ge as in fenge 分 隔, “separate”,

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 Morbid Manifestations 277

and geju 隔 拒, “refuse, resist”) describes a situation where the patient is

unable to ingest food or defecate. This is paralytic ileus.
[12] single yin conduits: This refers to the hepatic conduit that governs diseases of
the liver and the pericardiac conduit that governs diseases of the pulse
(dynamics of blood flow).
[13] belching [burping]: The Chinese term is 噫 yi (as in yixi 噫 嘻, “sighing”);
Suwen Chapter 49: “What gushes upward is sighing” (shang zou xin wei yi
上 走 心 為 噫). It may mean belching (ai 噯), because the word mimics the
sound of belching/burping.
[14] wind obstruction: This is a specific pathological term, fengjue 風厥, “obstruc-
tion due to the wind”. While it can have multiple meanings depending on the
circumstances, here it means disease of the liver.
[15] double yin conduits: This refers to the conduits of the heart and the kidney
that govern the diseases of their nominal organs. Where both the yin and
yang conduits are sick, there are altogether nine combinations. More combi-
nations are mentioned in Suwen Chapter 79. Yet there are still two combina-
tions missing (single yang: triple yin, and triple yang: double yin).
[16] triple yin conduits: This refers to the pulmonary conduit and the spleenic
conduits that govern diseases of their respective nominal organs.
[17] quadriplegia: The Chinese term weiyi 痿易〔亦〕means “atrophied and tired”,
(see 懈亦). This is weakness all over the body, especially quadriplegia as
described below. The ensemble of symptoms described in [16] and [17] is
strongly suggestive of poliomyelitis. It belongs to the same family of Picor-
naviridae mentioned above. Suggestions of polio were known from archeo-
logical findings in ancient Egyptian temple. So it is an old world disease.
[18] curable yang disease/incurable yin disease: When transmutation goes from
organ to organ in the generative mode, the disease is curable, a yang disease.
When transmutation goes from organ to organ in the inhibitive mode, it is
incurable, a yin disease.
[19] aggravated yin: Literally, “double” or “repeated yin” (chong yin 重 陰) because
the lung is yin relative to the heart for organs above the diaphragm. While all
zang-organs are yin in nature, the lung and the heart, which are above the
diaphragm, are relatively yang with respect to the three other zang-organs
below the diaphragm. Even then, the lung is relatively yin with respect to the
heart.
[20] expanded yin: when double yin kidney transmutes into triple yin spleen; it
puts the disease solidly in the yin category.

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 278 Neijing Zhiyao Yigu 內經知要譯詁

[21] entanglement [of qi flow]: Literally, “knotty” (jie 結), i.e. turbulent flow of qi
as if entangled in a knot.
[22] ascites with solid concretion: Literally, “stone water” (shi shui 石 水). This is
ascites with a palpable solid concretion, a late stage when the ascitic cells
start to congregate into a lumpy mass. Other clinical conditions that fit with
this description are cirrhosis of the liver, carcinoma of the peritoneal organs
and ovarian tumour.
[23] wasting symptoms: The Chinese term 消 xiao is generally taken to be the
abbreviated term for xiaoke 消渴 (wasting and thirsty), diabetes mellitus.
[24] inflammation of the pharynx: The Chinese term 喉 痺 houbi means “‘numb-
ness of the throat”. It is inflammation of the pharynx that leads to aphagia,
because of the loss of sensation.

[Section 8.4] Lingshu Chapter 10: The Conduits

《靈樞．經脈篇》曰：肺，手太陰也。是動則病肺脹滿、膨膨而喘咳、缺盆
中 痛，甚則交兩手而瞀，此謂臂厥。是主肺所生病者，咳、上氣、喘渴
（喝）、煩心、胸滿、臑臂內前廉痛厥、掌中熱。氣盛有餘，則肩背痛、風
寒汗出中風、小便數而欠；氣虛則肩背痛寒、少氣不足以息、溺色變。
大腸，手陽明也。是動則病齒痛、頸腫。是主津液所生病者，目黃、
口乾、鼽、衄、喉痺、肩前臑痛、大指次指痛不用。氣有餘，則當脈所過
者熱腫，虛則寒慄不復。
胃，足陽明也。是動則病洒洒振寒、善呻、數欠、顏黑；病至則惡人
與火，聞木音則愓然而驚、心欲動、獨閉戶塞牖而處；甚則欲上高而歌、
棄衣而走、賁響腹脹，是為骭厥。是主血所生病者，狂、瘧、溫淫汗出、
鼽、衄、口喎、唇胗、項腫、喉痺、大腹、水腫、膝臏腫痛，循膺、乳、
氣街、股、伏兔、鼾（骭）外廉、足跗上皆痛，中指不用。氣盛則身以前皆
熱，其有餘於胃，則消谷善飢、溺色黃；氣不足則身以前寒慄，胃中寒則
脹滿。
脾，足太陰也。是動則病舌本強、食則吐、胃脘痛、腹脹、善噫，得
後與氣，則快然如衰，身體皆重。是主脾所生病者，舌本痛、體不能動
搖、食不下、煩心、心下急痛、溏、瘕、泄、水閉、黃疸、不能卧、強立
股膝內腫厥、足大指不用。
心，手少陰也。是動則病嗌乾、心痛、渴而欲飲，是為臂厥。是主心
所生病者，目黃、脅痛、臑內後廉痛厥、掌中熱痛。

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 Morbid Manifestations 279

小 腸，手 太 陽 也。是 動 則 病 嗌 痛、頷 腫、不 可 以 顧、肩 似 拔、臑 似

折。是主液所生病者，耳聾、目黃、頰腫，頸、頷、肩、臑、肘、臂外後
廉痛。
膀 胱，足 太 陽 也。是 動 則 病 衝 頭 痛、目 似 脫、項 如 拔、脊 痛、腰 似
折、髀 不 可 以 曲、膕 如 結、踹 如 裂，是 為 踝 厥。是 主 筋 所 生 病 者，痔、
瘧、狂 癲 疾、頭 囟 項 痛、目 黃、淚 出、鼽、衄，項、背、腰、尻、膕、
踹、脚皆痛、小指不用。
腎，足少陰也。是動則病飢不欲食、面如漆柴、咳唾則有血、喝喝而
喘、坐而欲起、目目巟 目巟如無所見、心如懸若饑狀。氣不足則善恐，心惕惕
如人將捕之，是為骨厥。是主腎所生病者，口熱、舌乾、咽腫、上氣、嗌
乾及痛、煩心、心痛、黃疸、腸澼、脊股內後廉痛、痿厥、嗜卧、足下熱
而痛。
心主，手厥陰心包絡也。是動則病手心熱、臂肘攣急、腋腫，甚則胸
脅 支滿、心中憺憺大動、面赤、目黃、喜笑不休。是主脈所生病者，煩
心、心痛、掌中熱。
三焦，手少陽也。是動則病耳聾渾渾焞焞、嗌腫、喉痺。是主氣所生
病者，汗出、目銳眥痛、煩痛，耳後、肩、臑、肘、臂外皆痛、小指次指
不用。
膽，足少陽也。是動則病口苦、善太息、心脅痛、不能轉側，甚則面
微 有塵、體無膏澤、足外反熱，是為陽厥。是主骨所生病者，頭痛、頷
痛、目 銳 眥 痛、缺 盆 中 腫 痛、腋 下 腫、馬 刀 俠 癭、汗 出 振 寒，瘧，胸、
脅、肋、髀、膝外至脛絕骨、外踝前及諸節皆痛、小指次指不用。
肝，足厥陰也。是動則病腰痛不可以俯仰，丈夫 疒
貴 疝，婦人少腹腫；
甚則嗌乾、面塵脫色。是主肝所生病者，胸滿、嘔、逆、飧泄、狐疝、遺
溺、閉癃。

The pulmonic conduit is in the cheiro[telic]-tai-yin category. [1] When it is

affected by exogenous factors [2], the morbid signs are lungs bloating tight
like a drum, sonorous coughing and pain in the supraclavicular fossa [3]. In
severe cases, one seeks relief by crossing the arms across the chest while vision
is blurred [4]. This is called bijue, obstruction of qi in the arm [5]. It governs [6]
diseases due to malfunction of the lung such as coughing, qi gushing upwards,
sonorous and rough breathing, dysphoria, congestion of the chest, pain and
chills on the medial side of the upper arms, and hot palms. When there is an
exuberance of qi in this conduit, there will be pain in the back and shoulder;

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 280 Neijing Zhiyao Yigu 內經知要譯詁

on exposure to chilly draughts, one is prone to spontaneous sweating, thus

easily catching a cold. There are frequent passages of short-stream urine.
When there is insufficient qi in this conduit, the shoulder and back will feel
painful and cold. There will be shortness of breath with hardly a pause
between two breaths. The urine is discoloured.
The large intestinal conduit is in the cheiro[genic]-yang-ming category.
When it is affected by exogenous factors, there will be toothache and swollen
neck. It governs diseases due to disturbance of body fluids. The morbid signs
are jaundice, dry mouth, snivelling nose or nose bleed [7], numb throat and
pain in the front of the shoulder; the index finger does not respond to
command. When there is exuberance of qi in this conduit, areas along the
itinerary of the conduit are affected; they become hot and swollen. When
there is insufficient qi in this conduit, one will feel chilly and shivering instead;
in this case, it will be hard to warm up the afflicted parts.
The stomachic conduit is in the podo[telic]-yang-ming category. When it
is affected by exogenous factors, the morbid signs are shivering from cold,
sighing and yawning and a dark complexion on the face. A patient suffering
from this disease loathes to see other people or to sit near a fire. The patient
becomes apprehensive upon hearing rustling sounds in the woods, experi-
ences bumpy heartbeats [8] and prefers to imprison himself in a room with
closed doors and curtained windows. In severe cases, the patient climbs high
to shout, or runs amok while disrobing [9]; there will be noisy borborygmus
and a bloated abdomen. This is called ganjue, obstruction of qi in the shin [10].
It governs diseases due to disturbance in the blood; the morbid signs are
mania, recurrent cycles of fever and chills, profuse sweating in lingering fever,
snivelling nose and epistaxis, twisted mouth, lip sores (aphthosis), swollen
neck, numb throat, bloated abdomen, oedema, swollen and painful knees.
There will be pain [along the itinerary of this conduit] starting from the
pectoral muscles, passing by the breasts, down the inguinal canals, through the
quadriceps [11] of the thighs, coursing down the lateral sides of the shins to
the insteps of the feet. The middle toe does not respond to command. When
there is exuberance of qi in the conduit, the front of the body [chest and
abdomen] feels hot. Upon entering the stomach, the excessive qi will cause
facile digestion and frequent hunger [12] as well as yellow-coloured urine.
When there is insufficient qi, the front of the body feels cold [instead] and
tends to shiver; the stomach also feels cold and bloated.
The spleenic conduit is in the podo[genic]-tai-yin category. When it is

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 Morbid Manifestations 281

affected by exogenous factors, the morbid signs are stiff tongue, vomiting
upon food ingestion, stomachache, bloated abdomen, frequent belching; these
signs are greatly relieved upon defecation and passage of flatus. All parts of the
body feel heavy. It governs diseases due to malfunction of the spleen. The
morbid signs are stiffness in the back [root] of the tongue, the body becoming
rigid and hard to move, difficulty in ingesting food [dysphagia], dysphoria,
acute pain in the heart, loose stool, a movable mass in the abdomen [13], diar-
rhoea, dysuria, jaundice, feeling uncomfortable while lying down, although
forcing oneself to stand would cause pain in the knee and thigh, which are
swollen and cold. The big toe does not respond to command.
The cardiac conduit is in the cheiro[telic]-shao-yin category. When it is
affected by exogenous factors, there will be dry pharynx [14], pain in the
heart and thirst. This is called bijue, obstruction of qi in the arm [15]. It
governs diseases due to malfunction of the heart. The morbid signs are
yellowing [jaundice] of the eyes, pain in the hypochondrium, and the postero-
medial side of the upper arm feeling painful and cold, with hot palms.
The small intestinal conduit is in the cheiro[genic]-tai-yang category.
When it is affected by exogenous factors, there will be pain in the pharynx, a
swollen chin, inability to turn the head [stiff neck], the shoulder feeling
plucked away and the upper arm feeling fractured. It governs diseases due to
disturbance in mucous body fluid [16]. The morbid signs are deafness, jaun-
diced eyes, swollen cheeks and pain in the chin, shoulder, upper arm, and
elbow, as well as at the posterior edge on the lateral side of the upper arm.
The urinary bladder conduit is in the podo[telic]-tai-yang category. When
it is affected by exogenous factors, there will be throbbing headache, the eyes
feel as if they are being gouged out, the neck as if it is being pulled apart, the
waist as if it is being bent double and the thigh cannot bend, the popliteal
fossa is tight like a knot and the calf [is painful] as if it is being split open. This
is called huaijue, obstruction of qi in the ankle [17]. It governs diseases due to
malfunction of the sinews. The morbid signs are haemorrhoids, cycles of chills
and fever, mania, pain in the crown of the head and the neck, jaundiced eyes,
lacrimation, snivelling nose, epistaxis and pain in the neck, back, waist, sacral
region [the seat], popliteal fossa and calf. The small toe does not respond to
command.
The renal conduit is in the podo[genic]-shao-yin category. When it is
affected by exogenous factors, the patient will feel hungry but have no desire
to eat, the facial complexion looks dark and matte, there is coughing with

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 282 Neijing Zhiyao Yigu 內經知要譯詁

blood in the saliva, sonorous breathing, an inability to sit still, an unfocused

glare not fixing on any object, unsteady heartbeat as if starving for some time,
apprehension as a result of suppressed breathing and the heart will pound like
a fugitive on the run. This is called gujue, obstruction of qi in the bone [18]. It
governs diseases due to malfunction of the kidney [19]. The morbid signs are
hot breath, dry tongue, swollen throat, qi gushing upwards, dry and painful
pharynx, dysphoria, pain in the heart, jaundice, dysentery [20], pain along the
spinal column and the postero-medial side of the thigh, cold and flaccid limbs
[21], and a tendency to lie down with a painful and hot feeling in the soles of
the feet.
The pericardiac conduit is in the cheiro[telic]-jue-yin category. When it is
affected by exogenous factors, the patient feels heat in the palms, spasms in
the arm and elbow, swollen armpits, or even a congested chest and hypochon-
drium. The heart feels unsettled, there is flushing on the face, jaundiced eyes
and incessant hilarious laughter [for no reason]. It governs diseases due to
disturbances in the blood vessels [conduits]. The morbid signs are dysphoria,
pain in the heart and hot palms.
The three burners conduit is in the cheiro[genic]-shao-yang category.
When it is affected by exogenous factors, there will be deafness and tinnitus,
swollen pharynx and numb throat. It governs diseases due to disturbance in
qi. The morbid signs are hidrosis, pain in the outer canthus, the chin, behind
the ears, the shoulders, medial side of upper arm, elbow and lateral side of the
arm. The index finger does not respond to command.
The gall bladder conduit is in the podo[telic]-shao-yang category. When it
is affected by exogenous factors, there will be a bitter taste in the mouth,
sighing, pain in the heart and hypochondrium region of the chest, an inability
to turn over in bed; in serious cases, there is a [greyish] dusty appearance on
the face, and the body surface is devoid of grease [asteatosis], with the lateral
side of the feet feeling hot. This is called yangjue, obstruction of qi in the yang
conduit [22]. It governs diseases due to malfunction of the bones. The morbid
signs are headache, pain in the chin, outer canthus of the eye, supraclavicular
fossa with swelling, swollen armpits, swollen lymph nodes on the neck [23],
hidrosis, waves of shivering chills like malaria, pain in the chest, hypochon-
drium, rib cage, thigh, from the lateral side of the knee down the tibia to its
end [see ibid. 6-1-45] as well as all articulations proximal to the outer ankle.
The second toe does not respond to command.
The hepatic conduit is in the podo[genic]-jue-yin category. When it is

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 Morbid Manifestations 283

affected by exogenous factors, there will be pain in the waist, so much so that
one can neither bend forward nor backward, inguinal hernia in men, and
swollen underbelly in women; in severe cases, the pharynx is dry, the facial
complexion is pale and dusty. It governs diseases due to malfunction of the
liver. The morbid signs are congested chest, vomiting, turbulent flow of blood
and qi, passing undigested grains in the stool, retractable hernia, urinary
incontinence or anuria.

Explanatory Notes
This section picks up where it is left unfinished in Section 6.1. In Lingshu
Chapter 10: The Conduits (Jingmai 經 脉), each regular conduit is described in
three parts. The first part describes the itinerary, and that is the subject of
Section 6.1. The second part describes the clinical picture of each affected
conduit, and that is the subject of the present section (8.4). The third part
describes the appropriate methods of acupuncture to treat these symptoms.
This last part is not excerpted in NJZY.
The whole of Lingshu Chapter 10 is also divisible into three parts. The
first part describes the itinerary and clinical picture of the twelve affected
regular conduits that form the main substance of the chapter (Sections 6.1
and 8.4 in NJZY). The second part describes the morbid signs when qi is
exhausted in the five yin conduits that govern the five zang-organs, a clinical
situation comparable to multiple organ dysfunction. This part forms the
subject of Section 8.33 that follows later in this chapter. The third part of
Lingshu Chapter 10 describes in some detail the side branches of the regular
conduits, the 15 bieluo (one for each regular conduit, one each for Ren-mai
and Du-mai, and an additional large branch for the spleenic conduit) which
serve to connect with other side branches from other regular conduits to form
a network of principal conduits. Although this part is not excerpted in NJZY,
what is important in it is the definition of jingmai as opposed to luomai,
something that provides an important insight into the structure and function
of conduits (jingmai).
This part begins with the statement: “The twelve regular conduits run
deeply between the muscle bundles; they are not visible. What is often visible
is the podogenic tai-yin spleenic conduit when it travels across the front of the
medial ankle [24]; there is nothing to hide it at this place. Those conduits that
are floating and are commonly visible are the luomai.” This is the most precise

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 284 Neijing Zhiyao Yigu 內經知要譯詁

definition of jingmai (regular conduits) and luomai (side branch conduits) in

Neijing. One cannot help but associate the vision of the conduits with deep-
lying systemic blood vessels (arteries) and surface-lying arterioles respectively.
(Today there are still futile efforts made to look for the anatomical structure
of jingmai). There is, however, one small problem with this statement that
makes it hard to accept. To begin with, the spleenic conduit passing through
the front edge of the medial ankle corresponds to the anterior medial malle-
olus artery. While pulsation can be felt here, the usual site of pulse-taking in
this region is the dorsal pedal artery. This is the fuyang 趺 陽 site; it belongs to
the podotelic yang-ming gastric conduit. Zhang Zhong-jing used to take a
pulse at this site to evaluate the function of the stomach (especially when the
cunkou site pulsation is not evident). This is the “fuyang pulse” ( 趺 陽 脉),
according to the ancient classification of “three sites and nine modes” (san bu
jiu hou 三部九候). Another site favoured by Zhang Zhong-jing is the shao-yin
site behind the medial ankle (acupoint taixi 太 溪 K-13) that indicates renal
function. Again the “shao-yin pulse” (少陰脉) is sought only when the cunkou
site pulsation is not evident. The most reliable pulse-taking site is no doubt
the cunkou on the radial arterial at the level of the wrist. As Huangdi elabo-
rates later in the paragraph, he maintains that “conduits are usually not visible;
their plenitude in qi can be gauged by the qikou 氣 口 (‘aperture for apprecia-
tion of qi dynamics’, i.e. cunkou). All that are visible of the conduits is the side
branches.” These discussions leave us in no doubt that regular conduits are
indeed the systemic arteries and their dynamics in pulsation is an appreciation
of qi propagation.
The second part concerning the clinical picture of the affected regular
conduits can be conveniently divided into two subsections. The first subsec-
tion describes morbid signs when the conduit is affected by an exogenous
pathogenic factor. Literally the Chinese text reads: “When the said conduit is
agitated, the morbid signs are” (shi dong ze bing... 是 動 則 病 …… ). The verb
“agitated” (dong 動) is used in the passive voice, hence the conduit is being
affected by an exogenous factor. After defining this clinical presentation with a
specific term like “obstruction of qi flow in the arm” (bijue 臂 厥), the text
continues to describe the principal syndromes that are governed by this
conduit (shi zhu fei suo sheng bing... 是 主 肺 所 生 病 …… ). Here the verb
“govern” is used in the active voice, as if these indications are inherent proper-
ties of this conduit that may show up partly or fully. As these indications are
mainly related to the function of the relevant zang- or fu-organ, it seems

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 Morbid Manifestations 285

reasonable to conceive that they are actually the area of blood supply irrigated
by the conduit in question. In this sense, the conduit can be construed to
mean the systemic nerves, which often run parallel to the systemic blood
vessels lying deep between the muscle bundles (xing fen rou zhi jian 行分肉之
間). However, since it is not possible to feel the propagation of a nervous
impulse by tactile sensation, it would be more reasonable to limit the concept
of jingmai to arteries where pulsation can be readily felt. Thus Lingshu
Chapter 10 offers a fairly realistic picture of the principal traits of vascularisa-
tion in the circulatory system and their functional significance. All later efforts
to find the structure of jingmai have served only to deepen the mystery about
conduits that are non-existent in the first place. Modern-day critics of Chinese
medicine often deride it as not “evidence based”. Lingshu Chapter 10 is suffi-
cient in itself to demonstrate that Chinese medicine is more solidly based on a
systematic knowledge of anatomy and physiology than any other medical
knowledge of its time (e.g. Greek medicine). Lingshu Chapter 12: Conduits as
Water Courses (Jingshui 經 水) states that jingmai received blood and nour-
ished the body, that the blood it contained could be distinguished as either
clear [arterial] or turbid [venous] and the length of jingmai could be exam-
ined by post mortem (actually, the word used is “anatomy”, 解剖 jiepou).
The following table first appears in Section 6.1. It is recapitulated here,
summing up the principal physiological dysfunctions of the twelve regular
conduits:
111 Pulmonic cheirotelic tai-yin conduit: relates to diseases in the lung.
222 Large intestinal cheirogenic yang-ming conduit: relates to diseases
with the body fluids (jinye).
333 Stomachic podotelic yang-ming conduit: relates to diseases of the
blood.
444 Spleenic podogenic tai-yin conduit: relates to diseases in the spleen (as
conceived of in Chinese medicine).
555 Cardiac cheirotelic shao-yin conduit: relates to diseases in the heart.
666 Small intestinal cheirogenic tai-yang conduit: relates to diseases of
the mucous fluid (ye).
777 Urinary bladder podotelic tai-yang conduit: relates to diseases of the
sinews.
888 Renal podogenic shao-yin conduit: relates to diseases in the kidney.
999 Pericardiac cheirotelic jue-yin conduit: relates to diseases in the blood
vessels (mai).

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 286 Neijing Zhiyao Yigu 內經知要譯詁

1111 Three burners cheirogenic shao-yang conduit: relates to diseases of

the qi.
1111 Gall bladder podotelic shao-yang conduit: relates to diseases in the
bones.
1111 Hepatic podogenic jue-yin conduit: relates to diseases in the liver.

It must be noted that these signature symptoms, as well as all other symp-
toms described in each conduit, represent yet another effort to classify
diseases, this time according to conduit itinerary. This is probably useful when
one tries to treat these conditions with acupuncture, when one has to be sure
which acupoint to use, and more importantly, into which conduit to put the
needle. As stated in Section 6.1, a warning often quoted in this field is: “Better
to miss the acupoint, but never miss the conduit.” (ning shi qi xue, mo shi qi
jing 寧 失 其 穴，莫 失 其 經). It can also be argued that these clinical observa-
tions were collected together after numerous attempts to treat a particular
conduit. It is pure empiricism that need not answer to logic.
Translation of this section is as close to the original as possible. Additional
information and amendments are bracketed. From the sequence of the
conduits in the text, it is clear that each conduit dovetails into the following
one, although this is not explicitly indicated in the text. For the convenience of
readers who can read Chinese, and who would like to compare the translation
with the Chinese text, each conduit is preferably read with the corresponding
conduit in Section 6.1, and both sections should be read alongside the
comments from Dr. W. F. Pau.

Addendum by Dr. W. F. Pau

While the itinerary of all the conduits can be traced, for they are much
simpler than the anatomy of the nervous or vascular systems, the reasoning or
the pathophysiological mechanism behind the myriads of symptoms or indi-
cations discussed under each of the conduits does not always agree with
modern medical knowledge. Maybe the introduction of the acupuncture
needle at various points along the meridians (conduits) could alleviate these
symptoms.

Fei 肺, The Pulmonic Conduit

Agitation of the lung conduit causes symptoms which are compatible
with those of emphysema, except for pain in the the supraclavicular fossa,

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 Morbid Manifestations 287

which it has been suggested is due to a Pancoast tumour at the apex of the
lung. One could hypothesise that both emphysema and lung cancer share a
common inducer—cigarette-smoking. Crossing the arms across the chest
while leaning forward is the posture adopted by the patient during episodes of
tachypnoea.16 (But there is no reference to blurring of vision〔 mao 瞀〕).
While insufficient qi might be expected of emphysema, it is difficult to under-
stand what exuberance of qi might be in the context of ventilation and
perfusion dysequilibrium in the lungs at the acinar level.

Dachang 大腸, The Large Intestinal Conduit

Since water is absorbed mainly in the large intestine, it is acceptable that
the colon is considered a major organ governing the flow of body fluids. In ref.
53 (p. 50), the spleen is responsible for transferring the absorbed “clear
liquid”(containing dissolved nutrients) to the lungs for distribution all over
the body. So which organ plays a bigger role in this physiological function?
Many symptoms described in this subsection are difficult to explain,
among them toothache, swelling of the neck, jaundice and epistaxis. One
would expect diarrhoea to figure prominently in a malfunction of the colon,
but this symptom is not mentioned even in passing. It is not clear what is
meant by a “hot swelling” along the conduit. If pain starts in the index finger,
the hot swelling may mean lymphangitis or spreading cellulites from an
infected focus in the finger. Under these circumstances, the lymphatics would
drain to the axillary lymph nodes and swelling would have occurred in the
armpit and not in the neck. The observation of this symptom beggars
imagination.

Wei 胃, The Stomachic Conduit

This conduit is given the largest coverage in this Section (8.4), perhaps
because the stomach is the “sea of water and cereals”. The symptoms described,
such as fear of and apprehension about certain subjects, fire or another
person, coupled with abnormal behaviour such as autism and impulsive
action, which may be related to auditory hallucinations, are the building
blocks of the schizophreniform syndrome, or a lesser state, anxiety neurosis.
These days the difficult differential has to be determined by a psychiatrist. In

16
Harrison, Principles of Internal Medicine, 10th ed. (McGraw-Hill, 1983).

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 288 Neijing Zhiyao Yigu 內經知要譯詁

Section 8.25, it states that: “If qi is not travelling along its tract [gastric
conduit], one cannot sleep [peacefully].”17 The Neijing authors believed that
obstructed weiqi would interfere with peace of mind, to such an extent that
the subject could not sleep soundly.
Excessive weiqi may cause facile digestion and frequent hunger (xiao gu
shan ji 消穀善飢). This refers back to the opening sentence in this subsection,
which describes the stomach as “the sea of water and cereals”, where digestion
commences. In Section 8.2, it was mentioned that gastrointestinal hormones
control gastric acidity and digestion in general. With regard to indulgence in
sweet foods, a physiological mechanism which checks over-eating is the secre-
tion of hormones, GLP-1 and GIP, from the walls of the small intestine, which
regulate β-cell function of the pancreas to minimise the postprandial surge of
blood sugar, and which also slow the emptying time of the stomach, and at the
same time, induce a feeling of satiety. This mechanism guards against frequent
hunger and a tendency to diabetogenesis.
The stomach is a fu-organ, whereas the spleen is a zang-organ; the latter
governs the blood. The spleen is paired with the stomach in the zang-fu rela-
tionship which is the subject of the discourse Piweilun 脾 胃 論 by Li Dong-
yuan 李 東 垣. The statement that “it [the stomach conduit] governs diseases
due to disturbance in the blood” is somewhat confusing, as it contradicts
another statement in Suwen Chapter 44, quoted in Section 8.24, that the yang-
ming stomach conduit governs nourishing of the progenitorial ligament.18
Readers are entitled to an explanation.
As to the morbid signs mentioned, each sign taken in isolation is non-
specific; taken collectively, they do not conform to any syndrome known in
medicine. Although the middle toe may not respond to command, only one
branch goes into the lateral side of the middle toe, while the itinerary of this
conduit ends at the tip of the big toe.

Pi 脾, The Spleenic Conduit

It has to be accepted that the spleen in traditional Chinese medicine is not
the organ we know today. In Neijing times, traditional Chinese medicine prac-
titioners did not differentiate the spleen from the pancreas, and one has to

17
Lingshu Chapter 80《靈樞．大惑論》︰「陽明逆，不得從其道，故不得也。」
18
《素問．痿論》︰「陽明者，五臟六腑之海，主潤宗筋。」

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 Morbid Manifestations 289

assume that it is the pancreas we are talking about. Symptoms described under
the spleen conduit produce sign of indigestion, which is psychological in
origin and common in subjects with anxiety, depression, or hysteria. Air-swal-
lowing (aerophagy) can cause stomach pain, frequent belching and general
abdominal distension, or localised distension in the spleenic flexure of the
colon over the left upper quadrant. The discomfort is relieved by defaecation
or passage of flatus. The condition is sometimes called the splenic flexure
syndrome.
The appearance of jaundice signifies a physical illness and the symptoms
match those of acute or chronic pancreatitis, or associated cholelithiasis. Defi-
ciency in digestive enzymes is responsible for malabsorption, leading to
diarrhoea.
Stiffness of the tongue is mentioned twice. This symptom, coupled with
rigidity of the whole body, is reminiscent of catalepsy, which has been
discussed in Section 8.1 under the wording “zhu bao qiang zhi” 諸 暴 強 直.
While a hysterical person may act stiff in whichever part of the body he
chooses, he cannot feign jaundice. Stiffness of the tongue is typically seen in
pseudo-bulbar palsy, an upper motor neuron lesion of the hypoglossal nerve
(12th cranial nerve), but this neurological condition does not fit in with the
overall condition depicted here. Perhaps the term “stiffness of the tongue” (she
ben qiang 舌 本 強) can be replaced by “dysphagia” (shi bu xia 食 不 下) due to
laryngeal spasm. Here we may have a physiological explanation. One of the
physiological derangements in acute pancreatitis is hypocalcaemia, and it
causes tetany, of which laryngeal spasm is a symptom. This replacement does
not seem too unlikely, considering the interpretation of jia (see Footnotes [12]).
The interpetation of jia as a mass in the abdomen sounds more reason-
able in the context of this subsection. The palpable mass may be a pseudocyst
of the pancreas, a recognised complication of acute pancreatitis. But this mass
in not movable. Li Zhong-zi’s interpretion that jia is dysentery is consistent
with the symptoms, but the statement is awkwardly presented. One does not
have to mention loose stool, dysentery and diarrhoea in the same breath.

Xin 心, The Cardiac Conduit

The ancient Chinese practitioners did observe that cardiac pain could be
felt along the medial border of the arm. However, they did not go on to
explain the relation of anginal pain to exertion, nor its relief by rest, or by
taking of vasodilator medication. Other symptoms of heart failure, such as

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 290 Neijing Zhiyao Yigu 內經知要譯詁

breathlessness on exertion, nocturnal orthopnoea, palpitation, syncope and

oedema, are missing. There is such a thing as “silent infarction”. It is fair to
assume that the predisposing factors for atherosclerosis and ischaemic heart
disease as we know them today were relatively uncommon in a predominantly
rural community so that two thousand years ago the average medical practi-
tioner did not see many anginas or myocardial infarctions.
Why is jaundice mentioned under this heading? Jaundice, together with
pain in the hypochondrium, may indicate acute passive congestion of the liver
consequent upon acute right-sided heart failure.

Xiaochang 小腸, The Small Intestinal Conduit

The symptoms described in this subsection bear little or no resemblance
to those of the disorders of the small intestine known to modern medicine.
The pain in the neck, shoulder and inner side of the upper arm corresponds
largely to the pain experienced by patients who are also suffering from, respec-
tively, prolapsed disc of the cervical vertebrae, or painful shoulders occasioned
by rotor-cuff injury, subacromial bursitis, partial tear of the supraspinatus
muscle, or supraspinatus tendinitis. The word “largely” is used because pain
due to intrinsic lesion of the shoulder radiates from the tip of the acromion
process down the lateral side of the upper arm, not the inner side (nao 臑).
Intrinsic shoulder pain, as distinct from pain referred to the shoulder from
cervical spine disc lesion, seldom extends beyond the elbow.
It is hard to understand the pathophysiological basis of the other morbid
signs: jaundice, deafness, swollen cheek and pain in the chin. These cannot be
the result of an abnormality in the formation or distribution of mucous body
fluid.

Pang-guang 膀胱, The Urinary Bladder Conduit

When mention is made of headache, retro-orbital pain, stiff neck and
back pain, and generalised myalgia accompanied by cycles of chills and fever,
present-day physicians would be tempted to consider a viral aetiology, partic-
ularly with respect to diseases caused by the arthropod-borne Arboviruses.
The more familiar Arboviruses are those which cause yellow fever, dengue,
and West Nile fever, to name but a few. Dengue fever is also known as “break
bone fever”. Some of these diseases present with jaundice (notably in yellow
fever), epistaxis and other haemorrhagic manifestations, as in dengue haem-
orrhagic fever. The patient may become drowsy during the viraemic stage, and

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 Morbid Manifestations 291

then sink further into delirium, which mimics mania.

Another infection which bears a close resemblance to those mentioned
above is leptospirosis, which is caused by the invasion of the body through
broken skin or mucous membrane by the spirochaete Leptospira icterohaemor-
rhagiae and other related serotypes, present in water contaminated with the
urine of infected rats.
It is possible that the exogenous factors that affect the conduit are the
above-mentioned infectious agents.

Shen 腎, The Renal Conduit

Agitation of the renal conduit gives rise to symptoms of anxiety neurosis.
Fear and apprehension figure prominently in the anxiety state. The subject is
anxious for a reason. His complexion turns black, he notices blood in the
sputum, his breathing is laborious and he cannot focus on what he sees. This
picture is compatible with left-sided heart failure, of which blood-streaked
sputum is a symptom; and also with haemoptysis, when the underlying
pathology is a tight mitral stenosis. The dark complexion has to be interpeted
as being due to central cyanosis and not hypermelanosis due to endocrine (e.g.
Addison’s disease) or metabolic (e.g. haemochromatosis) diseases. The above
assumption leaves one with a lingering doubt, however—if the primary
problem is heart disease, why is the symptom complex, oddly labelled “gujue”
骨厥, not placed under the cardiac category?
Chronic renal failure can give rise to disorders in the gastro-intestinal and
musculo-skeletal systems as well as the nervous system, and this accounts for
the morbid signs listed here. For example, pain in the spinal column is expli-
cable as osteodystrophy, and a painful hot feeling in the sole of the foot as
peripheral neuropathy. Motor nerve involvement leads to loss of deep tendon
reflexes, muscle wasting, foot drop and eventually flaccid quadriplegia.
Full credit must be given to the Neijing authors for making these meticu-
lous observations in patients suffering from kidney problems so many centu-
ries before nephrology became a subspecialty in modern medicine.

Xinzhu 心主, The Pericardiac Conduit

The symptoms described in this subsection are both somatic and
psychiatric.
We need not look beyond our daily life for an exogenous factor that
affects this conduit, in this instance, myocardiac infarction. The immediate

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 292 Neijing Zhiyao Yigu 內經知要譯詁

complications of acute myocardiac infarction (AMI), like cardiogenic shock,

pulmonary oedema, ventricular aneurysm, ruptured papillary muscle of the
mitral valve, and thromboembolism are familiar to all physicians. However,
there are two less commonly discussed complications which give rise to symp-
toms weeks or months after the acute event.
The first is called “shoulder hand syndrome”, which is characterised by
painful swollen hand, painful stiff shoulder, and vasomotor instability. The
latter may present as either vasoconstriction with a pale, cool distal limb, or
vasodilation with a warm red, perspiring hand (zhang zhong re 掌 中 熱). The
above phenomena may persist for three to six months and be succeeded by a
phase of skin atrophy and contracture of palmar fascia and tendons of the
extremity.
The second post-myocardial infarction syndrome is known as Dressler’s
syndrome, characterised by fever, substernal and chest pain with radiation of
pain to the shoulders and interscapular areas arising from a few days to six
months after AMI. The pathomechanism is thought to be an auto-immune
reaction caused by anti-myocardium antibodies, which produces pericarditis,
pleuritis and pneumonitis. Congested chest and hypochondrium are thus
explained. These conditons respond to high-dose salicylate.
That leaves the psychiatric symptoms. It is understandable that someone
who has survived a myocardiac infarction has cause for celebration and
laughter.
Today, when an illness is unexplained and symptoms bizarre, drug abuse
is a strong possibility. It is hard to imagine, however, what substances people
living two thousand years ago might have been abusing. Alcohol comes readily
to mind (red face). Nowadays there is a host of drugs which cause central
stimulation, causing euphoria, ecstasy, increased energy level, increased
muscle tension, agitation and flashbacks. Peripheral release of catecholamines
or pre-synaptic serotonin re-uptake inhibition underline some of these effects.
Jaundice may be a result of the hepatotoxic effect of these drugs.

Sanjiao 三焦, The Three Burners Conduit

In Section 8.3, it was remarked that the symptoms of deranged cheiro-
genic shao-yang conduit (yi yang fa bing 一 陽 發 病) resemble the manifesta-
tions induced by different genotypes of the enteroviruses. But those are quite
different from the indications presented in this subsection. So which is the real
three burners conduit?

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 Morbid Manifestations 293

Notwithstanding that the three burners refer to regions in the thorax,

upper and lower abdomen, respectively, the indications mentioned in this
subsection relate to the head and neck, shoulders and upper extremities, all far
from these sites.
In analysing the symptoms described under the influence of exogenous
factors, it is reasonable to attribute deafness and tinnitus to otis media, as
there is an infected focus in the pharynx, from whence infection spreads to the
middle ear through the Eustachian tube. Pain at the outer canthus and over
the chin is subserved by the ophthalmic division and the mandibular division
of the trigeminal nerve, respectively. This should constitute trigeminal
neuralgia. Pain at the back of the ear, which is in the itinerary of the conduit,
is subserved by the lesser auricular nerve, which is a branch of the second
cervical nerve. The pain in the shoulder, upper arm and elbow have sources at
either the cervical vertebrae, the thoracic inlet, or the shoulder joint itself.
Movement of the index finger is controlled by muscles innervated by the
radial nerve (extensors) and the median nerve (flexors and lumbricals) and
these nerves arise from trunks of the brachial plexus. The plexus is susceptible
to pressure effect at the intervertebral foramen, the thoracic inlet, or the axilla,
giving rise to localised or referred pain, and paralysis of different muscle
groups of the upper extremities.
There is a frustrating lack of description of symptoms referrable to the
thorax and the abdomen.

Dan 膽, The Gall Bladder Conduit

The symptoms of yangjue 陽 厥 merit a systemic review of the subject’s
general conditon because of the pain syndrome and the dry skin. The latter
may be a manifestation of atopy, hypothyroidism, nutritional deficiency,
underlying malignancy, or simply old age. In the absence of physical abnor-
malities, a psychiatric assessment is warranted, to rule out a depressive illness.
In Chinese medicine, bone health is related to the kidney (ibid. 8-24-9).
How come this gall bladder conduit also governs diseases of the bone? Zhang
Jie-bin probably also saw this anomaly and felt a need to explain the associa-
tion between gall bladder and bone. Thus: “The bile tastes bitter, and bitter-
ness has an affinity for the bone. That is why the gall bladder governs the
disease of the bone.” (dan wei ku, ku zou gu, gu dan zhu gu suo sheng bing 味
苦，苦 走 骨，故  主 骨 所 生 病。 ) (from footnote 80 in Zhang Deng-ben,
ref. 1). This odd explanation is not based on the conduit theory. It would not

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 294 Neijing Zhiyao Yigu 內經知要譯詁

be accepted by modern physiologists. The pain in the head region is similar to

that described in the “three burners” subsection. It could be either migraine or
trigeminal neuralgia. The “sabre tassel” (ma dao xie ying 馬 刀 挾 纓) is
construed to mean enlarged lymph nodes in the axilla (ye xia zhong 腋 下 腫),
but usually refers to enlarged lymph nodes in the neck region (ibid. 8-28-17).
A diligent search for a suppurative lesion on the upper extremity, the breast
and the adjacent chest wall is called for. Swelling and pain in the supraclavic-
ular fossa could be due to tumour of the brachial plexus, aneurysm of the
subclavian artery, or the presence of a cervical rib. However, the absence of
neurological or vascular symptoms in the related upper extremities does not
support these diagnoses.
It is hard to explain the pain which covers the rib-cage, the hypochon-
drium, the thigh, knee and tibia down to its lower end and, additionally, pain
in the articulations proximal to the ankle. These are a great quantity of tissues
spread over a wide anatomical domain, and the patient would be crippled by
such bone and joint pains. Does it matter any more that he/she cannot move
the second toe, and this toe alone? The second toe is not along the gall bladder
conduit, which ends at the dorsal side of the tip of the fourth toe, with a
branch sent to the nail of the big toe at acupoint sanmao 三毛.
It is amazing that the acupuncturists of a bygone era picked the fourth
toe as the terminus of the gall bladder conduit, for the anatomy here is a little
complicated. The medial and the lateral side of this toe are supplied by sepa-
rate digital nerves: the medial side by a branch of the medial plantar nerve and
the lateral side by a branch of the lateral plantar nerve; both nerve twigs go
round the tip of the toe to end at the distal part of the extensor (dorsal) aspect
of the distal phalanx.
The same is true of the big toe. The nail is supplied by the first digital
branch of the medial plantar nerve, which is one of the two main branches of
the posterior tibial nerve which runs on the “yin” (posterior) aspect of the leg,
while the hairy part proximal to the nail is supplied by a cutaneous branch of
the musculocutaneous nerve, which runs on the “yang” (anterior) aspect of
the leg.

Gan 肝, The Hepatic Conduit

Section 8.1 of this Chapter begins with these four-word couplets: “zhu
feng diao xuan, jie shu yu gan” 諸 風 掉 眩，皆 屬 於 肝, meaning that all wind
diseases presenting with involuntary body movement and dizzy spells or

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 Morbid Manifestations 295

syncope of sudden onset fall into the category of deranged liver conduit. How
is it that these wind symptoms are conspicuously absent in this subection? In
their place are clinical features like painful lumbar spine, inguinal hernia,
urinary incontinence, none of which are hepatic symptoms by modern
criteria.
The interpretation of bilong 閉 癃 as “anuria” is interesting because of the
existence of hepatorenal syndrome (HRS), a rare complication of advanced
hepatic diseases. HRS is defined as the development of renal dysfunction in
patients with acute or chronic severe liver disease in the absence of any other
identifiable cause of renal pathology.
In Type I HRS, there is rapid, progressive renal failure with doubling of
serum creatinine to over 221 μmol/L (2.5mg/dL) or halving of creatinine
clearance to less than 20 ml/min. over a period of less than two weeks. Type I
HRS carries a very poor prognosis, the median survival being two weeks. Type
II HRS is a slowly progressive renal failure that is typically associated with
ascites that is unresponsive to diuretics, and has a median survival of approxi-
mately six months, unless the patient undergoes liver transplantation.
The ashen grey complexion cannot be equated with jaundice, the latter
being a cardinal sign of liver disease. Paradoxically, jaundice is mentioned
under the subsections dealing with the large intestine, spleen, heart, small
intestine, urinary bladder, kidney and pericardiac conduits. The liver and the
gall bladder are left out.
The scrotal hernia is attributable to increased intra-abdominal pressure
caused by ascites. In fact, any cause of increased intra-abdominal pressure,
such as chronic cough, straining at micturation or defecation, can give rise to
a hernia if the abdominal wall musculature is also weak.
Turbulent flow of blood and qi, if it occurs in the thorax, could indicate
congestive heart failure and therefore, chest congestion; if it occurs in the
splanchnic circulation, it could mean portal hypertension and the develop-
ment of collateral circulation and portosystemic shunting. If this speculation
is right, then the ancient Chinese physicians had conceived the idea of circula-
tion of body fluids, although not in the same anatomical detail as William
Harvey in 1628. Any disturbance of normal circulation is given the term “ni”
逆 , which is as weighty a term as “shock” or “stroke” used in modern
medicine.
To sum up, it would be fair to state that this two-line subsection contains
as many inconsistencies as accuracies.

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 296 Neijing Zhiyao Yigu 內經知要譯詁

Footnotes

[1] cheirotelic pulmonic conduit: The Chinese text has: “pulmonic [conduit] is
cheiro(telic) tai-yin ….” This is a rewording by Li Zhong-zi of the opening
statement in Section 6.1, “The pulmonic cheiro(telic) tai-yin conduit …”, in
order to identify the conduit in question, linking the two parts from the two
different sections. This rephrasing does not appear in Lingshu Chapter 10.
There was an important annotation by Li Zhong-zi regarding the pulmonic
conduit: “All the vessels [conduits] are directed to the lung, and then pass on
to other vessels sequentially, ending up in the hepatic conduit. It continues
like this until it comes to the pulmonic conduit again, making one complete
cycle.” This is a macro-circulation, with each perfused organ aligned in
sequential order. Li Zhong-zi first published NJZY in 1642. In 1628, William
Harvey published his De Motu Cordis, firmly establishing the concept of
blood circulation. But in Harvey’s mode, the systemic arteries branch out to
each organ, return to the heart via the veins and connect to the pulmonary
circulation. Lingshu Chapter 16: Nutritive Qi (Yingqi 營 氣) describes the
perfusion of the nutritive qi, i.e. the body fluid that contains nutritive
elements, [i.e. the blood], following an itinerary identical to the conduits.
This is actually a description of blood circulation (ying qi zhi suo xing 營 氣
之所行, “that is how the yingqi goes”)
[2] exogenous factors: The Chinese word 動 dong means that the conduit is
stirred, agitated, or disturbed so that there is a noticeable difference from the
normal function, due to the action of an exogenous factor. This is different
from abnormal performance of the conduit due to indigenous factors. See [6]
below.
[3] pain in supraclavicular fossa: Pancoastal tumour at the lung apex sometimes
presents as pain in the supraclavicular fossa. In Chinese medicine, pain in
this fossa is always taken to mean lung abscess (feiyong 肺廱), in other words,
lung cancer.
[4] vision is blurred: The Chinese word 瞀 mao has multiple meanings, the most
relevant in the present context being “blurred vision”. Zhuangzi talked about
blurred vision but he meant metaphorically bewilderment. (《莊 子．徐 無
鬼》︰「余適有瞀病。」)
[5] obstruction of qi flow in the arm: The term bijue 臂 厥 refers to a specific
clinical situation when turbulent qi flow that is obstructed in the pulmonic
conduit is felt at the level of the arm. Jue 厥: devoid of, obstructed, reversed,
loss of consciousness, cold limbs, weak pulse etc. are all due to lack of qi.

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 Morbid Manifestations 297

[6] governs: The Chinese word zhu 主, means “to govern, master, direct” etc.
When the said conduit is not functioning well, it indicates a spectrum of
signs pertinent to this conduit.
[7] snivelling nose and bleeding nose: Snivelling nose (qiu 鼽) is often used to
describe a running nose with clear dripping and bleeding nose, blood. (nü
衄, epistaxis)
[8] This sentence is a strong reminder of a similar expression in Zhuangzi:
Dasheng 莊 子． 達 生: “Upon hearing footsteps, the lonely cave dweller is
overcome with joy.” (wen ren zu yin, qiong ran er xi 聞人足音, 跫然而喜). A
similar description of this autistic state of mind is also presented in Suwen
Chapter 49, where it is ascribed to a predominance of yinqi.
[9] runs amok while disrobing: This is a vivid description of a kind of anxiety
neurosis. Suwen Chapter 30 describes a similar situation, where the patient is
disrobing, climbing and chanting and at the same time anorexic. This was
due to disease in the podotelic yang-ming stomachic conduit. (《素問．陽明
 解》). Again in Chapter 49, the same symptoms and the same cause. (《素
問．解篇》)
[10] obstruction of qi flow in the shin: The clinical term is ganjue 骭厥.
[11] futu: 伏 兔, literally “crouching rabbit”, describes the quadriceps on the thigh.
Acupoint ST-32 of the same name lies six Chinese inches above the knee on
the lateral side of the thigh.
[12] frequent hunger: The Chinese term 消 穀 善 飢 xiaogu shanji (facile digestion
of grains and frequent hunger) is a common expression to describe poly-
rexia, an early sign of diabetes mellitus.
[13] movable mass in abdomen: The Chinese character 瘕 jia is often used in
combinations such as zhengjia 癥瘕 (zheng 癥, as in zhengjie 癥結, “a knot”),
and refers to a fixed mass accumulated inside the abdomen, usually in
women. Li Zhong-zi in his annotations explained this as dysentery, because
the character 瘕 jia was bracketed between tang 溏 (loose stool) and xie 泄
(watery diarrhoea), and took this passage to be describing three degrees of
severity in diarrhoea. While jia has multiple meanings, none of them could
be interpreted as “dysentery”. At best, it is a similar situation to pi 癖 which is
due to fluid accumulating on one side of the abdomen. Still it is referring to
a mass like zhengjia (fixed or movable abdominal mass, especially in women).
See ref. 39.
[14] dry pharynx: The Chinese text specifies yigan 嗌乾 (yi 嗌 = yan 咽, “pharynx”,
which is different from kougan (口乾, “xerostomia”).

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 298 Neijing Zhiyao Yigu 內經知要譯詁

[15] obstruction of qi flow in the arm: Bijue 臂厥, the same as [5] above. Both the
cheirotelic pulmonic conduit and the cheirotelic cardiac conduit travel down
the arm.
[16] mucous body fluid: Here the text specifies ye 液 (mucous body fluid) as
different from jinye 津 液 (body fluids in general), in the large intestinal
conduit. In any case, the disturbance can be due to abnormality in fluid
composition and/or distribution in various compartments.
[17] obstruction of qi flow in the ankle: The clinical term is huaijue 踝厥 (huai 踝,
“ankle”).
[18] obstruction of qi flow in the bone: The clinical term is gujue 骨厥.
[19] malfunction of the kidney: According to the “five elements” theory, the
kidney governs the bone (calcium content). Here it is evidently also involving
adrenal function due to the emotive responses.
[20] dysentery: Changpi 腸 澼, “slimy stool in dysentery”. Slimy stool and haema-
tochezia (changpi bianxue 腸 澼 便 血) occurs in Suwen Chapter 28. Pi 澼
(washing); on pingpi 洴 澼 (gently rinsing silk or cotton floss), see Zhuangzi
on the laundry washers who had a secret recipe to protect the hands. (《莊
子．逍遙遊》: 洴澼絖)
[21] flaccid limbs : The clinical term is weijue 痿 厥; wei 痿 (atrophy) refers to
muscular atrophy in the limbs, hence they become “flaccid”, but it is due to
lack of qi flow (innervation?).
[22] obstruction of qi flow in yang conduits: The clinical term is yangjue 陽 厥
because the gall bladder conduit is a yang conduit.
[23] swollen lymph nodes: Madao xiaying 馬 刀 俠(挾 xie)纓 describes a chain of
swollen lymph nodes on the neck like the tassel (ying) of a sabre (madao).
[24] medial ankle: according to Taisu, this should be “medial”, not “outer“ ankle.

[Section 8.5] Suwen Chapter 28: An Overall View on

Diseases of Excess and Deficiency

《素問．通評虛實論》︰邪氣盛則實，精氣奪則虛。

When the evil qi is exuberant, it is a disease of excess; when the qi of essence is

depleted, it is a disease of deficiency.

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 Morbid Manifestations 299

Explanatory Notes
This is the key sentence in Suwen Chapter 28: An Overall View on Diseases of
Excess and Deficiency. Suwen Volume 8 contains 6 chapters; the first three
(Chapters 25–27) discuss the theoretical basis of acupuncture. Chapter 28
covers diseases of excess and deficiency, their presentation, diagnosis by pulse
pattern and prognosis, and cites some examples of special diseases. Only the
last third of the chapter deals with clinical acupuncture guidelines. Chapter 29
covers the spleenic and stomachic conduits, while the latter appear again in
the short Chapter 30. From this heterogeneous volume with an accent on
acupuncture, only the opening sentence of Chapter 28 is excerpted in NJZY.
This statement is the most important consideration after assessing a disease
state in terms of yin-yang. Li Zhong-zi devoted a lengthy commentary (trans-
lated below) to this short excerpt:
“This sentence constitutes the leitmotif of medicine. These words are
standards of reference for ten thousand generations to follow; they are seem-
ingly easy to understand, but their true meanings are profound and difficult
to comprehend.
The evil qi consists of wind, coldness, summer heat, wetness and fire. The
qi of essence is also called the righteous qi (zhengqi) [1]; it is derived from the
[digestion of] cereals.
When this qi [of essence] is exuberant and the evil qi is starting to spread
its influence, a disease of excess is formed. When the pulse is forceful at all the
three sites [of pulse-taking], a pulse pattern of [a disease of] excess becomes
apparent. Purgation is the answer to disease of excess: in severe cases, use
sudorifics, emetics and cathartics; in mild cases, it is enough to diminish the
fire and dissipate the qi [congestion].
When this qi [of essence] is depleted, a disease of deficiency ensues;
the loss of essence [due to sexual indulgence] and blood, physical and
mental stress constitute internal deprivation. Administration of sudorifics,
cathartics, emetics, and cooling agents will lead to external deprivation. When
the pulse is weak at all three sites [of pulse-taking], a pulse pattern of [a
disease of] deficiency becomes apparent. Replenishment is the answer to
diseases of deficiency; in mild cases, use warm tonics, in severe cases, use hot
tonics.
It is lamentable to note that proponents of the teachings of Zi-he [2] and
Dan-xi [3] are prone to use purgatives [whether or not it is a disease of

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 300 Neijing Zhiyao Yigu 內經知要譯詁

excess], while proponents of Dong-yuan [4] and Li-zhai [5] are prone to use
tonics [whether or not it is a disease of deficiency]. Each of them sticks to his
biased view; they can rarely resolve the [clinical] situation with satisfaction.
This is what we call ‘to match the disease with the principle of treatment’; it is
a far cry from applying the principle of treatment to deal with a particular
disease [6].
Those who are skilful with the principles of treatment will find it suffi-
cient to distinguish the true meaning between excess and deficiency. Included
in these words are situations where excess or deficiency is predominant, or
insignificant, and there are also cases of seeming excess or deficiency; they
deserve careful consideration.
When trying to replenish in a case of severe deficiency, use strong-acting
or warm tonics; milder drugs would not be effective. When trying to purge in
a case of severe excess, use quick-acting and potent drugs; slow-acting drugs
may leave the chance for complications to develop. For mild deficiency, use
70% tonics and 30% purgatives, so as to leave one side open (sic) [7] [to cover
a possible element of excess]. For mild excess, use 70% purgatives and 30%
tonics so as to leave one side open (sic) [to cover any unexpected complica-
tion, in case the purgatives are too strong for the case].
When it comes to distinguishing what seem to be cases of excess or defi-
ciency, the whole world [medical community] is totally confused. It is said
that even in extreme deficiency, there are signs of excess; if purgatives are
directed against this element of excess, the treatment will bring opposite
results. Likewise, in extreme excess, there are signs of debility; if tonics are
applied to treat this element of debility, the disease will only get worse. There-
fore, the judgement [of excess or deficiency] must be unambiguous while the
method of treatment must be carefully weighed.
Whether it is a matter of using purgatives to tackle the evil qi, hoping that
the zhengqi will re-establish itself, or of nurturing the zhengqi so that the evil
qi will dissipate of its own accord, there are thousands of different strategies,
but it is central to maintain the integrity of zhengqi. Alas, while the erroneous
application of tonics in a case of excess will necessarily augment the action of
the evil qi, this is a result that could still be redeemed, being the lesser of two
evils. On the contrary, with the erroneous application of purgatives in a case
of deficiency, the genuine qi [8] is exhausted instantly and the result is irrevo-
cable; this is the worst calamity.
All these concern matters of life and death; they are not minor issues.

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 Morbid Manifestations 301

Those who take [a] life in their hands [the medical profession] must exercise
extreme caution.”

This commentary is typical of the rhetoric used in Chinese medicine to

explain the intricacy of symptom analysis (bianzheng lunzhi 辨 證 論 治). It
uses a florid language that conveys the ultimate confidence of a consummate
master in clinical practice. It is nothing short of being dialectical (bianzheng),
the argument is faultless but the conclusion is difficult to apply.
As far as Li Zhong-zi’s commentary is concerned, there are two moot
points.
First, the idea of leaving one side open is projecting a concept of human
virtue onto a medical situation; this approach may not work. In treating
cancer with Chinese medicines, some tonics are often co-administered with
anti-cancer drugs that are necessarily cytotoxic. In pharmacokinetic terms, in
the treatment of tuberculosis, or when administering a course of antibiotics,
one must see to it that the complete course of medication is achieved, other-
wise drug resistance could develop swiftly. Second, there is no way to ascertain
an element of excess in deficiency, or vice versa, or to adjudicate a case of
apparent excess or deficiency, since there is not a quantitative guideline to
judge which way the balance will tip. It has just been argued that Chinese
medicine is solidly evidence-based (See Explanatory Notes in Section 8.4).
This positive statement may perhaps be modified to say that clinical Chinese
medicine is not “quantitatively” evidence-based, because evidence without
quantification is at best descriptive. Li Zhong-zi lost no time in warning that
the prudence of using 70% tonics with 30% purgatives could be readily over-
ridden if a case of genuine deficiency was treated with purgatives. This
descriptive language is difficult to apply under clinical conditions for a new
hand would be very hesitant to adopt a realistic method of treatment correctly.
Quantitative clinical medicine is of course a modern concept, involving labo-
ratory data presented with ranges and means. In ancient times, the judgement
was entirely subjective, though perhaps improved by a great deal of experi-
ence. Thus all the wisdom of Li’s commentary lies in the result, not the predic-
tion. Only a favourable outcome can tell that a diagnosis was correct in the
first place. That makes it very difficult to pass on acquired knowledge in clin-
ical Chinese medicine, and every great master has to reinvestigate the intricacy
of symptom analysis. This accounts for a low rate of reproducibility and rele-
gates Chinese medicine to the realm of art rather than science.

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 302 Neijing Zhiyao Yigu 內經知要譯詁

Footnotes

[1] righteous qi (zhengqi) : According to Li Zhong-zi, the righteous qi (zhengqi

正 氣) consists of the infinitesimal [particles] of essence derived from the
[digestion] of cereals (jing qi ji zheng qi 精 氣 即 正 氣). This is energy
provided by the digestion of carbohydrates. Lingshu Chapter 3: “The right-
eous qi is the spirit.” (shen zhe, zheng qi ye 神 者，正 氣 也). The spirit is the
integrity of the mind, i.e. the ability to react to changes in the environment.
The two statements put together suggest that the righteous qi is the capacity
of the body to adapt to a changing environment with corresponding changes
of the internal environment. In modern parlance, this is the function of the
central nervous system working in harmony with the autonomic nervous
system (which regulates the internal vegetative functions). From the same
source, the evil qi (xieqi 邪 氣) is defined as an exogenous (guest, foreign)
factor that would do harm to the body (ke zhe, xie qi ye 客 者，邪 氣 也).
Zhengqi and evil qi are often used together as a contrasting pair of concepts.
Their reciprocal waxing and waning will decide whether a disease can occur.
Suwen Chapter 33: “For the evil qi to gather together [to show effect], the
[righteous] qi must be deficient.” (xie zhi suo cou, qi qi bi xu 邪 之 所 湊，其
氣 必 虛). This qi must mean the righteous qi (zhengqi 正 氣). (See Section
8.11). In practical terms, the genuine qi (zhenqi 真 氣) is often used as the
dynamic expression of zhengqi. In Lingshu Chapter 75, Huangdi asks what
the difference is between genuine qi (zhenqi), righteous qi (zhengqi ) and evil
qi (xieqi). Qibo answers : “The genuine qi is a natural [genetic] endowment,
it blends with the qi of [derived from the] cereals and fill up the body. [This
is similar to the definition of qi of essence by Li Zhong-zi]. The righteous qi
is the correct wind [climate], it comes from a definite direction [a distin-
guishable climatic pattern]; it is neither excessive nor deficient. The evil qi is
a wind [that induces] deficiency; it strikes deep in men with harmful effect
[i.e. an exogenous pathogen]. … The correct kind of wind [seasonal climatic
conditions] has only limited effect in men; it is mild and supple and cannot
override the genuine qi.” Hence, the absence of zhengqi becomes evident
when the evil qi raises its head. This is tantamount to saying that one
becomes aware of diminishing health (zhengqi) when disease sets in. In
Suwen Chapter 27: “The genuine qi is the qi of the conduits.” (zhen qi zhe,
jing qi ye 真氣者, 經氣也) Qi of the conduits (jingqi) is blood pressure, more
exactly systolic pressure. So for the zhengqi to be dominant, the heart should
beat forcefully (with an adequate energy supply); this dynamic aspect of

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 Morbid Manifestations 303

zhengqi is called genuine qi (zhenqi). In conclusion, the genuine qi (zhenqi) is

the capacity to stay healthy by warding off evil qi (xieqi) as a manifestation
of righteous qi (zhengqi) and the material basis is the qi of essence (jingqi 精
氣) and qi of the conduits (jingqi 經氣, “pulse pressure”).
[2] Zi-he: Zhang Cong-zheng 張 從 正, also known as Zi-he 子 和 (1156–1228),
one of the the four Jin-Yuan clinical masters and founder of the purgative
school.
[3] Dan-xi: Zhu Zhen-heng 朱 震 亨, alias Dan-xi 丹 溪 (1281–1351), one of the
four Jin-Yuan clinical masters and founder of the yin-nourishing school.
[4] Dong-yuan: Li Gao 李 杲, alias Dong-yuan 東 垣 (1180–1251), one of the
four great Jin-Yuan clinical masters and founder of the digestive school.
[5] Li-zhai: Xue Ji 薛 己, also known as Li-zhai 立 齋 (1487–1559), a great Ming
dynasty clinician who produced many authoritative writings, much appreci-
ated by Li Zhong-zi. Xue stressed the importance of spleenic (digestive)
function and heralded in the school of warm tonics.
[6] particular disease: Li Zhong-zi was strongly critical of his incompetent peers
who tried to seek a stereotypical pattern of symptoms that would fit the
“book” (standard method of treatment) (lai bing he fa 賴病合法, “relying on
the disease fitting the rules”) rather than applying the principle of treatment
to each particular clinical case with necessary modification. This bad practice
persists up to this day, sometimes with the clinician asking suggestive ques-
tions to solicit answers that, according to the “book” would fit with a certain
type of disease. Without being too harsh on clinicians of lesser competence,
the reasoning process in symptom analysis is entirely subjective and qualita-
tive; decision making is only aided by an enormous pool of personal
experience.
[7] to leave one side open: The quotation (網 開 三 面 wang kai san mian) comes
from an episode in Shiji: Yinbenji 史 記．殷 本 紀. When King Tang (湯 王)
went hunting, he cornered his prey with nets on one side only, leaving the
other three sides open to escape. This was to extend his benevolence even to
the animals he was hunting (de ji qin shou 德 及 禽 獸), so that they were not
hunted to extinction. Confucius echoed this idea by not fishing with a net
but only a line, and by not shooting a roosting bird that had come home to
rest.19 Today, this aphorism is often written as “leaving one side of the net
open” (wang kai yi mian 網開一面), i.e. to live and let live.

19
《論語．述而》
：「釣而不綱，弋不射宿。」(diao er bu gang, yi bu she su).

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 304 Neijing Zhiyao Yigu 內經知要譯詁

[8] genuine qi: Zhenqi, see Explanatory Notes of this section on zhengqi, zhenqi
and jingqi.

[Section 8.6] Suwen Chapter 62: On Modulation of Qi Flow

in the Conduits

《素問．調經論》曰：帝曰：陽虛則外寒，陰虛則內熱；陽盛則外熱，陰盛
則內寒，不知其所由然也。
岐伯曰：陽受氣於上焦，以溫皮膚分肉之間。今寒氣在外，則上焦不
通；上焦不通，則寒氣獨留於外，故寒慄。
帝曰：陰虛生內熱奈何？
岐伯曰：有所勞倦，形氣衰少，穀氣不盛，上焦不行、下脘不通，胃
氣熱。熱氣熏胸中，故內熱。
帝曰：陽盛則外熱奈何？
岐伯曰：上焦不通，則皮膚致密、腠理閉塞、玄府不通、衛氣不得泄
越，故外熱。
帝曰：陰盛生內寒奈何？
岐伯曰：厥氣上逆，寒氣積於胸中而不瀉，不瀉則溫氣去，寒獨留則
血凝泣，凝則脈不通，其脈盛大以濇，故中寒。

Huangdi said: “Deficiency in yang [qi] will cause surface cold [1]. Deficiency
in yin [qi] will cause internal heat [2]. Exuberance of yang [qi] produces heat
on the body’s surface [3], exuberance of yin [qi] produces internal cold [4].
What is the reason?”
Qibo said: “Yangqi is generated by the upper burner, it warms the skin
and the muscles. Now that coldness remains on the body’s surface, the upper
burner is not operative. Since the upper burner is inactive, the body’s surface
remains cold. That is why one shivers.”
Huangdi said: “Why is there internal heat when yin [qi] is deficient?” [5]
Qibo said: “Being worn out physically, the body form degenerates, qi
becomes inadequate, and digestion is ineffective. Consequently, the upper
burner is inoperative, the pyloric sphincter [6] is closed [so that food cannot
pass through to the intestines], and the stomach function is blocked, trapping
heat. Heat is fuming in the chest, giving rise to internal heat.”

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 Morbid Manifestations 305

Huangdi said: “Why is there heat on the body’s surface when yang [qi] is
exuberant?”
Qibo said: “If the upper burner is inoperative, the body’s surface is tightly
knitted and the subcutaneous striae are closed, so that the sweat pores [7] are
clogged. Consequently, the defensive qi [weiqi] cannot dissipate through the
skin, causing heat on the body’s surface.”
Huangdi said: “Why is there internal cold when yin [qi] is exuberant?”
Qibo said: “In turbulent qi flow, it goes upward. Cold gathers in the chest
and can be drained nowhere. Since it cannot be drained, warmth (yangqi) will
dissipate, leaving coldness behind so that blood thickens [8]. With thickened
blood, the conduits are not free flowing, and that makes the pulse strong but
hesitant, because the interior of the body is cold.

Explanatory Notes
There are two volumes in Suwen in which each contains only one chapter
(Chapter 62 in Volume 17 and Chapter 74 in Volume 22). The topic of
Chapter 62 is sufficient in itself to give an idea of pathogenesis. (Chapter 74 is
on climatic cycles). Huangdi is curious why are there hotness or coldness that
affect only the surface of the body, or the interior of the body, without
affecting the whole body. Huangdi admits that he is well aware that the media
of vitality are the essence, the qi and the body fluids that permeate all parts of
the body such as the limbs, the nine apertures (sensory organs), the five zang-
organs, the 16 compartments [9] and 365 articulations. If these media are
displaced towards a state of either deficiency or excess, disease ensues. By
regulating the qi flow to these body parts, and in particular the five zang-
organs, through replenishment or purgation, that depend on certain tech-
niques in needle manipulation, diseases can be cured. Qibo explains that it
can all be reduced to five domains of excess and five domains of deficiency.
These stem from the magnitude of qi flow in the five zang-organs that deter-
mine the level of spirit shen 神, that resides in the brain, qi 氣 (the lung), xue
血 (the heart), xing 形 (the spleen) and zhi 志 (the kidney). The modus oper-
andi of the five zang-organs is inherent in their connection through the
conduits (here the term jingsui 經 隧 is actually visualising the conduit as a
tunnel) in which flow the blood and qi (the force that drives blood flow). If
the dynamics of this flux are not harmonious, hundreds of diseases might
arise out of these changes. Towards the end of the chapter, Qibo adds that

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 306 Neijing Zhiyao Yigu 內經知要譯詁

while the zang-organs represent the five principal physiological systems, each
of them form a functional pair with a certain fu-organ (wu zang yu liu fu wei
biao li 五 臟 與 六 腑 為 表 裡). Since the performance of the fu-organ can be
readily observed as surface signs and evaluated by pulse-taking, the perform-
ance of the zang-organ can be assessed. It is also important to note that in this
chapter, Qibo recognises that the rise of the evil qi (xie 邪, “pathogen”) is due
to external factors like inclement weather (belonging to the yang category) or
idiopathic factors like an irregular life style and emotional stress (belonging to
the yin category). Taken as a whole, the entire chapter can stand alone as a
treatise on pathogenesis that is based on three premises:

1) Sources of evil qi (pathogens) affect distribution of vitality media in

the zang-organs.
2) Zang- and fu-organs form internal-external pairs.
3) Diagnosis by pulse-taking.

If the relationship between these three premises could be established, it

follows naturally that through regulating the flux of qi by acupuncture, the
optimal plenitude of the vitality media in the zang-organs could be re-estab-
lished. While the main substance of Suwen Chapter 62 deals with the disease
state of excess or deficiency, which serves to amplify the discussion in Section
8.5 but is not excerpted by Li Zhong-zi, Section 8.6 focuses its attention on
other disease states in terms of interior and exterior, cold and heat and their
four combinations. These six cardinal parameters are differentiated into two
groups, viz.
yin : deficiency, cold, interior
yang : excess, heat, exterior
This concept of disease categorisation as a “disease state“ (bingtai 病 能),
is quite different from the nosological approach in Section 8.4 that hinges on
the immediate cause or principal symptom. It soon became the main
reasoning process in disease categorisation in routine clinical practice but it
was not acknowledged in writing until Cheng Guo-peng 程 國 彭 (1679–?) in
his Yixue xin wu 醫 學 心 悟 (Enlightenment in Medicine), published in 1732.
While acknowledging the primary importance of the teaching of Zhang
Zhong-jing, who proposed the “disease categorisation by the six conduits” (liu
jing bian zheng 六 經 辨 證) that dominated clinical Chinese medicine ever
since its first appearance in the third century, Cheng quietly added in his book,
which is largely clinical, a short paragraph on disease categorisation (bianzheng

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 Morbid Manifestations 307

辨 證 ) by these eight cardinal parameters. However, the term “ba gang

bianzheng” 八綱辨證 was becoming popular largely through teaching Chinese
medicine in colleges. This idea was immediately consolidated, but sketchily,
in the following paragraph, Yi men ba fa 醫門八法 (The Eight Principal Rules
in the Practice of Medicine), in which the eight main therapeutic approaches
(hidrosis, catharsis etc.) were postulated. “Disease categorisation by the eight
cardinal rules” and the “eight principal therapeutic approaches” have consti-
tuted the core of clinical Chinese medicine up to this day, although many
practitioners are not concerned with the source of reference, dazzled as they
are by the celebrity of Zhang Zhong-jing and his teaching.

Footnotes

[1] surface cold: Waihan 外 寒 is due to an inadequate supply of yangqi to the

body’s surface as a result of reduced thermogenesis (the upper burner being
inoperative) or inadequate hypodermal circulation. In homeotherms like the
human body, heat is constantly dissipated through the body’s surface to the
environment. If the heat loss is not compensated for by an increase in energy
metabolism (yangxu 陽 虛), there will be aversion to cold, and in extreme
case, shivering, a reflex action to activate the muscles for heat production.
[2] internal heat: Neire 內 熱 is a mild fever without any outward signs of fever.
It is associated with consumptive diseases that persistently challenge the
body for physiological compensation. It is typical in tuberculosis, rheuma-
tism, helminthiasis, tumours, bacterial/viral infections and other chronic
diseases. The inflammatory process that accompanies these diseases involves
the release of cytokines from macrophages, monocytes and leukocytes; they
were previously described as endogenous pyrogens. It is amazing to think
that ancient practitioners conceived the idea that internal heat (neire) could
be mediated by an endogenous factor/substance. To differentiate internal
heat from fever caused by exposure to cold (shanghan), they noted that
internal heat was a mild fever that came often in the afternoon (wu hou chao
re 午後潮熱) or at night (yere 夜熱) and was localised in the palms and soles
or the chest (wu xin fan re 五心煩熱). The mouth tasted bitter and urine was
short-streamed and discoloured. It is the most worrying condition among
the four combinations of exterior/interior and cold/heat. In the following
paragraph, Qibo ascribes the internal heat to an over-worked stomach (weiqi
re 胃氣熱), with the heat of a fuming stomach congested in the chest (gastric
ulcer?). Alternatively, weiqi re could be due to stomach retention and the

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 308 Neijing Zhiyao Yigu 內經知要譯詁

gastro-oesophageal reflex which causes heart-burn was conceived of as a

kind of internal heat. Neire could have been a common disease in Neijing
times. Suwen Chapter 47 Qibing lun 奇 病 論 pinpoints the cause of diabetes
mellitus (xiaoke 消 渴) in obese people as the result of overfeeding that
produced “internal heat” (neire 內熱).
   Zhuangzi described a certain Zhang Yi, who was a broker of power in the
community for rich and poor alike, and died of “neire” at the age of 40.
Zhuangzi lamented the fact that such a resourceful person, who took great
care of his outside but neglected his inside, must die of an internal disease
over which he had no control.20 Zhuangzi mentioned neire on three other
occasions, all in the context of a serious clinical case other than debility (see
Zeyang 則 陽 and Renjian shi 人 間 世). Perhaps it was a consumptive disease
with low tidal fever.
[3] heat on the body’s surface: Waire 外 熱 is due to increased thermogenesis or
hypodermal circulation where the skin is hot to the touch. Consequently,
more heat is lost than necessary to maintain homeothermia. In the following
paragraph, Qibo ascribes the surface heat to a default in thermoregulation
(sweating and hypodermal circulation).
[4] internal cold: Neihan 內 寒 is a result of the systematic degeneration of
organic functions, and in particular adrenal deficiency. Body fluid distribu-
tion is unbalanced, and there is an accumulation of metabolic products that
cannot be dispelled. There will be colic pains, diarrhoea or emesis, oedema,
accumulation of phlegm, and cold limbs. In severe cases, there is a drop in
core temperature. Qibo ascribes this situation to circulation failure and body
fluid retention.
[5] internal heat: “Yin deficiency generates internal heat” (yin xu sheng neire 陰
虛 生 內 熱). This quotation is famous in Chinese medicine. It refers to a
much dreaded clinical situation where “yin” means the vitality media. It is
also called “virtual fever” (xure 虛熱).
[6] pyloric sphincter: The Chinese text has “lower stomach” (xiawan 下 脘), i.e.
the pyloric sphincter. Gastric emptying depends on a number of humoral
factors and reflex actions that control the relaxation of the pyloric sphincter.
[7] sweat pores: The Chinese text has xuanfu 玄 府, literally ‘‘obscure mansion”,
because sweating comes from seemingly minute and obscure compartments
in the skin.

20
《莊子．達生》︰「張毅四十而有內熱之病以死。」

Neijing.indb 308 2010/2/26 6:59:22 PM

 Morbid Manifestations 309

[8] blood thickens: If coldness in the chest could cause thickening of the blood,
meaning a hypercoagulative state, the likely sequelae would be myocardial
infarction. Depending on the size of the infarct, there are several eventuali-
ties. The patient may suffer sudden death, which is presumably not the case
in Huangdi and Qibo’s thinking because they were commenting on the pulse
pattern. Or, the patient may lapse into congestive heart failure, a hypometa-
bolic state but not necessarily hypothermic, as peripheral vasoconstriction
and accumulation of oedematous fluid under the skin serve to insulate the
body against heat loss. In congestive heart failure, the doctor should not
expect a strong pulse to be palpable. The third scenario is that the infarct is
small or even “silent” clinically, but the ischaemic myocardium is susceptible
to ventricular arrhythmia. It is possible to detect a strong but hesitant pulse,
in runs of ventricular premature beats. (Comments by Dr. W. F. Pau)
[9] 16 compartments: They are the arms and legs, nine apertures and five zang-
organs, which together add up to 16 (according to Wang Bing). Alternatively,
this refers to the 16 principal body regions (functions) governed by the 16
principal conduits, i.e. 12 regular, Ren and Du, and two Qiao conduits. The
latter statement seems to be more reasonable as the original text mentions
“four limbs, nine apertures and five zang-organs”. (《素問．調經論篇》「
: 五
臟五脉矣。」)

[Section 8.7] Lingshu(?): Chapter on Modulation of Qi Flow

in the Conduits

《靈樞．調經篇》曰：因飲食勞倦損傷脾胃，始受熱中，末傳寒中。

Due to a wrong diet or physical exertion, the [functions of] the spleen and
stomach are damaged. In this case, disease will first appear as heat [1] in the
middle burner. [If the situation aggravates], it will eventually turn into cold [2]
in the middle burner.

Explanatory Notes
This excerpt is not to be found in Lingshu or Suwen. Neither Zhang Deng-ben
nor Qin Bo-wei could account for the source of this quotation, even though it

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 310 Neijing Zhiyao Yigu 內經知要譯詁

was accepted as an inadvertent insertion by Li Zhong-zi, or by later editors of

NJZY. First of all, Li refers to excerpts from Suwen as “lun” 論 (“discourse”,
which has here been translated as “On a certain subject”) and those from
Lingshu as “pian” 篇 (chapter). In fact, the majority of the 81 chapters in
Suwen are entitled “xxx Lun Pian” (e.g. Shanggu tianzhen lunpian diyi 上 古 天
真 論 篇 第 一 (“Discussion on Genuine Nature in Remote Antiquity”, Chapter
1). In Suwen, “lun” refers to the dialogue between Huangdi and Qibo (and in
the last seven chapters, between Huangdi and Leigong). There are only nine
chapters that are entitled “pian”. Annotators like Gao Bao-heng and Lin Yi
have explained that these chapters were statements of fact rather than records
of discussions, so it was not appropriate to call them “discourses”. In fact, the
contents of Chapters 30 and 54 (“pian” only) are still in the form of a dialogue
between Huangdi and Qibo. Furthermore, Suwen Chapters 2, 48, 55 and 59
are entitled “lun pian” but in fact do not constitute a form of dialogue. In spite
of this minor inconsistency, all other chapters from Suwen are entitled “lun
pian”. This is in stark contrast with the material from Lingshu, in which all
chapters carry a terse title, mostly of two key words, such as “Jingmai dishi” 經
脉 第 十 (“Conduits Number 10”). If Li Zhong-zi took the liberty of entitling
the excerpts from Lingshu “pian”, in order to distinguish them from excerpts
from Suwen (“lun”), he must have been aware that there was no chapter in
Lingshu that talked about modulation of qi flow in the conduits like Suwen
Chapter 62: On Modulation of Qi Flow in the Conduits (Tiaojing lunpian 調 經
論 篇) (Section 8.6). Of the 81 chapters in Lingshu, only 11 chapters are not
records of discussions between Huangdi and Qibo, while in 17 chapters, with
Leigong etc. (some chapters have both Qibo and Leigong). According to the
convention in Suwen, these non-dialogues (statements of fact) could be placed
in the same category as “pian”; but these chapters do not touch on qi modula-
tion. That raises the question as to what editions of Suwen and Lingshu Li
Zhong-zi used as the source of his excerpts.
After Wang Bing compiled Suwen by his own efforts in 762, this edition,
as revised by the official Bureau for Emendation and Annotation of Medical
Classics, had a preface added by its editors-in-chief, Gao Bao-heng and Lin Yi,
in 1057. This is the Northern Song edition entitled Chongguang buzhu
Huangdi Neijing Suwen 重 廣 補 注 黃 帝 內 經 素 問 (Chongguang buzhu, “once
again broadly amended and annotated …”). Based on an authentic copy of
this Northern Song edition, Gu Cong-de 顧 從 德 undertook a re-carving of
the woodblocks for the text in 1550, the so-called “Gu edition” (Gu ben 顧 本).

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 Morbid Manifestations 311

Today this is the most widely circulated and authentic source reference for
Suwen. Li Zhong-zi must have been able to consult this edition when he first
published his NJZY in 1642. This original edition of NJZY was lost and a copy
(not necessarily of the original) resurfaced in 1764, for which Xue Xue pref-
aced and promoted its reappearance. When it was reprinted in 1933 by The
Commercial Press, the editor Xie Guan 謝觀, a notable clinician, educator and
editor in the field of Chinese medicine, did not remark on this excerpt, which
did not appear in Lingshu. As to Lingshu, an authentic version was not avail-
able until 1155, when Shi Song 史 崧 from what is now Chengdu 成 都, took
the trouble to release an edited version, based on an ancient copy in his family
library. This edition was reproduced by a member of the royal family (趙 府 居
敬 堂 本, “the Ju Jing Tang edition”) during the Jiajing reign-period (1522–
1566). This coincided with the publication of the “Gu edition” of Suwen.
Therefore it is probable that reliable source references for both Suwen and
Lingshu were available to Li Zhong-zi. In the 1933 reprint of NJZY, one can
see that Li Zhong-zi took this excerpt very seriously and elaborated on its
context with a lengthy annotation. The unaccountable source of this excerpt is
a significant fault in the integrity of the bibliography in NJZY, although it
should not reflect on the sincerity of Li’s contribution to popularising the
study of Neijing.

Footnotes

[1] appear as heat: The middle burner is involved with digestion and metabo-
lism. When it overworks, it becomes hot (rezhong 熱中). Overfeeding dimin-
ishes digestive function. When a disease emerges, the patient tries to take
tonics to fortify the body, but this is often counterproductive, as tonics are
rich food and a diseased body has a reduced capacity to digest and metabo-
lise food. Consequently there will be food stasis. A proper diet and an
adequate supply of nutrients are the central tenets of the Digestive School
(Butu pai 補 土 派). It is a common practice in Chinese families to observe
food taboos when sick. For an emerging cold (flu), for instance, the Chinese
will avoid sweet and greasy foods (which are high in energy and hard to
digest). Perhaps “heat” is an over-generalisation that may include heart-burn
and gastric ulcer. In the latter case, bacterial infection is involved, ascribable
to a wrong diet (See Section 8.28 on gastric boils). Stress would also affect
digestion, causing non-ulcer dyspepsia. This is included under physical
exhaustion.

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 312 Neijing Zhiyao Yigu 內經知要譯詁

[2] turn into cold: How can a disease with hot symptoms eventually turn into
cold? In this case, it is indigestion. When a person eats badly and becomes
anorexic, he eats selectively and minimally. Inflammation of the stomach
turns into atrophic gastritis. Decreased acid secretion (hypochlorhydria and
then achlorhydria) impairs iron absorption, and this leads to iron-deficient
anaemia. In severe cases, it could evolve into Addisonian pernicious anaemia.
Anaemia can be construed to mean a cold condition. ([1] and [2] are
comments from Dr. Pau.)

[Section 8.8] Suwen Chapter 19: On a Comparison between

Normal Pulse Patterns and Critical/Moribund Pulse Patterns

《素 問．玉 機 真 藏 論》曰：脈 盛、皮 熱、腹 脹、前 後 不 通、悶 瞀，此 謂 五

實；脈細、皮寒、泄利前後、飲食不入，此謂五虛。漿粥入胃，泄注止，
則虛者活；身汗，得後利，則實者活。

When the pulse is robust, the skin is hot to the touch and the abdomen is
bloating. There are anuria and constipation, dizziness and blurred vision. This
belongs to the “five signs of grave excess”.
When the pulse is feeble, the skin is cool to the touch; there is inconti-
nence behind and in front [1] and dysphagia. This belongs to the “five signs of
grave deficiency.”
With gruel and porridge [2] entering the stomach, incontinence of both
kinds will stop; patients suffering from diseases of deficiency will recover. If it
is possible to induce sweating and there is no difficulty in defecation, patients
suffering from diseases of excess will recover.

Explanatory Notes
The importance of Suwen Chapter 19 in detecting moribund pulse patterns
has been explained in Section 4.7 (see above). This is devoted to the discus-
sion of a genuine zang-organ specific pulse pattern that is devoid of a stomach
component (weiqi). The present excerpt is the last paragraph in the chapter.
Since genuine zang-organ specific pulse patterns are moribund pulse patterns
that are detectable when all five zang-organs fail, Huangdi wishes to know
what the signs (hou 候) of moribund diseases are in terms of excess or

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 Morbid Manifestations 313

deficiency (xu shi yi jue sheng si 虛 實 以 決 生 死). Qibo is of the opinion that
when these five signs of grave excess or deficiency appear simultaneously, it
indicates multiple organ failure and the patient is sure to die. Li Zhong-zi
identified the five signs as follows:

Organ Excess Deficiency

Heart strong pulse weak pulse
Lung skin hot to the touch skin cool to the touch
Spleen bloating cannot hold food
Kidney anuria and constipation diuresis and diarrhoea
Liver blurred vision and dysphoria short of breath

Since weiqi (stomach qi, normal digestion and absorption) is the basis of
a dynamic normal pulse pattern, the present section illustrates the integrity of
digestive function as a kind of litmus test for a fair prognosis. When a very
sick person can ingest a mouthful of porridge, there will be a favourable prog-
nosis because the “rice qi (energy from rice) arrives” (colloquially, mi qi dao
米氣到). See also Section 8.33 on prediction of the timing of the last moment.

Footnotes
[1] incontinence behind and in front: This refers to total loss of autonomic
nervous control.
[2] gruel and porridge: when the patient is very sick, there is negative energy
balance. It is important to maintain a minimum energy supply. This is often
achieved in the form of cereal-based thin liquid food. A handful of whole-
grain rice (with rice germ) is boiled to give a thin soup (porridge), then the
clear supernate, commonly called supreme rice soup (miwang tang 米 王 湯),
is skimmed off. (Miwang, literally “king of rice”, refers to the rice germ).
Alternatively, the rice grains are ground into flour from which a thin gruel21

21
gruel: 漿 粥. A thick gruel is zhou 粥 (porridge or congee), a thin gruel is jiang 漿.
Suwen Chapter 1: yi jiu wei jiang 以 酒 為 漿, “drink wine like gruel”. In the old days,
before the perfection of the cooking pot, cereals were consumed mainly as a thick
gruel. This was the staple diet. Therefore bingeing in fermented cereal products
instead of gruel was an indulgence that led to the downfall of many rulers.
(Zhanguoce, Wei er: yi di zhi jiu, hou bi you yi jiu wang guo zhe 戰 國 策．魏 二：儀
狄製酒，後必有以酒亡國者).

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 314 Neijing Zhiyao Yigu 內經知要譯詁

is prepared. By the same token, when reviving a cholera victim, one can rehy-
drate the patient with such a thin rice soup with salt added to it.

[Section 8.9] Suwen Chapter 39: On Pain

《素問．舉痛論》曰：帝曰：余知百病生於氣也，怒則氣上，喜則氣緩，悲
則氣消，恐則氣下，寒則氣收，熱則氣泄，驚則氣亂，勞則氣耗，思則氣
結。九氣不同，何病之生？
岐伯曰：怒則氣逆，甚則嘔血及飧泄，故氣上矣；喜則氣和志達、榮
衛通利，故氣緩矣；悲則心系急、肺布（佈）葉舉而上焦不通、榮衛不散、
熱氣在中，故氣消矣；恐則精却，却則上焦閉，閉則氣還，還則下焦脹，
故氣不行矣；寒則腠理閉、氣不行，故氣收矣；炅則腠理開、榮衛通、汗
大泄，故氣泄矣；驚則心無所倚、神無所歸、慮無所定，故氣亂矣；勞則
喘息汗出、外內皆越，故氣耗矣；思則心有所存、神有所歸、正氣留而不
行，故氣結矣。

Huangdi said: “I know all diseases are caused by [disturbance of the righteous]
qi [1]. The qi surges upward when one is angry, slackens when one is joyful,
dissipates when one is sad, sinks [is unable to rise] when one is apprehensive,
condenses [is unable to disperse] when one is cold, leaks [out of the body]
when one is hot, unsettles when one is frightened, depletes when one is tired
and entangles when one is pining. These nine modes of qi movement are
different: what disease will come out of them?”
Qibo said: “When one is angry the flow of qi is turbulent, and in severe
cases one will be spitting blood (haematemesis) and passing undigested grains.
It is because qi surges upward. When one is joyful, the flow of qi is peaceful
and the mind is free of worries, both the nourishing qi (rongqi) [1] and the
defensive qi (weiqi) are smooth flowing, so qi flow slackens. When one is sad,
the connection of the heart with other organs are tense [inadequate supply of
blood], the lung expands and the lobes are raised, [thus compressing] the
upper burner [that] is now not thoroughly operative, rendering the nour-
ishing qi and the defensive qi unable to disperse, thus trapping the heat in the
chest, compromising the [beneficial effect of the righteous] qi. When one is
apprehensive, the qi of essence (jingqi) withdraws and becomes unavailable;
since the qi of essence regresses, the upper burner is occluded, forcing the

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 Morbid Manifestations 315

[righteous] qi to seek an outlet through the lower burner that is now bloating.
In this case, the normal upward flow of [righteous] qi is blocked. When one
feels cold, the subcutaneous striae are serried. The [righteous] qi cannot
disperse [through the skin] and condenses. When one is feverish, the subcuta-
neous striae are widely porous, the nourishing qi and defensive qi are free
flowing, and one will sweat profusely. That is why the [righteous] qi is leaking
out of the body. When one is frightened, the heart feels unsettled, the mind
cannot concentrate, and thoughts run wild; therefore the flow of [righteous]
qi becomes turbulent. When one is tired, panting for breath and sweating, the
[righteous] qi is consumed inside as well as dissipated out of the body; it will
become depleted. When one is pining eagerly and the mind is focused intently
on something, the [righteous] qi stagnates and [its flow] becomes entangled.

Explanatory Notes
Suwen Chapter 39 is a concise treatise on pain. The key word in the title (Ju
tong lun 舉痛論), is ju, which literally means “lifting” or “listing”, hence listing
all kinds of pain. This is however excerpted in Section 8.22. The present
section does not deal with pain in the strict sense. It is talking about qi distur-
bance as the ultimate cause of all kinds of diseases. This “qi” is presumably the
zhengqi, the righteous qi, the capacity of the body to maintain itself in a state
of dynamic equilibrium in face of constantly changing external and internal
environments. In physiological terms this is homeostasis, or the capacity for
physiological compensation. In Chinese medicine, it is called qiji 氣機 (literally
“mechanism of qi”, but here actually “movement of qi”). The term qiji is a
heavily loaded one. Zhuangzi used it to mean, in a broad sense, vitality, i.e. the
balance between yinqi and yingqi. There is also the term bingji 病 機 (patho-
mechanism) that has been dealt with in Section 7.1.
The present section lists nine immediate causes that could disrupt the
smooth flow of zhengqi (bai bing sheng yu qi 百 病 生 於 氣). Of these, six are
emotional, two are environmental (ambient temperature) and only one is due
to life-style (tiredness). Since qi, or one aspect of zhengqi, is the dynamic force
that propels blood in circulation, disruption in qi flow will necessarily disrupt
blood flow in the conduits (mai). It follows that where blood supply is inade-
quate, there will be pain. This last paragraph in the chapter serves to justify
the 14 clinical situations when blood supply is cut due to the invasion of cold
(hanqi). This is not exactly the cold evil qi (hanxie, “cold exposure”) as a

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 316 Neijing Zhiyao Yigu 內經知要譯詁

causative factor in pathogenesis. Cold qi (hanqi) is actually describing a state

of circulatory failure that will be discussed in further detail in Section 8.22.
Suffice it to quote here the opening paragraph of Suwen Chapter 39, where
Huangdi asks Qibo if it is true that genuine knowledge can be verified on
oneself (yan yu ji 驗於己). Qibo is taken aback by this lofty question and does
not know exactly what to answer. So Huangdi reduces his query to the ques-
tion of what kind of qi would cause acute pain in the five zang-organs. Qibo
replies firmly that: “Blood flows in the vessels, circulating [huan zhou 環 週,
an early idea of closed-circuit blood circulation] incessantly. When the cold qi
(hanqi 寒 氣) attacks the vessels, the blood flow will become sluggish or even
stop altogether. If the hanqi remains outside the blood vessels [vasoconstric-
tion?], there will be diminished blood flow. If the hanqi resides inside the
blood vessels [increased viscosity?], qi cannot pass through [no pulsation].
That is the reason for acute pain.” Having defined the genesis of pain, the
chapter develops into detailed descriptions of the 14 kinds of pain caused by
an invasion of hanqi, in a long passage quoted in Section 8.22. But it is note-
worthy that Qibo goes on to explain: “Pain can be visualised. In relevant
regions on the face representing the organs [see Section 3.2, wu se ge jian qi bu
五 色 各 見 其 部], yellow and red indicate heat, white [pale, pallid] indicates
cold, blue and black indicate pain.” This is apparently referring to vasodilation
(red, heat), vasoconstriction (white, cold) and blood stasis in circulation
failure (blue/black, cyanosis). (This is assuming the afflicted organ is linked to
the surface area with conduits). While the present section provides a theoret-
ical premise for the genesis of pain, and Chapter 39 lists 14 cases of pain due
to circulation failure (which is probably the most common cause of pain in
internal medicine), the most significant information derived from these two
sections, which account for nearly the entire chapter in Suwen, is the fact that
mai is construed to mean the conduit in blood circulation, which is propelled
by qi (pulse pressure). The movement of qi to maintain a certain range of
blood pressure is qiji, or simply “qi” in this section. It is small wonder that
emotional stress, temperature insult and physical exhaustion can profoundly
affect blood pressure, and hence blood supply to the organs.

Footnote

[1] nourishing qi (rongqi): Rongqi 榮 氣 is the same as yingqi 營 氣, e.g. both

rongyang 榮養 and yingyang 營養 mean “nourishment”.

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 Morbid Manifestations 317

Addendum by Dr. W. F. Pau

On anger (nu ze qi ni 怒則氣逆)
It is commonly believed that acute psychological stress can cause exacer-
bation of peptic ulcer, thereby providing an explanation for haematemesis.
This is supported by the occurrence of gastric erosion in patients suffering
from burns or head inury. It is also true that emotion can upset gastrointes-
tinal motility, as in irritable bowel syndrome, in which shortening of intestinal
transit (see also intestinal wind in ibid. 8-10-17) can lead to the passing of
undigested food in the stool. But what determines the upsurge of qi as
abnormal and the downward flow of qi as normal, Qibo does not explain.
There is a situation described later in the paragraph where apprehension (kong
恐) prevents qi from flowing upwards into the upper burner, thereby forcing
it to seek an outlet through the lower burner.

On joy (xi ze qi huan 喜則氣緩)

This seems to be a desirable situation, if all kinds of qi are in equilibrium
with one another. Therefore, it is surprising that Zhang Deng-ben interpreted
this slow flow of qi as unphysiological (ref. 1). Apparently he warned that a
person should control his emotion even in moments of joy, in order to
conserve zhengqi 正氣.

On sadness (bei ze xin xi ji 悲則心系急)

Xinxi 心 系22 may be interpreted as increased heart rate and increased
peripheral resistance, manifestations of an over-reactive sympathetic nervous
system, which is what sadness would induce. Sympathetic stimulation would
favour bronchial dilatation, and thus better ventilation of tidal volume.
Whether this makes the upper burner more, or less, congested, is a matter of
opinion.

On apprehension (kong 恐)
Here the qi of essence withdraws. The upper burner is occluded, forcing
the qi to seek an outlet downwards. If qi stands for blood flow, occlusion of

22
Author’s note: In Chinese medicine, xinxi 心 系 refers to all the systemic arteries
linked to the heart, supplying the other four zang-organs. See Wang Hong-han,
Origin of Medicine [ibid. 6-1-1].

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 318 Neijing Zhiyao Yigu 內經知要譯詁

the upper burner would mean impediment of the central venous return. Such
a state occurs in several clinical situations: congestive heart failure, cor pulmo-
nale, constrictive pericarditis, tricuspid valve incompetence, or pulmonary
embolism. Apprehension could certainly precipitate these serious situations. If
qi stands for a smooth flow of essence along the conduits, occlusion of the
upper burner would interrupt the podogenic spleenic, hepatic and renal yin
conduits, resulting in massive turbulence of qi. If qi stands for the ability of
the constitution to react promptly to changes in the internal environment,
then qi withdrawal (jingque 精 卻) would mean the body is unable to mount a
sympathetico-adrenal response through the secretion of catecholamines, a
serious situation. Qibo’s explanation sounds unphysiological because fear or
apprehension prompts the “fight or flight” response.

[Section 8.10] Suwen Chapter 42: On Wind

《素問．風論》曰：風者，善行而數變。腠理開則洒然寒，閉則熱而悶。其
寒也則衰飲食，其熱也則消肌肉，故使人怢慄而不能食。

風氣與陽明入胃，循脈而上至目內眦。其人肥，則風氣不得外泄，則
為熱中而目黃；人瘦，則外泄而寒，則為寒中而泣出。

風氣與太陽俱入，行諸脈俞，散於分肉之間，與衛氣相干，其道不
利，故使肌肉憤月真而有瘍；衛氣有所凝而不行，故其肉有不仁也。
癘者，有營氣熱胕，其氣不清，故使其鼻柱壞而色敗、皮膚瘍潰。風
寒客於脈而不去，名曰癘風。

風中五藏六府之俞，亦為藏府之風；各入其門戶所中，則為偏風。

風 氣 循 風 府 而 上，則 為 腦 風；風 入 系 頭，則 為 目 風，眼 寒；飲 酒 中

風，則為漏風；入房汗出中風，則為內風；新沐中風，則為首風；久風入
中，則為腸風，飧泄；外在腠理，則為泄風。故風者，百病之長也。至其
變化乃為他病也，無常方，然致有風氣也。

[Diseases caused by] “wind” [1] are prone to migrate and have multiple forms
of presentation [2]. If the subcutaneous striae are loose, one feels briskly cold
[3]; if tight, one feels hot and suffocating. When [the “wind” is] cool, there
will be loss of appetite; when hot, there will be muscle wasting. These

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 Morbid Manifestations 319

alternating attacks of hot and cold [“winds”] will make one dispirited [4] and
anorexic.
If “wind” penetrates the podotelic stomachic yang-ming conduit, it will
follow the course of the conduit and reach the inner canthus of the eye [5]. In
this case, for an obese person, the “wind” cannot exit, so that heat is trapped
inside the body and the eye turns yellow. For a thin person, the “wind” exits
out of the body and he feels chilly while tears flow.
If “wind” penetrates both [cheirogenic small intestine and podotelic
urinary bladder] tai-yang conduits, it will go to the shu acupoints [6] of these
conduits and distribute itself among the muscles. There the “wind” confronts
the defensive qi, obstructing its normal flux. This will make the [affected]
muscles swell abruptly [7] and become ulcerative. Because the defensive qi is
prevented from flowing freely, the muscles affected will suffer from loss of
sensation.
Leprosy [8] is due to heat congestion in the nourishing qi, causing tissue
putrefaction. The qi [air] is foul [in the lung], resulting in collapse of the nasal
ridge [saddle nose], discoloration [9] and lesions on the skin. This is because a
cold “wind” resides in the blood vessels and refuses to go away; it is called the
ferocious wind [10].
When “wind” strikes the five potency-level acupoints of the regular
conduits, it becomes a “wind” disease typical of the relevant zang- or fu-organ
afflicted. When it enters through these shu acupoints it becomes a localised
“wind” disease [11].
When “wind” enters the acupoint fengfu [12] and goes up to the brain, it
becomes “cerebral wind” [disease] [13]. When “wind” enters the head and its
affiliated organs, it becomes “ocular wind” [disease] [14] because the eyeballs
feel cold. When one is stricken by the “wind” after heavy drinking, this is a
“leaking wind” [disease] [15]. When “wind” strikes while one is sweating after
intercourse, it becomes an “internal wind” [disease] [16]. When “wind” strikes
soon after bathing, it becomes “cephalic wind” [disease] [17]. When “wind”
lingering among the muscles eventually penetrates the guts, it becomes “intes-
tinal wind” [disease] (haematochezia); [in this case] undigested grains pass
out [18]. If “wind” stays all the time in the subcutaneous striae, it is a “seeping
wind” [disease] [19]. Therefore, “wind” is the primary cause of hundreds of
kinds of diseases [20]. Wind-induced diseases will evolve to become other
kinds of diseases. There is no regular pattern of presentation; the only
common cause among them is [some aspect of] “wind”.

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 320 Neijing Zhiyao Yigu 內經知要譯詁

Explanatory Notes
Suwen Chapter 42: On Wind is the first of four chapters that constitute Vol. 12.
These are four special topics, like specialties in clinical medicine, that deserve
particular attention. They are Chapter 42: On Wind (wind-induced disease);
Chapter 43: On Arthralgia; Chapter 44: On Atrophy and Chapter 45: On
Obstruction of Qi Flow. They are all excerpted in Chapter 8 of NJZY. Although
each topic is represented by one key word such as “wind”, or “atrophy”, they
are actually covering a broad range of morbid manifestations of which the
only thing in common is some aspects of “wind”, or the consequence of “wind”
action. Of these, the “wind” is the most complicated as it is also one of the six
evil qi (xie 邪, “excesses, abuse”), the causative factors in pathogenesis.
Wind is air movement and air is our immediate environment, just as
water is for fish. We only have to imagine how a fish could survive in foul
water and we will realise the harm it may cause us to breathe in polluted air. It
is not surprising that lung cancer is so common, even for non-smokers who
suffer from an environment of pollutants produced by the smokers. In this
section, “wind” is always put between quotation marks, implying that it is
more than the physical wind, a whiff of air.
In the context of Chinese medicine, “wind” can be first of all a movement
of air that can be cold (fenghan 風寒, “hypothermic exposure”), hot (fengre 風
熱, “exposure to hot wind”, but often referring to the inflammation that
follows), wet (fengshi 風濕, “rheumatism” caused by a cold, wet environment),
dry (fengzao 風 燥, “desiccating wind”) or warm (fengwen 風 溫, “exposure to
warm and humid climate”, actually the latent period of viral infection with a
low fever). Here, “wind” is both the causative factor, or co-factor (wind aggra-
vating the associated evil qi or wind borne factor), and the morbid result.
“Wind” is more often referring to the sudden onset of a disease like a wind
stirring, such as epilepsy, catalepsy (ibid. 8-1 諸部強直，皆屬於風), syncope
(ibid. 8-1 諸 風 掉 眩), tetanus (poshangfeng 破 傷 風, “sudden onset of tetany
due to open wounds”), seizure (jingfeng 驚 風, “sudden onset of convulsion,
like being frightened”) or gout (tongfeng 痛 風, “painful wind”). Indeed, a
stroke is commonly called zhongfeng 中 風 (struck by wind), but unlike
zhonghan 中 寒 (hypothermic exposure), or zhongshu 中 暑 (heatstroke),
zhongfeng describes the process rather than the cause. This is evident in
migratory pain like arthralgia (xing pi 行 痺, ibid. 8-23), or localised pain like
migraine (piantoufeng 偏 頭 風 , “wind striking one side of the head”).

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 Morbid Manifestations 321

Hemiplegia (pianfeng 偏 風) describes the result of “wind” striking one side of

the body. Eventually, “wind” can be simply gas accumulation inside the body,
often the guts, and the use of carminatives (qufeng 祛 風) (like cardamon) is
frequent. There are dozens of over-the-counter preparations devoted to this
effect. Besides dispelling wind physically, qufeng is a way to neutralise the
“wind”-induced symptoms like qufeng jiebiao 祛風解表 (“dispelling wind and
loosening the body surface” by using diaphoretics and febrifuges to counteract
the early signs of a flu). Therefore, the manifold meanings of “wind” must be
taken in the context of its combination with other terms. The combined terms
fengsu 風 俗 or fengqi 風 氣 mean “folklore, vogue or fad”. Consequently,
wenfeng 聞風 or fengwen 風聞 refers to catching a hint of the changing vogue.
The connotations of “wind” are as complicated as those of qi 氣 or shen 神 in
Chinese medicine.
This section lists a number of unrelated diseases, explaining their patho-
genesis by way of demonstrating the diversity of “wind” and its effects. In the
original text, more details are devoted to manifestation of “wind”-like diseases
pertinent to the five zang-organs (physiological systems), as well as the
stomach (digestive function) and the head (excruciating headache). The key
phrase, “Wind is the primary cause of hundred kinds of diseases” (feng zhe bai
bing zhi zhang 風 者 百 病 之 長), was corroborated by another quotation early
in Suwen Chapter 3: “Wind is the beginning of hundred kinds of diseases” (feng
zhe bai bing zhi shi 風 者 百 病 之 始). (In English, “it is an ill wind that blows
nobody any good.”) In the language of the “five elements”, the wind belongs to
the wood category with liver as its organ of affinity. Thus “wind”–induced
diseases tend to strike the liver first. When the “liver wind” agitates (gan feng
dong 肝 風 動, “a surge of blood pressure”), it is a premonition of more serious
neurological disorders like stroke or seizure. Sun Si-miao 孫 思 邈 devoted the
whole of Volume 8 in his Qianjin fang 千 金 方 (Thousand Gold Prescriptions),
to “wind” diseases, largely following the theoretical framework of Suwen set
out in this chapter.

Footnotes

[1] “wind”: “Wind” between quotation marks means more than the physical
wind, but one of the many aspects associated with wind-induced diseases.
[2] multiple forms of presentation: This is the key phrase on wind (shan xing er
shu bian 善 行 而 數 變), literally “adroitly walking away and frequently
changing”, defining the primary characteristic of wind diseases as being

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 322 Neijing Zhiyao Yigu 內經知要譯詁

migratory and volatile.

[3] briskly cold: More than just feeling chilly, the original text used the character
洒 xian (“shudder”; this is not the simplified form of the character 灑, sa,
“spraying”). It means a sudden attack of cold that makes one shudder by
reflex to produce heat.
[4] dispirited: The Chinese character 怢 tu means “oversight, forgetful” while li
慄 means “shivering from cold or fear”. The combined term tuli is best
described as neurasthenia.
[5] inner canthus of the eye: The stomachic yang-ming conduit starts from
acupoint yingxiang by the side of the nostril and below the eye. It travels in a
podal direction to the big toe, from where it dovetails into the podogenic
tai-yin spleenic conduit. The inner canthus is not along the itinerary of
either conduit. Rather, the inner canthus of the eye is the terminus of the
cheirogenic tai-yang small intestinal conduit that dovetails into the podotelic
tai-yang urinary bladder conduit. Dr. W. F. Pau rightly points out that this
apparent anomaly was not noticed by previous annotators.
[6] shu acupoints: The shu acupoints (shuxue 腧穴, or simply shu 俞, are the five
potency-level acupoints (translation according to Needham, or more specifi-
cally, the shu acupoint among them. ibid. 4-10-9. See below). The shu
acupoints are sensitive loci along the conduit that are amenable for the
modulation of qi flow as well as penetration of external evil qi. They are each
indicated for a particular range of symptoms in each regular conduit.
[7] swell abruptly: The Chinese character 憤 fen, means “to react angrily, precip-
itously” while 月真 means swelling. The combined term describes sudden
muscle swelling, a kind of inflammatory myopathy.
[8] leprosy: The Chinese character 癘 li, with the “sickness” radical, is specifically
“leprosy”, lifeng 癘 風 (ferocious wind). It can also mean a pestilent epidemic
when used in the combination yili 疫 癘. Confucius lamented that he was
going to lose his disciple Bo-niu, such a fine man he said, while holding the
latter’s hand (《論 語．雍 也》:「伯 牛 有 疾。」) Bo-niu suffered from an
incurable disease that later annotators believed to be lai 癩=癘, i.e. leprosy.
The fact that Confucius did not shy away from holding a leper’s hand
reminds us of celebrities shaking hands with AIDS patients today.
[9] discoloration: The appearance of maculae of hypopigmentation is the first
sign of leprosy.
[10] ferocious wind: This is clearly a description of lepromatous skin lesion.
Leprosy has been well documented since ancient times. Zuozhuan: Duke of

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 Morbid Manifestations 323

Zhao 4th year says: “When there is no frost and hail, ferocious disease (liji 癘
疾) will not arrive [descend from the sky].” This links malevolent disease
with inclement weather; it presented as a virulent boil. In Shanhaijing:
Xishanjing 山海經．西山經, there was even a cure for malevolent disease in
the forms of a bird called feiyi 肥 遺. In Neijing Chapter 55, leprosy (dafeng
大 風 ) was treated with acupuncture. Chaulmoogra (Hydnocarpus
anthelmintica), famous in Indian folklore for treating leprosy, is actually
called “大 楓 子” da feng zi in Chinese. The reason given by Neijing for the
genesis of leprosy is hardly related to the pathogenic mycobacteria we know
today, but the symptoms described in Neijing (collapse of nasal ridge, discol-
oration and lesion of skin) are typical of lepromatous leprosy. Note that li 癘,
with the “sickness” radical, may also refer to a number of skin lesions and
boils, such as the leonine face in leprosy; it is equivalent to lai 癩 (mangy).
The thinning of the eyebrows in leprosy may be mistaken for the result of
mange until further lesions appear (e.g. loss of fingers). But the term lifeng
厲風 (ferocious wind) is actually referring to leprosy. It was later abbreviated
to feng 瘋, “wind” with the “sickness” radical, putting it definitely in the cate-
gory of “wind” disease. It is usually called mafeng 麻 瘋, ma 麻, meaning
“dishevelled like a ball of flax”, a reference to the rugged face of a leper.
Leprosy is not transmitted through repeated skin contact, like that in a
family group, but more acutely by contact with the nasal secretion of the
leprous person; that may consolidate the idea of wind disease when nasal
mucus is sprayed during sneezing (cold air lodged in blood vessels). (For
more about leprosy, see ref. 53, Section 5.1.2.)
[11] localised wind: This is commonly regarded as hemiplegia (pianfeng 偏 風),
the signature symptom, as if the evil “wind”, the causative factor, strikes only
the afflicted half of the body. In this case, it is also called pianku 扁 枯
(lopsided, wilting), describing the muscular atrophy as the disease per se.
Zhuangzi described Dayu as suffering from pianku, being worn out by the
hard work he devoted to managing water.23 In the context of the present
quotation, this is actually referring to localised, or organ/tissue specific “wind”
disease as listed later in the paragraph. In the next paragraph, not quoted,
there are graphic descriptions of “wind” disease pertinent to the five zang-
organs, as well as the stomach and the head.

23
《莊子．盜跖》︰「禹偏枯。」

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 324 Neijing Zhiyao Yigu 內經知要譯詁

[12] acupoint fengfu: Literally the “wind parlour” (fengfu 風 府), this is an impor-
tant acupoint on the Du conduit (DU-16), lying on the midline of the nape
at the level of the hair margin. The occipital nerve and artery lie under this
acupoint. It is used to treat neurological disorders like the sequelae of stroke,
schizophrenia and epilepsy. It is believed that “wind” penetrates the brain
through this point, causing neurological disorders. This is not to be confused
with the acupoint fengchi 風 池 (“wind pond”, GB-20) of the gall bladder
conduit, which lies lateral to fengfu at the same level.
[13] “cerebral wind”: Naofeng 腦 風. This is generally taken to mean a severe
contracting headache. At the time of Neijing, the brain, one of the “odd”
visceral organs, was simply considered to be the “sea” of the marrows (the
spinal cord, not the bone marrow). The neural function of the brain was not
recognised until Wang Qing-ren 王 清 任 (1768–1831) in the Qing dynasty.
However, headache should not be equated with “brain ache”, as the brain per
se is devoid of pain receptors; these are found in the brain membranes
(meninges) and blood vessels inside and outside the skull. Hence, “cerebral
wind”, or intense headache, might be related to vasoconstriction of cerebral
arteries (not a throbbing or pressure headache). “Cerebral wind” should not
be confused with the “cephalic wind” that follows.
[14] “ocular wind”: Mufeng 目 風. It is hard to imagine how the eye can feel cold.
Maybe this is referring to a kind of ocular palsy that originates in the brain.
According to Dr. Pau, disease in the eye is either neuronal (optic neuritis or
optic atrophy) or vascular (retinal artery or vein thrombosis). Since “wind”
acts swiftly, it likely causes an acute vascular condition. Referring to Section
8.22, on cold qi residing inside or outside the blood vessels, it is fair to argue
that cold air residing in the blood vessels causes stagnation of blood flow,
and the condition fitting this change is central retinal artery occlusion
(CRAO), where acute painless loss of monocular vision is the usual
presenting symptom. CRAO represents an ophthalmologic emergency and
delay in treatment results in permanent loss of vision. The causes of CRAO
includes carotid artery stenosis due to atherosclerosis, embolism related to
atrial fibrillation or bacterial endocarditis, hyperviscosity syndrome and
giant cell arteritis. The other cause of sudden loss of vision is acute angle
closure glaucoma. This presents with severe eye pain and blurred vision.
Examination of the eye reveals turbid, greenish hazy liquid content behind a
dilated pupil and vascular congestion at the rim of the cornea. The patho-
genesis is a sudden increase in intra-ocular pressure caused by obtruction of

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 Morbid Manifestations 325

the drainage of aqueous humour from the anterior chamber of the eye. But
this conditon hardly conjures up the image of a cold eye.
[15] “leaking wind”: Loufeng 漏 風. After heavy drinking, one sweats profusely
(“leaking”). At this moment, the drunk person is particularly sensitive to an
attack of cold draught, which could trigger an episode of acute hypothermia.
In Neijing Chapter 46, a stroke following post-drinking hidrosis is called
“wine wind” (jiufeng 酒 風, “an attack of wind after inebriation”.). There is a
standing prescription to accompany it, containing Alisma plantago-aquatica,
Atratylodes macrocephala and Pyrola rotundifolia; this is one of the 13
prescriptions given in Neijing. The dosage is described in detail towards the
end of the chapter. “Profuse sweating, but one cannot wear thin clothing.
Sweating as soon as one eats [food-induced thermogenesis], even all over the
body. There is panting and aversion to draughts. Clothing is always soaked,
leading to xerostomia and polydipsia. [The patient] becomes physically
intolerant.”
[16] “internal wind”: Neifeng 內 風. This is post-coital apoplexy. It is called
“internal” because it is believed the internal essence is depleted after
intercourse.
[17] “cephalic wind”: Shoufeng 首 風. Whenever there is vasodilation in hypo-
dermal circulation, after drinking wine, having intercourse or bathing, there
is hidrosis and body heat loss. In Chinese medicine, the subcutaneous striae
are believed to be wide open, leaving one susceptible to an attack of extra-
neous evil qi, like wind, heat, cold, wet etc. “Cephalic wind” fits into this
category; it is described in greater detail in the last part of this chapter in
Neijing. It is characterised by headache and profuse sweating on the face,
together with an aversion to draughts.
[18] “intestinal wind”: Changfeng 腸 風 is usually translated as “haematochezia”
(bright red blood in the stool). But the text contains no hint of intestinal
bleeding; it suggests rather a lingering causative factor (jiu feng ru zhong 久
風 入 中). The passing of undigested food in the stools (sunxie 飧 泄) is the
only defined symptom. In Western medicine, this is understood to indicate
the presence of malabsorption syndrome with steatorrhoea because of inad-
equate digestion of fat. For example, chronic liver disease with decreased
production of bile salt, biliary tract obstruction, chronic pancreatitis, or
regional ileitis, and gluten-sensitive enteropathy could also present steator-
rhoea. In disaccharidase deficiency syndromes, the undigested lactose,
sucrose or maltose undergoes fermentation in the small intestine, producing

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 326 Neijing Zhiyao Yigu 內經知要譯詁

an osmotic effect, and causing a shift of fluid from the bowel wall into the
lumen. Shortening of intestinal transit time such as that encountered in
hyperthyroidism, irritable bowel syndrome, drug (purgative and laxative)
effect, fistula between bowel loops due to malignancy or regional enteritis, or
the carcinoid syndrome, results in diarrhoea. Undigested food particles can
sometimes be found in the stools in these conditions. This is not necessarily
accompanied by gastrointestinal bleeding. (Dr. W. F. Pau)
[19] “seeping wind”: xiefeng 泄 風. If the “wind” lingers around the body’s surface
for a long time, the subcutaneous striae will remain porous, and sweat “seeps”
out continuously. There is a detailed description towards the end of this
chapter in Neijing: “polyhidrosis, staining of the clothes, dry mouth, moist
skin, physical intolerance.”
[20] hundred kinds of diseases: This is the key phrase regarding the pathogenic
nature of “wind”. See Explanatory Notes of this section.

[Section 8.11] Suwen Chapter 33: On Several Severe Febrile

Diseases

《素問．評熱病論》曰：邪之所湊，其氣必虛。

For the evil qi to gather together [to show effect], the [righteous] qi must be
deficient [in the first place].

Explanatory Notes
Suwen Chapter 33 discusses the complications in several severe febrile diseases,
of which the last one is fengshui 風水 (oedema due to an attack of “wind”’; the
characters are the same ones which are translated as “geomancy”). Fengshui
itself is a result of the mistreatment of shenfeng 腎 風 (renal oedema, an attack
of “wind” on the kidney) by acupuncture. Several chapters in Suwen talk
about oedema. But in this Chapter, Qibo gives a detailed explanation of every
symptom of fengshui, which are summarised in the key phrase quoted here.
The significance of this key phrase goes well beyond renal oedema or its
mistreatment. It is the primary cause of all diseases. It is clear to the author of
this chapter that when the righteous qi (zhengqi 正 氣) is weak, the evil qi will

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 Morbid Manifestations 327

strike. This concept of pathogenesis is as valid in Chinese medicine as in

modern medicine. Righteous qi is thus construed to represent physiological
compensation, autonomic regulation and immuno-defence. It is the summa-
tion of the gyrostatic mechanism which one seeks to conserve, or even
improve, in the maintenance of health and in macrobiotics. As Chinese medi-
cine puts it, genuine qi is the ensemble of the defensive qi and nourishing qi.
To be wholesome physically and morally as a prerequisite of health is not new
in Chinese ethics. Xunzi declared that putrefied meat generated maggots.24 Su
Dong-bo 蘇 東 坡 (1037–1101) further elaborated on this statement, saying
“Things must first rot before worms will grow therein”, which is now a well-
known axiom (Fan Zheng lun 范增論).

[Section 8.12] Suwen Chapter 45: On Syncopic Diseases

《素問．厥論》曰：陽氣衰於下，則為寒厥；陰氣衰於下，則為熱厥。
前陰者，宗筋之所聚、太陰陽明之所合也。春夏則陽氣多而陰氣少，
秋冬則陰氣盛而陽氣衰。此人者質壯，以秋冬奪於所用，下氣上爭不能
復，精氣溢下，邪氣因從之而上也。氣因於中。陽氣衰，不能滲營其經
絡，陽氣日損，陰氣獨存，故手足為之寒也。
酒入於胃，則絡脈滿而經脈虛。脾主為胃行其津液者也，陰氣虛則陽
氣入，陽氣入則胃不和，胃不和則精氣竭，精氣竭則不營其四肢也。此人
必數醉若飽以入房，氣聚於脾中不得散，酒氣與穀氣相搏，熱盛於中，故
熱遍於身，內熱而溺赤也。夫酒氣盛而慓悍，腎氣日衰，陽氣獨勝，故手
足為之熱也。

When yangqi [in the three podotelic yang conduits] is weak in the legs [1], the
limbs are cold [2]. When yinqi [3] [in the three podogenic yin conduits] is
weak in the legs, they become feverish.
The external genitalia at the front are the confluence point of the primor-
dial ligament [4]. This is where the tai-yin [podogenic spleenic] and yang-
ming [podotelic gastric] conduits converge. In spring and summer, the yangqi
is in abundance and the yinqi is in dearth; in autumn and winter, the reverse is

24
《荀子．勸學篇》「
: 肉腐蟲生。」(rou fu chong sheng).

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 328 Neijing Zhiyao Yigu 內經知要譯詁

true. If a person with a robust physique is robbed of [his essence] while being
indulgent [in sexual activities], then the lower burner [governing the kidney]
will seek in vain for assistance from the middle and upper burners [digestion
and energy supply], and the qi of essence drains downward [through the lower
orifice, i.e. the external genitalia]. The extraneous evil qi will take this oppor-
tunity to ascend [through the conduits and strike at the middle burner]. Qi
[energy supply] must eventually come from the middle burner. Now that the
yangqi [of the middle burner] is weak, it cannot deliver nourishment to the
conduits and their side branches. With yangqi weakening by the day, there
remains only yinqi [in the conduits]; that is why the limbs are cold [5].
When wine enters the stomach, the side branches are full [vasodilation]
whilst the main branches are devoid [of blood] [6]. The principal function of
the spleen is to distribute the body fluid [with its nutrients] derived from the
stomach. In this case, if yinqi [of the stomach] is insufficient, yangqi will take
over, rendering the stomach dysfunctional. With gastric hypofunction, the qi
of essence rapidly dwindles, and eventually there is not enough to nourish the
four limbs. This is bound to happen with a person who is frequently drunk
and engages in sexual activity with a full stomach; the qi [blood supply] is
concentrated in the spleen, being unable to disperse. The wine effect interferes
with digestion [7] and heat is trapped inside the middle burner [that is
running in high gear]. From here, heat spreads all over the body, giving rise to
an endogenous febrile condition, indicated by red-coloured urine. The expres-
sion of wine is primarily fervid and aggressive. So when renal function is
weakening by the day, yangqi dominates and the limbs become feverish.

Explanatory Notes
Suwen Chapter 45 talks about syncope, of mainly two groups, viz. the hot and
cold syncope, (excerpted in this section), and the syncope pertaining to the six
yin/yang categories of conduits (i.e. all the zang- and fu-organ specific
conduits). In Neijing, there are 11 kinds of syncope (see ref. 18, p. 367), of
which the cold and hot syncope discussed in this section are caused by an
over-indulgent life style, primarily sexual indulgence and secondarily
overeating.
Syncope is defined as a transient loss of consciousness due to impairment
of blood flow to the brain. The acute hypotension that results makes one feel
dizzy, with cold sweats and cold limbs. In Western medicine, syncope can be

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 Morbid Manifestations 329

due to a number of causes that can be broadly divided into two groups, circu-
latory and cardiac. Under circulatory syncope come vasovagal syncope or
common fainting; over-sensitive carotid sinus; postural hypotension related to
general debility and prolonged bedrest, drug effect (e.g. anti-hypertensive
drugs, diuretics, nitrates and vasodilators); decreased venous return to the
heart due to hypovolemia, cough syncope, or during a Valsalva manoeuvre.
The pathophysiology is failure of the peripheral vasoconstrictive mechanism
and failure of reflex increase in heart rate to compensate for hypotension
caused by pooling of blood in the venous bed when the person assumes an
upright posture. Normally, improvement of venous return to the heart is
facilitated by muscle contraction in the limbs but this mechanism may also
fail. These compensatory vasomotor reflexes are seriously compromised in
peripheral neuropathy (e.g. diabetic or alcoholic polyneuropathy), and also in
rare cases like the familial, autonomic nervous dysfunction known as
dysautonomia.
Under cardiac syncope comes inadequate cardiac output due to pump
failure, which is evident in acute myocardial infarction. The next such cause is
left ventricular outflow obstruction, in the condition of aortic stenosis and
hypertrophic sub-aortic cardiomyopathy, both of which are responsible for
exertional syncope; right ventricular outflow obstruction, as in primary
pulmonary hypertension, or pulmonary embolism; decreased cardiac output
and hence blood flow to the brain, which may be caused by a variety of cardiac
arrhythmia; either tachyarrhythmia (e.g. paroxysmal ventricular tachycardia),
atrial tachycardia or flutter with 1:1 atrio-ventricular conduction; or extreme
bradycardia due to complete heart block where there is loss of consciousness,
often with twitching of limbs, known as a Stokes-Adams attack; or the sick
sinus syndrome (consisting of sinus node arrest, sinus bradycardia or sino-
atrial block). When syncope is related to change of posture, one should think
of ball-valve thrombus in the atrium, or atrial myxoma, both of which
obstruct blood flow to the mitral valve.
Transient ischaemic attack (TIA) due to stenosis of the carotid artery or
the intracerebral arteries may be difficult to distinguish from syncope.
Syncope is different from coma in that the former is usually sudden and brief,
with or without notable sequelae, depending on the complexity of the situa-
tion. It is usually a brief episode of fainting (hunjue 昏厥). A lengthy comatose
state (shijue 屍厥) reminds us of the famous story of Bianque resuscitating the
Prince of Guo, who had been lying unconscious for the better part of the day

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 330 Neijing Zhiyao Yigu 內經知要譯詁

(Si-Ma Qian: Historical Record). The explanation afforded by Bianque

followed the same vein as the one in Neijing. Si-Ma Qian may have had access
to early medical text that served as the source material of Neijing, in which
Chapter 63 actually spells out the term shijue. In light of the lengthy discus-
sion on syncope outlined above, shijue may not be a simple syncope. (The
above discussion incorporates contributions from Dr. W. F. Pau).
While the signature symptom of syncope is fainting, the presentation of
cold limbs is perceived as a result of obstruction to the smooth flow of blood
and qi. Nijue 逆 厥, not necessarily fainting, is indicative of turbulent qi flow.
It is also called sini 四 逆 because the four limbs are involved. The famous
medication Sini tang 四 逆 湯 from Shanghanlun contains notably aconitum, a
potent cardiotonic drug.
Returning to cold and hot syncope, it is clear that the subtext of this
section is preaching sexual moderation. In feudal as well as modern times,
access to women is a measure of personal wealth and power; however sexual
indulgence undermines health in all times. Lingshu Chapter 4 states that
sexual indulgence could harm the kidney. In Zuozhuan, Duke of Zhao first
year (541 bc), Yi He 醫 和, a famous physician from the Dukedom of Qin was
sent to look after the Duke of Jin; he lamented that the Duke’s disease was
incurable because he was too often intimate with women. The Duke, not
convinced, asked: “Is intimacy with women forbidden?” Yi He replied
succinctly: “With moderation.”25 Then he went on to lecture the Duke on the
virtue of moderation in health maintenance, which was extrapolated to the
ethics of running the state.

Footnotes

[1] legs: This is a reference to the three podotelic yang conduits, viz. yang-ming
(gastric), shao-yang (gall bladder) and tai-yang (urinary bladder). By the
same token, the three podogenic yin conduits are tai-yin (spleenic), shao-yin
(renal) and jue-yin (hepatic). These three pairs, forming an internal-external
relationship between them, account for most of the vital vegetative function
of the body
[2] limbs are cold: Because of hypotension, the extremities of the body feel cold.
It is believed that qi (blood pressure) and blood flow are obstructed, or even

25
《左傳．昭公一年》
：「女不可近乎？」曰：「節之」。

Neijing.indb 330 2010/2/26 6:59:27 PM

 Morbid Manifestations 331

reversed, resulting in a condition called jueleng 厥冷, then eventually syncope

(hunjue 昏 厥). Cold limbs are thus considered a prodrome of syncope
(juezheng 厥證) although the patient is not actually fainting
[3] yinqi: Yangqi and yinqi refer to the integrity of the function of these zang-
organs (yinqi) and fu-organs (yangqi); they are thus labelled because of the
yin/yang categorisation of the conduits. Hypofunction of a zang-organ is
perceived as a dimunition of yinqi in the podogenic yin conduits, with a rela-
tive predominance of yangqi.
[4] primordial ligament: Jin is the connective tissue that links the body parts; it
does not convey qi (like jing, conduits) or blood (like mai, blood vessels).
The usefulness of jin is that it is the structure that connects muscle with bone
(jian in jijian 肌 腱, jinjian 筋 腱, muscle tendon, not to be confused with
jingjin 經 筋), or bone with bone-forming joints (jie 節, “synovial capsules”).
Other ligaments, fascia, or organ capsules are generally called membranes
(jinmo 筋 膜, not to be confused with moyuan 膜 原). Like the conduits and
blood vessels that form a network, jin of all kinds is believed to converge on
a main primordial ligament (zongjin 宗 筋, zong means “converge towards”,
or “gather together at the origin”) that is located at the external genitalia. In
the case of men, the phallus is perceived as a sizable ligament and is some-
times, out of modesty, called zongjin. In this context, “zong” means “progen-
itor” (as in 祖 宗 zuzong). In Lingshu Chapter 65, Qibo states explicitly that
the eunuchs had their “progenitorial ligaments” removed; that was why they
were not hirsute on the lips. Castration involved also the removal of the
gonads.
[5] limbs are cold: Cold extremities are the first sign of inadequate blood supply
due to obstruction of qi flow. The ultimate cause is traced to insufficiency of
renal essence (adrenal function), which in turn undermines energy supply
from the middle burner. It is not yet syncope, but it constitutes a character-
istic prodrome of syncope.
[6] devoid (of blood): This is a lucid description of the cause of syncope. Periph-
eral vasodilation diminishes venous return, cutting off cerebral blood supply,
which results in fainting.
[7] interferes with digestion: Literally, “the action (qi) of wine confronts the qi
of the cereals [digestion to release energy]”. Alcohol has a vasodilatory effect.
When blood remains in peripheral circulation, there is not enough blood to
flow to the digestive tract for digestion and distribute the nutrients for ther-
mogenesis. Heavy drinking induces heat loss. If this is not compensated for

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 332 Neijing Zhiyao Yigu 內經知要譯詁

by increased energy production, but instead worsened by physical exertion

during intercourse, apoplexy may result. A vernacular term to describe this
outcome is mashangfeng 馬上風 (“stricken by wind while riding a horse”).

[Section 8.13] Suwen Chapter 32: Treatment of Febrile

Diseases by Acupuncture

《素問．刺熱論》曰：肝熱病者，左頰先赤；心熱病者，額先赤；脾熱病
者，鼻先赤；肺熱病者，右頰先赤；腎熱病者，頤先赤。

A febrile disease of liver origin will first show up as a flushing left cheek. A
febrile disease of heart origin will first show up as a flushing brow. A febrile
disease of spleen origin will first show up as a flushing nose. A febrile disease
of lung origin will first show up as a flushing right cheek. A febrile disease of
kidney origin will first show up as a flushing jaw [1].

Explanatory Notes
Suwen Chapter 32 is one of the four chapters (Chps. 31–34) in Volume 9 that
deal with febrile diseases. Of these, Chapter 31: On Febrile Diseases is the most
important; it sketches an outline which was later fully expanded in Shang-
hanlun, notably the time course of disease development in terms of disease
transmutation from one conduit to another. That is the quintessence of Zhang
Zhong-jing’s teaching and is the subject of the next Section [8.14]. Chapter 32
provides a comprehensive appraisal of febrile diseases of zang-organ origin,
their presentations, treatment by acupuncture and prognosis. This is followed
by the paragraph that is excerpted here. The assignment of localities on the
face that indicate for a specific zang-organ is a typical example of “five
elements” reasoning. The liver belongs to the wood: east category, thus the left
cheek. By the same token, heart—fire: south, the face, that is the brow.
Spleen—earth: centre, the nose. Lung—metal: west, the right cheek. Kidney—
water: north, the jaws. This was the view of Zhang Yin-an 張 隱 庵 (ca. 1610–
1674), who had produced a popular annotated edition of Neijing, Huangdi
Neijing Suwen jizhu 黃 帝 內 經 素 問 集 注 (with a preface by the author) in
1670. What is important in this paragraph is the sentence that follows, but is
not excerpted. “Although the disease is not full-blown, start applying the

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 Morbid Manifestations 333

needle when the flushing appears, this is the so-called “treat to pre-empt the
disease” (zhi wei bing 治 未 病).” This famous dictum of Chinese medicine is
found in the last paragraph of Suwen Chapter 2, of which there are excerpts in
Sections 1.3 and 1.4, which do not include this famous quotation. While it is
an excellent idea to pre-empt a disease, with the first indication showing up
on the face, the exact zang-organ specific localities do not agree with those
described in Section 3.2, which is excerpted from Lingshu. From Chapter 33,
only one sentence is quoted, which forms the subject of Section 8.11. Chapter
34 provides further insight into the presentation and mechanism of febrile
diseases and related symptoms.

Footnote

[1] jaw: The Chinese word 頤 yi is not exactly the jaw, but the lower part of the
cheek behind the corner of the mouth. See ibid. 6-1-17.

[Section 8.14] Suwen Chapter 31: On Febrile Diseases

《素問．熱論》曰：帝曰：今夫熱病者，皆傷寒之類也。或愈或死，其死皆
以六七日間、其愈皆以十日以上者，何也？
岐伯對曰：巨陽者，諸陽之屬也。其脈連於風府，故為諸陽主氣也。
人之傷於寒也，則為病熱，熱雖盛，不死；其兩感於寒而病者，必不免於
死。
（傷寒）一日，巨陽受之，故頭項痛、腰脊強；二日，陽明受之，陽明
主肉，其脈俠鼻絡於目，故身熱、目痛而鼻乾、不得卧也；三日，少陽受
之。少陽主膽，其脈循脅絡於耳，故胸脅痛而耳聾。三陽經絡皆受其病而
未入於藏者，故可汗而已；四日，太陰受之。太陰脈布胃中，絡於嗌，故
腹滿而嗌乾；五日，少陰受之。少陰脈貫腎，絡於肺，系舌本，故口燥、
舌乾而渴；六日厥陰受之。厥陰脈循陰器而絡於肝，故煩滿而囊縮。三陰
三陽、五藏六府俱受病，營衛不行，五藏不通，則死矣。
其未滿三日者，可汗而已；其滿三日者，可泄而已。

Huangdi said: “Generally speaking, febrile diseases are due to cold exposure [1].
Some patients can survive the disease, some not. If the patient succumbs to
the disease, he will die in six or seven days. If the patient can survive the
disease, it takes more than ten days to recover. Why is that?”

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 334 Neijing Zhiyao Yigu 內經知要譯詁

Qibo answered: “The great yang [conduit] [2] governs all the other yang
conduits; its itinerary links with the acupoint fengfu (of the Du conduit) [see
ibid. 8-10-11]. That is why yang conduits are full of qi. When one is stricken
by cold, there will be fever. Although the fever is high, one may not die.
However, if there is double exposure [3] and one becomes sick, death is
inevitable.”
“[When one is stricken by cold] [4] for the first day [5], the great yang [i.e
the tai-yang] conduit takes the blow; that is why there is headache and pain in
the neck with stiff waist and back. On the second day, the yang-ming conduit
is afflicted. Since the yang-ming conduit supplies the muscles and its itinerary
passes by the side of the nose and branches to the eyes, therefore the body is
feverish, the eyes hurt and the nostrils are dry. Consequently, one cannot lie
down to rest. On the third day, the shao-yang conduit is afflicted. Since the
shao-yang conduit supports the gall bladder [6] and its itinerary courses up
the rib-cage to link with the ear, the chest and hypochondrium are hurting
and the ear is deaf. If the three yang conduits and their branches are afflicted
but [cold evil qi has] not yet reached the zang-organs [via the yin conduits], it
suffices to induce sweating [in order to relieve the symptoms]. On the fourth
day, the tai-yin conduit is afflicted. Since the tai-yin conduit spreads its side
branches over the stomach and it branches to the throat, the abdomen bloats
and the throat is dry. On the fifth day the shao-yin conduit is afflicted. Since
the shao-yin conduit passes through the kidney, sending branches to the lung
and links to the root of the tongue, therefore the mouth is parched and the
tongue is dry and one feels thirsty. On the sixth day the jue-yin conduit is
afflicted. Since the jue-yin conduit circumvents the external genitalia and
sends it branches to the liver, there is dysphoria and retraction of the scrotum.”
“If these symptoms appear within three days [without suffering from
double exposure], it suffices to induce hidrosis. Over three days, it suffices to
induce catharsis.” [7]

Explanatory Notes
It is widely accepted that Suwen Chapter 31: On Febrile Diseases (Re lun 熱 論)
is the “ancestral version” (zuben 祖 本) of Shanghanlun 傷 寒 論 (SHL). The
similarity in content between the two leaves little doubt that Zhang Zhong-
jing must have read and been inspired by this chapter in Suwen when he wrote
his own version as “Shanghan lun” (On Cold Exposure) during his tenure as

Neijing.indb 334 2010/2/26 6:59:28 PM

 Morbid Manifestations 335

governor of Changsha (202–203).26 Zhang declared that he had diligently

sought ancient references and read widely in order to compile his book,
although references to Suwen and Jiujuan (i.e. Lingshu) by name in the preface
may perhaps be a later annotation rather than his own words. In either case,
Re lun was the title of a treatise quoted in Suwen Chapter 33: On Several Severe
Febrile Diseases.27 Thus a treatise on fever was not a novel idea to Zhang
Zhong-jing.
So is the last paragraph, lamenting on the lack of professionalism among
his peer, Huatuo among them. Huatuo 華 佗 (?–208) was the skilful surgeon
who treated Cao Cao and Guan Yu. Inventor of atropine-induced anaesthesia,
he was among the entourage of skilled persons, fangshi 方 士, at the service of
Cao Cao. (See ref. 53, p. 75). But what version of Neijing Zhang had consulted
remains unknown, as no one had seen the original manuscript or transcript of
SHL except Wang Shu-he 王 叔 和, who edited and arranged SHL from frag-
ments, hardly two to three decades (at the latest, in 235) after Zhang’s death.
Lin Yi’s group published the current version of SHL and its companion title
Jingui yaolüe 金 匱 要 略 no later than 1065–1066. Lin Yi and his team in the
Bureau for Emendation of Medical Classics produced first and foremost
Neijing; they must have accepted the linear relationship between Suwen: Re
lun and SHL. That said, however, it is necessary to establish a number of
salient points in common in order to consider SHL as an expansion of Suwen:
Re lun.

1. The cause
Shanghan 傷 寒 is literally “injury through exposure to cold”, or “attack by the
cold evil qi” (as in the modern term shangfeng 傷 風, “catch a cold”), and was
quite common in ancient North China, particularly at the period of turmoil
towards the end of the Eastern Han dynasty. Zhang Zhong-jing declared that
two-thirds of his clan of 200 kinsmen had died over a period of ten years, 70%
of them victims of “cold exposure” (shanghan). However, shanghan was only
the most common, or most acute/severe, external causative factor that
produced a febrile symptom. See, for example, Nanjing Question 58: “There

26
See Qian Chao-cen 錢超塵, Shanghanlun wenxian tongkao 傷寒論文獻通考 (The
Extensive Bibliography on Shanghanlun) (Beijing: Xuewan chubanshe, 1993).
27
《素問．評熱病論》
：「且夫《熱論》曰。」

Neijing.indb 335 2010/2/26 6:59:28 PM

 336 Neijing Zhiyao Yigu 內經知要譯詁

are five kinds of shanghan, viz. stricken by wind, cold, warm humidity, febrile
disease and ‘warm’ disease. Their afflictions are different.” With these diverse
causative factors and a common signature symptom of fever, febrile disease
can evolve into a great number of complications in what Zhang Zhong-jing
described as miscellaneous diseases (zabing 雜 病). Indeed, the complete title
of his work is Shanghan zabing lun 傷 寒 雜 病 論. It was only through the
offices of Lin Yi that the part on febrile diseases was separated from the rest
(SHL has ten volumes, 22 chapters, 112 prescriptions and Jingui yaolüe has
three volumes, 25 chapters and 262 prescriptions).

2. The presentation
Febrile diseases are characterised by an ensemble of major symptoms, always
including fever, and a typical pulse pattern (this was added by Zhang Zhong-
jing). This “pulse plus syndrome” profile (maizheng  證) represents six stere-
otypes, each coded by a 3-level yin or yang conduit. For example: Tai-yang
pulse/symptom: floating pulse, stiff and painful neck, headache with aversion
to cold. These morbid signs represent affliction of the functions governed by
the podotelic urinary bladder conduit. All six stereotypes of febrile disease are
thus assigned to a systemic physiological function governed by conduits of
podo-origin and functional parity (zang-fu, exterior-interior, yin-yang), such as:
Kidney — urinary bladder
Liver — gall bladder
Spleen — stomach
As far as acute febrile diseases are concerned, functions governed by
conduits of cheiro-origin, i.e. the heart, lung and three burners, are not
directly involved.

3. The transmutation
The six stereotypes are perceived as six stages in the evolution of a febrile
disease (liu jing chuan bian 六經傳變). The passage from one stage to the next
is considered a transmutation (chuan, then bian) of the disease according to
the sequence which follows:

Tai-yang (day 1): initial stage of febrile response, surface symptoms;

according to the eight cardinal rules, this is a state of exterior-cold,
floating pulse.
Yang-ming (day 2): peak stage of febrile response, whole body affected,

Neijing.indb 336 2010/2/26 6:59:28 PM

 Morbid Manifestations 337

particularly the stomach, intense fever, interior-excess-hot, strong

pulse.
Shao-yang (day 3): transitional stage of febrile response, mixed fever and
chills with fever remitting, interior-hot-deficient, taut pulse.
Tai-yin (day 4): beginning of fever remission, compromised digestive
function and a weakened body, interior-deficient-cold, weak pulse.
Shao-yin (day 5): residual fever or chills, body greatly weakened and defi-
cient, interior-deficient-cold, weak pulse.
Jue-yin (day 6): final stage of febrile response, every physiological func-
tion weakened, virtual fever alternating with cold limbs, weak pulse.

The number of days indicates the sequence of transmution rather than

actual units of time. Even then, this sequence of transmutation is not inevi-
table. It can be a direct hit (zhizhong 直 中) on one of the conduits, or hitting
two conduits at the same time (hebing 合 病). The transmutation is also not
clearcut. New symptoms may appear while the main clinical features of the
currently afflicted conduit are still evident (bingbing 並病).

4. The treatment
Suwen: Re lun only mentions two methods of treatment, i.e. hidrosis and
catharsis. But in SHL, all the eight principal methods of treatment are
employed.
Suwen: Re lun sets a paradigm in clinical medicine, taking acute febrile
response as one typical case. Zhang Zhong-jing expanded this into 397 exam-
ples in SHL. By doing so, the clinical guideline for disease management is
clearly delineated; it can be reduced to the central tenet of “bian zheng lun zhi”
辨 證 論 治 (differentiate the symptoms to arrive at a treatment plan). Zhang
Zhong-jing is no doubt the founding father of clinical Chinese medicine in
the sense that he set out the basic rules for disease management. But in spite
of the apotheosis of Zhang Zhong-jing, SHL is not meant to be a bible of
inflexible and ultimate truth. Clinicians should not simply match the disease
state of a patient, symptom by symptom, and select one of the time-tested
prescriptions in SHL (ibid. 8-5-6). The quintessence of Zhang Zhong-jing’s
teaching is adherence to a universal protocol (fa 法) that is applicable to all
clinical situations. Today, there are NICE (National Institute for Health and
Clinical Excellence) clinical guidelines in the UK that sum up the state of the
art for major diseases; this is collective wisdom validated by statistical analysis.

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 338 Neijing Zhiyao Yigu 內經知要譯詁

But in Zhang Zhong-jing’s time, he took it upon himself to document his

clinical experience, during his mandate as provincial governor, in order to
uphold a standard of moral and technical professionalism. He might not even
have practised medicine for a living, as he left few miraculous anecdotes like
Huatuo. He concludes his preface to SHL with touching modesty, saying that
“SHL may not cure all kinds of disease, [but] it could nevertheless prompt the
reader to seek the origin of diseases. If he ponders over my collection of expe-
riences, he will get it more than half right.” An old friend of the author, an
experienced orthopaedic, declares that his rule of thumb is: Where does it
hurt (that is, diagnosis)? Why does it hurt (that is, pathology)? If these two
questions are adequately answered, the method of treatment is in the market.

5. Other significance
Besides defining the course of development for febrile disease, and whether it
is terminal or otherwise, there are three important observations that are as
valid today as they were when first postulated.
In Suwen: Re lun:

111 According to Qibo, to treat febrile disease, maintain the normal func-
tion of the visceral organs, and “wait till the disease remits” (bing ri
shuai er yi 病 日 衰 而 已). Fever (pyrexia) is a defence mechanism; it
helps the body to fight off infection with increased metabolism
through increased thermogenesis. If the source of the pyrogen (e.g.
bacterial or viral) is removed, fever will subside. It is not helpful to
apply a febrifuge as soon as there is a slight rise in body temperature.
Of course, extremely high fever damages the brain, saps energy
reserves and suppresses appetite; therefore, it is necessary to take
adequate measures to prevent the damaging effects of high fever (ice
bags, or in Chinese medicine, gypsum or rhinocerus horn). But it is
common sense to allow a febrile disease to come and go and let the
body’s defence mechanism take its course.
222 The aftermath of febrile disease is loss of appetite and weak diges-
tion. It is not wise to eat rich food soon after the fever subsides. As
Qibo said: “At the first sign of convalescence, do not eat meat, other-
wise the fever will relapse. Overfeeding leads to (unfavourable)
sequelae.” Food taboos are an important measure in disease manage-
ment. “When catching a cold, do not eat oily and sweet foods.”

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 Morbid Manifestations 339

(shangfeng ji you tang 傷 風 忌 油 糖). Such is the wisdom of mothers

and grannies.
333 If there is no immediate response after cold exposure, there is a latent
period that is marked by a watershed time point at the summer
solstice. Before that, it manifests as a “warm disease” (bingwen 病 ),
later evolved into wenbing 溫 病 (“a warm disease”, very often a viral
infection). After that, it manifests as a “summer heat disease” (bingshu
病 暑, which may be compared to sunstroke). In this case, there will
be sweating, but there should be no attempt to stop it.

Addendum by Dr. W. F. Pau

The discussion of febrile illnesses caused by cold exposure and related types
(shanghan zhi lei 傷 寒 之 類) hints that ancient physicians dealt with many
categories of fever; some were of acute onset and ran a short course, others a
protracted course of some weeks leading to either death or recovery. Today, it
is understood that the acute febrile diseases are mostly infectious diseases
caused by either viruses, bacteria or parasites. Chills, headache, myalgia, back
pain and malaise are common to these fevers, equivalent to those described by
Qibo as Day 1, or Stage 1 symptoms. The differential diagnosis include
common cold, influenza, infectious mononucleosis, malaria, dengue fever,
typhoid fever, typhus, brucellosis and leptospirosis. One would expect the
ancient physicians to have approached the patient in the same way their
present day counterparts do, by history taking and physical examination with
the four basic diagnostic methods: inspection, auscultation and olfaction,
interrogation and palpation, of which pulse analysis was an integral part, as
set out in the opening paragraph of Chapter 6 in The Cultural Fabric of
Chinese Medicine (ref. 53). Since the head, the brain, the nape of the neck, the
scapula, the spine and the waist all lie along the itinerary of the podotelic tai-
yang conduit, the Neijing authors labelled this early stage of the disease as the
tai-yang stage. The evolution of symptoms sets the disease pattern, which
includes the appearance of new symptoms, as well as the fever pattern—
continuous, remittent, intermittent or relapsing.
Qibo’s Stage 2 illness featured eye pain and dry nose. Retro-orbital pain is
a prominent symptom in dengue fever and leptospirosis, while dry nose prac-
tically rules out upper respiratory tract diseases like the common cold and
influenza. Add epistaxis and one might consider typhoid fever as a candidate.
The conspicuous absence of any reference to skin rash during the first week of

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 340 Neijing Zhiyao Yigu 內經知要譯詁

illness is significant, as several infectious diseases with exanthem could be

ruled out. By this time, the modern-day physician should have ordered a set of
laboratory tests, namely, complete blood picture, blood smear, chest radiog-
raphy, urinalysis, culture of body fluid and serological tests, which most likely
would enable him/her to clinch the diagnosis. The Neijing physician, lacking
such resources, had to fall back on his clinical sense. It is not certain whether
there was such a thing as epidemiology in those days, for a cluster of patients
with like symptoms and signs would alert the physician to the possibility of
contagious diseases, which is of tremendous importance from a public health
standpoint.
By Day 3, or Stage 3, fresh symptoms include pain at the rib-cage and the
hypochondrium, which may indicate either pleurisy or inflammation of the
liver, but these symptoms are still not specific. Deafness is singled out. Apart
from being a feature of ear infection, deafness is a rare complication of
typhoid fever. Day 3 was set as the watershed which divides febrile illness into
those which run a mild course, moving towards spontaneous recovery or
requiring a single treatment such as induction of hidrosis, and those which
progress relentlessly to a fatal end, which is the Stages 4 through 6 referred to
in the text.
Considering that the three zang conduits are involved, the symptoms
cited are relatively mild. For example, bloating of the abdomen is non-specific,
while dry mouth and tongue indicate dehydration. It is unthinkable that
induction of catharsis in a dehydrated patient constitutes sensible treatment.
By Day 6, all six conduits would have been afflicted. An experienced physician
should be able to observe such terminal signs as shock, bleeding diathesis
(indicating disseminated intravascular coagulation), tachypnoea (adult respi-
ratory distress syndrome), anuria (acute renal failure), jaundice (acute liver
failure) and clouded sensorium. It is surprising that the ancient Chinese
physicians selected retraction of the scrotum as a terminal sign. This is
nothing more than stimulation of the cremasteric reflex. The phenomenon is
also mentioned in a Lingshu chapter, Section 8.33, on conduits, under “qi
exhaustion at the jue-yin hepatic conduit.”

Footnotes

[1] cold exposure: Shanghan 傷寒, literally “hurt by cold”, is like shangfeng 傷風,
“hurt by wind”. It is not so much that the physical cold or wind hurts, but
that the body is surprised in a moment of weakness, and an external

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 Morbid Manifestations 341

pathogen, for example microbes, strikes. So shanghan is a typical case of

“external affection” (waigan 外 感). Even though cold exposure will lead to
febrile response, it is definitely not the same as typhoid fever with “rose
spots” (ban zhen shang han 斑 疹 傷 寒), although it shares the same label.
However, cold exposure in the strict sense, like falling into cold water in
winter, can also cause fever.
[2] great yang [conduit]: Juyang 巨 陽. This is a synonym for the tai-yang
conduit, often meaning the urinary bladder conduit. (See Suwen Chapters 10
and 45, ibid. Section 8.15 below and ibid. 6-2-55)
[3] double exposure: When both a yang conduit and its corresponding yin
conduit are affected at the same time, it is a double exposure, liang-gan 兩感,
(literally “doubly affected”). Later in the chapter, the symptoms of double
exposure are spelled out, but not quoted in this section. They are as follows:
Day 1—tai-yang and shao-yin: headache, dry mouth, dysphoria.
Day 2—yang-ming and tai-yin: bloating abdomen, fever, loss of appetite,
disordered speech indelirium.
Day 3—shao-yang and jue-yin: deafness, retraction of scrotum, inability to
ingest even liquid food, unconsciousness, will die within 6 days.
[4] stricken by cold: The original text specified “cold exposure”, but this was not
excerpted.
[5] first day: Day 1 etc. denotes the sequence rather than the actual number of
days. It can be construed to mean Stage 1, or Phase 1 etc. in modern medical
parlance.
[6] gall bladder: the Taisu version has “bone” which does not seem to make
sense. It is generally accepted that the Taisu version of Neijing is more
archaic, hence closer to the original. By convention, shao-yang—gall bladder,
yang-ming—stomach and tai-yang—urinary bladder are well established,
unless otherwise indicated.
[7] catharsis: Given the fact that Neijing was based on medical knowledge gained
from the practice of acupuncture, to mention two general approaches
(hidrosis and catharsis) in febrile disease management may indicate that
these two methods are actually two modes of needle manipulation rather
than herbal treatments. Later, Zhang Zhong-jing used all the eight principal
methods of treatment. (See ibid. 7-4-13). However, the main thrust in
treating febrile disease is still acupuncture, as detailed in the next chapter,
Suwen Chapter 32: Treatment of Febrile Diseases by Acupuncture (Chire lun
刺熱論).

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 342 Neijing Zhiyao Yigu 內經知要譯詁

[Section 8.15] Suwen Chapter 35: On Malaria

《素問．瘧論》曰：帝曰：夫痎瘧皆生於風，其畜（蓄）作有時者，何也？

岐伯對曰：瘧之始發也，先起於毫毛，伸欠乃作，寒慄鼓頷，腰脊俱
痛；寒去則內外皆熱，頭痛如破，渴欲冷飲。

陰陽上下交爭，虛實更作，陰陽相移也。陽并於陰，則陰實而陽虛：
陽明虛，則寒慄鼓頷也；巨陽虛，則腰、背、頭、項痛；三陽俱虛，則陰
氣盛。陰氣盛，則骨寒而痛。寒生於內，故中外皆寒。陽盛則外熱，陰虛
則內熱，外內皆熱則喘而渴，故欲冷飲也。此皆得之夏傷於暑。熱氣盛，
藏於皮膚之內、腸胃之外，此營氣之所舍也。此令人汗空疎（疏）、腠理
開，因得秋氣，汗出遇風，及得之以浴，水氣舍於皮膚之內，與衛氣并
居。衛氣者，晝日行於陽，夜行於陰。此氣得陽而外出，得陰而內薄，內
外相薄，是以日作。

其氣之舍深，內薄於陰，陽氣獨發，陰邪內著，陰與陽爭不得出，是
以間日而作也。

邪氣客於風府，循膂而下。衛氣一日一夜大會於風府，其明日日下一
節，故其作也晏。其出於風府，日下一節，二十五日下至骶骨，二十六日
入於脊內，注於伏膂之內（）。其氣上行，九日出於缺盆之中。其氣日
高，故作日益早也。

夫寒者，陰氣也；風者，陽氣也。先傷於寒而後傷於風，故先寒而後
熱也，病以時作，名曰寒瘧；先傷於風而後傷於寒，故先熱而後寒也，亦
以時作，名曰溫瘧；其但熱而不寒者，陰氣先絕，陽氣獨發，則少氣煩
冤，手足熱而欲嘔，名曰癉瘧。

邪氣與衛氣客於六（風）府，有時相失，不能相得，故休數日乃作也。

溫瘧者，得之冬中於風，寒氣藏於骨髓之中；至春則陽氣大發，邪氣
不能自出；因遇大暑，腦髓爍，肌肉消，腠理發泄。或有所用力，邪氣與
汗皆出。此病藏於腎，其氣先從內出之於外也。如是者，陰虛而陽盛，陽
盛則熱矣，衰則氣復反入，入則陽虛，陽虛則寒矣。故先熱而後寒，名曰
溫瘧。

癉瘧者，肺素有熱，氣盛於身，厥逆上沖，中氣實而不外泄，因有所
用力，腠理開，風寒舍於皮膚之內、分肉之間而發。發則陽氣盛，陽氣盛
而不衰則病矣。其氣不及於陰，故但熱而不寒；氣內藏於心而外舍於分肉
之間，令人消爍脫肉，故命曰癉瘧。

Neijing.indb 342 2010/2/26 6:59:30 PM

 Morbid Manifestations 343

Huangdi asked: “Since malaria is caused by wind, why does its confinement
and outbreak occur regularly?” [1]
Qibo answered: “The onset of malaria begins with [indisposition]
among the body hairs [at the body’s surface], then one feels like stretching
and yawning. There are chills and a chattering jaw, the waist and the
spine hurt. When the chills are over, the body is feverish inside and outside.
A splitting headache is accompanied by intense thirst, a craving for cold
drink.”
“Since the yinqi and yangqi are each fighting to get into the other’s usual
path, each of them may become excessive or deficient in turn, because each
has gone off course [not travelling in its natural course]. If yangqi has merged
into the yin domain, yinqi becomes excessive and yangqi becomes deficient.
When the yang-ming conduits [large intestine and stomach] are deficient in qi
flow, one feels chilly and the jaw begins to chatter. When the tai-yang conduits
[small intestine and urinary bladder] are deficient in qi flow, one feels pain in
the waist, back, head and neck. When all the three yang conduits [2] are defi-
cient in qi flow, the yinqi will predominate. In this case, the bones will feel
chilly and painful. Because the chill is generated from within, both the interior
and exterior of the body feel chilly. When yangqi is predominant, the surface
of the body is feverish. When yinqi is deficient, the interior of the body feels
hot [3]. Since the body is feeling hot both inside and outside, [the patient] is
panting and thirsty, thus craving for cold drink. This is because the patient
had been afflicted with summer heat during summer. Although the heat is
exuberant, it lies dormant under the skin but not in the bowels; this is exactly
the place where the nourishing qi resides. This renders the sweating pores
wide open, and the subcutaneous striae become porous. If at this moment one
is caught by the cool draught of autumn, or caught in a draught while
sweating or coming out of the bath, the water vapour [evil qi] will be trapped
under the skin, residing concurrently with the defensive qi. Now that the
defensive qi travels in the yang domain in daytime and in the yin domain at
night, the evil qi will transpire out of the body if it is strengthened by yangqi,
or penetrate deep inside the body if it is strengthened by yinqi. The outward
movement confronts the inward movement [of the defensive qi], that is why
[quotidian malaria] occurs every day.” [4]
“If the evil qi is deeply entrenched, encompassing the yin domain, yangqi
goes its own way [without being able to travel to the yin domain] so that the
evil qi is deeply entrenched in the yin domain. In this case, the yinqi and

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 344 Neijing Zhiyao Yigu 內經知要譯詁

yangqi get entangled while the evil qi cannot find its way out; that is why
[tertian malaria] occurs every other day.” [5]
“When the evil qi loiters at the acupoint fengfu [6], it will go down along
the spinal column [7]. Since the defensive qi completes its round in a day and
a night, it returns to acupoint fengfu (after 24 hours). Next day, it moves one
vertebra further down so that the attack occurs one day later each time.
Starting from acupoint fengfu, going down at the rate of one vertebra each
day, it takes 25 days to reach the sacrum [8]. By the 26th day, the evil qi enters
the spine and drains itself into the Chong conduit, lying deep in the back
muscles [9]. From here, it travels upwards. By the 9th day, it reaches the supra-
clavicular fossa. Because the evil qi goes up higher each day, the attack occurs
earlier by one day.” [10]
“The cold evil qi is yin in nature. The wind evil qi is yang in nature.
Hence, if the patient is first afflicted by cold, and then by wind, [the malarial
attack] will begin with chills and then fever. It occurs regularly and is called
cold malaria [11]. On the contrary, if the patient is first afflicted by wind, and
then cold, [the malarial attack] will begin with fever and then chills. It also
occurs regularly; it is called warm malaria [12]. There is also a kind of malaria
that manifests only fever but not chills. It is due to the exhaustion of yinqi in
the first place, so that yangqi can express itself unopposed. Patients like this
will feel short of breath and dysphoric, warm in the limbs and nauseated. This
is called icteric malaria.” [13]
“When the evil qi and the defensive qi pass through acupoint fengfu in
transit, sometimes they miss the rendezvous and cannot act on each other.
That is why [the malarial attack] will rest for a few days before it occurs again;
[this is quintan or nonan malaria]. [14]
“Warm malaria is due to an exposure to [cold] wind in winter, the cold
evil qi is hoarded in the bone marrow [exoerythrocytic stage?]. Then comes
spring when the yangqi is flourishing, the evil qi is subdued and fails to express
itself. It has to wait till summer is in full swing, and the brain is stunned by
heat [15], muscles are emaciated and the subcutaneous striae are porous,
hence there is profuse sweating. Then as soon as one exerts oneself, the evil qi
leaves the body together with sweat. The disease is hoarded in the kidney;
when the evil qi leaves the body, it spills from the kidney to the interior of the
body first, before it can finally find its way out. In this way, yinqi becomes defi-
cient and yangqi becomes exuberant, resulting in fever. When yangqi is dimin-
ishing, the evil qi [that has not left the body] may re-enter the body’s interior,

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 Morbid Manifestations 345

thus causing a deficiency in yangqi, resulting in chills [16]. Therefore, malaria

with fever preceding chills is called warm malaria.”
“When a patient is suffering from icteric malaria, he is harbouring hot
evil qi in the lungs for some time. The body has plentiful qi that tends to surge
upward but is prevented from doing so because the middle burner is also
congested [with qi]. Under such circumstances, if [the patient] exerts himself
physically, the subcutaneous striae will open wide, and the cold and wind evil
qi residing under the skin and between the muscles will take advantage of this
opportunity to express themselves [17]. When the evil qi is rampant, yangqi
becomes exuberant. If the yangqi is undiminshed, icteric malaria occurs.
Because in icteric malaria, the evil qi cannot reach as far as the yin domain
[remaining in the hepatic stage?], there is only fever but no chills. [Usually]
the evil qi remains in the heart; when it spills over to the muscles, it will cause
muscle wasting [18]. That is why it is called icteric malaria.”

Explanatory Notes
The fact that the chapter on malaria (Suwen Chapter 35) starts a new
volume (Vol. 10), to differentiate it from Vol. 9 and its four chapters on febrile
diseases, is a real indication that the author(s) of Neijing had a good idea of
what they were talking about. It is followed closely by Chapter 36: On
Acupuncture Treatment of Malaria. The other two chapters (37 and 38) are not
concerned with malaria. The two chapters on malaria stand out as the longest
chapters on any disease, although they are much shorter than the chapters on
climatic cycles.
Some of the passages on malaria appeared verbatim in Lingshu Chapter
79. There, malaria is considered a wind-induced or wind-borne disease, which
as we now know is a half-truth due its vector, mosquitoes. In Taisu, passages
on malaria were placed together under “Febrile Diseases” (shanghan), towards
the end of the volume, although the text was very much the same. On the
contrary, Jingui yaolüe devotes a whole chapter (Chapter 4) to the symptoms,
pulse pattern and treatment of malaria. This chapter in Jingui yaolüe provides
a detailed account of the management of malaria. The clinical approach and
herbal treatment are a good complement to the contents of Neijing, with
faithful adherence to the theoretical framework of malaria defined therein.
Later, Ge Hong 葛 洪 (ca. 284–364) introduced the use of fresh juice squeezed
from Artemisia annua (qinghao 青 蒿) to treat malaria. Many centuries later,

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 346 Neijing Zhiyao Yigu 內經知要譯詁

this led eventually to the discovery of artemisin (qinghaosu).28 It can be fairly

concluded that since Neijing times, malaria has been under control in China.
The term malaria (literally, “foul air”) refers to the environmental factor
of the disease, which is in the same context as paludism (Latin: palus, marsh).
The term “ague”, or “ague fever”, which describes correctly the association of
bouts of fever with chills, is indeed very close to the Chinese term 瘧 nüe,
which is derived from nüe 虐 (torture, cruelty). Much more than a febrile
disease, malaria “tortures” the patient with alternating bone-shattering chills
and burning fever, profuse sweating, more debilitating with each cycle.
Before the parasitology of malaria was known, the symptoms were
ascribed to environmental factors as pathogens (zhang qi 瘴 氣, “humid air of
the tropical forest”), just as, in the West, ergotism was considered the work of
the Devil because of the frantic behaviour of those suffering from it. So it is
not surprising that Neijing relied on the medical theories of its time to explain
the pathogenesis of malaria. But what is so surprising is the fact that Neijing
describes malaria correctly, more or less like presenting a faithful record of a
battle without specifying the weaponry employed. In order to appreciate how
much truth is in Suwen Chapter 35, it will suffice to review briefly the natural
history of malaria.
When a female Anopheles mosquito bites a person, it squirts a small
amount of its saliva into the wound, to facilitate smooth blood flow. If the
saliva contains the plasmodium sporozoites, the patient is infected. Sporozo-
ites in human blood must quickly enter the liver cells to avoid destruction by
the human defence mechanism. A sporozoite multiplies in the liver cell to
become a multinucleate schizont that eventually causes the hapatocyte to
burst, releasing thousands of uninucleate merozoites into the bloodstream.
This ends the pre-erythrocytic (or hepatic) stage of the parasitic development;
it may last ten to fourteen days or more, depending on the species of plasmo-
dium. Among them, with the exception of Plasmodium falciparum, merozoites
remaining in the liver can reinfect the liver cells and perpetuate the hepatic
stage of the disease for a long time in a para-erythrocytic stage.
Meanwhile, merozoites in circulation enter red blood cells and grow into
ring-shaped trophozoites. Feeding on the haemoglobin in the cells, the

28
J. B. Jiang et al., “Antimalarial Activity of Mefloquine and Qinhaosu,” The Lancet,
No. 8293 (1982): 285–288.

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 Morbid Manifestations 347

trophozoites multiply to form multinucleate schizonts, then uninucleate

merozoites, which will burst the red blood cell and be released into the blood
stream, infecting new red blood cells. The burst is the immediate cause of a
bout of fever that lasts about two hours, preceded by a shorter duration of
chill (about half an hour). The fever can be so severe that the patient suffers
delirium and hallucinations. This is accompanied by profuse sweating, after
which the patient feels relieved, but hugely debilitated. The disease seems to
have blown over until the next bout of fever, which is worse because the
patient is by now much weaker. The periodicity between two bouts of fever (i.e.
the erythrocytic stage) depends on the exact species of the plasmodium. It is
48 hours for P. vivax and P. ovale (tertian malaria), about 36 hours for P. falci-
parum (subtertian malaria, or pernicious malaria) and 72 hours for P.
malariae (quartan malaria).
After two of these asexual erythrocytic cycles, the trophozoites differen-
tiate into male and female gametes. The patient is now infective. If a suitable
mosquito bites the patient, the gametes will continue their life cycle in the
mosquito to become infective sporozoites again. For female Anopheles
mosquitoes, one full meal of blood will suffice for them to lay eggs and die.
But the natural reservoir of plasmodium is the human body. For any indi-
vidual, malaria is self-perpetuating until the patient is cured one way or the
other (by acupuncture or herbal treatment), or the patient develops an immu-
nodefence that suppresses the morbid manifestions. The epidemiology of
malaria today is a testament simply to the lack of hygienic habitats in devel-
oping countries and the enormous pool of human reservoir living there.
The presentation of malarial fever can be divided into three phases:
The cold phase that last about 30 minutes. The cold sensation is due to
vasoconstriction. The patient feels intensely cold, with chattering jaws and
shivering body. In spite of the chill, body temperature actually rises rapidly.
The hot phase onset is abrupt and severe. It lasts two hours or more. Body
temperature rises higher than in any other febrile disease. The patient may
become delirious. High fever is accompanied by sweating.
The sweating phase is characterised by polyhidrosis that renders the
patient greatly exhausted. The patient falls asleep with extreme fatigue as if
cured, only to relive the same experience in the next bout of fever.
The red blood cells release merozoites, pyrogens (hence fever) and
partially degraded haemoglobin. The last accumulates to give pigmentation
on the skin, or jaundice in general. As a result of haemolysis, the patient

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 348 Neijing Zhiyao Yigu 內經知要譯詁

becomes anaemic and suffers from muscle wasting. Infected red blood cells
start to adhere to capillary linings and the liver and spleen are much enlarged.
In acute cerebral malaria of falciparum origin, the sequestration of red blood
cells (of which more than 2% are infected) may occur in the brain. There is
even higher body temperature, loss of consciousness and eventually coma and
death. Artemisin (qinghaosu) is particularly effective in reducing the magni-
tude of parasitaemia, and hence save a patient from cerebral malaria.
Besides being classified by its periodicity of fever cycles, malaria can above
all be divided into an acute (falciparum) and a chronic group (vivax, ovale,
malariae). Zhang Zhong-jing preferred to consider three categories, i.e., alter-
nating chills and fever, chills only and fever only. Zhang also recognised
chronic malaria (nüemu[mei] 瘧 母〔痗〕) [19], with the added sign of
splenomegaly. With this background information in mind, it is now possible
to appreciate the fact and fiction of Neijing malaria.
Neijing described correctly all types of malaria in terms of chronicity,
although the explanation is a far cry from modern parasitology. In the mid-
nineteenth century, when cinchona was already being cultivated on a grand
scale in India and Indonesia as a miraculous cure for malaria, the protozo-
ology of malaria was still unknown. In any case, before the discovery of plas-
modium and its life cycle towards the end of the nineteenth century, malaria
was best described according to its chronicity.29 In China, malaria was already
well recognised in Zuozhuan.30 Later, in Shanhaijing 山 海 經 (pre-Qin to early
Han), two plants were named as cures for malaria (nüe, meaning “alternating
chills and fever”). Thus it is not surprising that the authors of Neijing were
able to record faithfully different types of malaria and their treatment. Suwen
Chapter 36 is devoted entirely to the treatment of malaria by acupuncture,
presumably by enhancing immunodefence. However, in Chapter 35, after
explaining the different types of malaria, Qibo tries to enlighten Huangdi as
to the right moment for applying a needle during a bout of fever. Unlike other
diseases of excess or deficiency, where needling can be applied to mitigate the
presentation of the morbid signs, in malaria, needling was only applicable
when the symptoms started regressing. “Do not apply the needle during a

29
M. Honigsbaum, The Fever Trail (Farrar, Straus and Giroux 2001, or Macmillan
2001).
30
Duke of Zhao, 19th year 瘧, 20th year 痎, 痁.

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 Morbid Manifestations 349

scorching fever, do not apply the needle when there is a gushing pulse, do not
apply the needle when there is drenching sweat.” (wu ci he he zhi re, hun hun
zhi mai, lu lu zhi han 無刺熇熇之熱，渾渾之脉，漉漉之汗。 ) This passage
acknowledges de facto the three phases of a bout of malarial fever. This coin-
cides with the burst of the merozoites from the red blood cells. Today, no anti-
malarial drug can prevent the burst of red blood cells; all they do is to check
the growth of the trophozoites or stop the schizogony. Therefore, it is fair to
conclude that in Neijing, at least in the chapter On Malaria, the authors knew
what they were talking about and this knowledge remains valid up to this day,
with little revision. In many instances, the evil qi (xieqi) seems hard to define.
Here, it is a tangible entity, a pathogen in the form of a parasitic organism.
Malaria is coming back with a vengeance in the present age.31 Perhaps it is
time to read Neijing again.

Addendum by Dr. W. F. Pau

It is truly remarkable that the traditional Chinese medicine practitioners of
ancient times were able to recognise malaria as a febrile disease distinct from
others by virtue of the varied periodicity of the paroxysms. By 1885, Italian
pathologists had discovered the association of the paroxysms with the biolog-
ical behaviour of the different forms of malarial parasites. Before that time,
nobody had any idea as to why one disease had such varied presentation.
In the Explanatory Notes, an accurate account of the parasitology and the
pathogenesis of malaria has been given. The clinical manifestations, periodic
paroxysms of chills, rigour and fever, are so characteristic as to make malaria
stand out from other febrile illnesses. Yet malaria is cited in the differential
diagnosis of practically all kinds of fever, which goes to show that a definitive
diagnosis of malaria cannot be clinched on the clinical presentation alone but
has to rely on the identification of the plasmodium in a blood smear, an inves-
tigation ordered by the clinician with a good nose. Any person who has
sojourned in a malarial area and subsequently falls ill should be suspected of
having malaria until it is proven otherwise.
On this premise, one can agree that the explanation given in Zhang Deng-
ben’s book (page 273, ref. 1) that “warm malaria” and “icteric malaria” are
pseudo-malaria, is too presumptive.

31
See National Geographic, July 2007.

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 350 Neijing Zhiyao Yigu 內經知要譯詁

The statement that “warm malaria is due to an exposure to wind in

winter” is enough to make readers doubt whether “warm malaria” is true
malaria. Mosquitoes do not thrive in winter in the flood plains of the Yellow
River and the Yangzi, nor in most districts apart from Hainan, Taiwan and
parts of Yunnan. Therefore, patients in the heartland of China, where the
majority of medical practitioners of Neijing times lived, could not have
contracted malaria. However, it is a known fact that the incubation period of
malaria can be as long as one year, or even longer, and a person bitten by an
infected mosquito in late summer one year may manifest symptoms in the
following year.
But, later in the paragraph, the Neijing authors suggest a hypothesis,
which was tantalisingly close to the truth about the pathophysiology of
malaria. They say that the disease is hoarded in the kidney. They single out the
kidney because of the relationship between the season and the zang-organ
most likely to be affected by the evil qi; in winter, this is the kidney (see
Section 8.16). “When the evil qi leaves the body, it spills from the kidney to
the interior of the body first before it can finally find its way out.” They envis-
aged that the plasmodium (evil qi) would break out of the zang-organ (actually,
the liver) and spill into the body fluid (blood plasma) before making its way
to the outside, not vaporising into the air along with sweat, but moving into
the sucking apparatus of a feeding mosquito! “When yangqi is diminishing,
the evil qi may re-enter the body” may be interpreted as the rupture of the red
blood cells with spilling of the merozoites into the plasma and the parasitisa-
tion of other red blood cells, or the reception of a fresh dose of sporozoites
from an infected mosquito. So, whether chills come before or after fever
should not cause confusion, particularly if there is a double infection.
It is more difficult to interpret “icteric malaria”. This seems to be chronic
malaria superimposed on a pre-existing lung or intestinal infection; the
co-morbidity accounts for the muscle-wasting.
Even more enigmatic is the description that the evil qi would travel down
the vertebral column at a constant pace, one vertebra per day, indicated by a
progressively lengthened interval between paroxysms. Such a pattern of devel-
opment does conform to the clinical observation that the paroxysms become
less frequent and finally disappear as parasitised red blood cells are being
removed from the plasma by the reticulo-endothelial system of the body. It is
quite probable that the vertebral column description is meant to be a guide
for acupuncturists.

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 Morbid Manifestations 351

Footnotes

[1] occur regularly: The evil wind as a pathogen is unpredictable; disease caused
by evil wind comes and goes unannounced. With this in mind, the bouts of
malarial fever occur regularly although it is thought of as a wind-borne
disease. The paroxysmal nature of malarial fever makes it distinguishable
from other febrile diseases. The Chinese word 蓄 作 xuzuo (confinement, i.e.
remission, and outbreak, i.e. relapse) describe truly the intermittency of
malarial fever.
[2] Here, the shao-yang conduits are missing, but shao-yang is considered the
hinge linking the tai-yang and yang-ming conduits (see Suwen Chapter 6:
Shao-yang wei shu 少 陽 為 樞), so it is taken for granted that the shao-yang
conduit must be deficient too when the tai-yang and yang-ming conduits are
both deficient in qi flow. See the explanation by Zhang Yin-an (Suwen
Chapter 35, ref. 12).
[3] interior feels hot: This is a reference to virtual fever (or internal fever, neire
內熱) due to yin deficiency. It is a local fever of low temperature, often in the
palms of the hands and soles of the feet. See ibid. 8-6-2.
[4] quotidian malaria: Quotidian malaria (rizuo 日 作, “daily outbreak”) is actu-
ally double tertian malaria, i.e. the patient is infected with two different
batches of plasmodium. But it can be two different kinds of plasmodium, e.g.
subtertian and tertian.
[5] tertian malaria: After explaining the discrepancy in the chronicity of malarial
attacks, the original text in Neijing comes back to explain the reason for
tertian malaria (jianzuo 間 作). To quote verbatim: “Because the evil qi pene-
trates the interior and confronts the visceral organs, which are linked across
[the body cavity] by the mesentery (muyuan 募 原), it is travelling a longer
route, penetrating deeper into the body and as a result moving slower. It falls
behind the movement of the defensive qi and cannot transpire together with
the defensive qi [at the fengfu acupoint]. For this reason, the attack occurs
every other day”. The mesentery, as well as the pancreas, are loose adipose
tissues and soon degenerate after death. Ancient anatomists had no concrete
idea of these loose organs/tissues, as they had of the firm visceral organs. But
all clinicians down the ages held firmly to the idea of muyuan as the patho-
logical hearth where resides the malaria parasites, thus acknowledging an
exoerythrocytic stage.
[6] acupoint fengfu: 風府 DU-16, is considered a dedicated acupoint for treating
malaria (as well as other neurological disorders). However, a unique

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 352 Neijing Zhiyao Yigu 內經知要譯詁

acupoint, nüemenxue 瘧門穴, not belonging to any regular conduit (jing wai
qi xue 經 外 奇 穴), is located at the rim of the web between the middle and
ring fingers on the back of the hand.
[7] spinal column: The term “spinal column” (lü 膂) refers both to the vertebra
and the back muscles (erector spinae). Here, it means going through the
vertebral column. It can also mean the aorta that travels with the vertebral
column.
[8] sacrum: Li Zhong-zi counted 3 cervical and 21 spinal vertebrae between the
fengfu acupoint and the sacrum. Actually there are 7 cervical, 12 thoracic and
5 lumbar vertebrae. Fengfu is at the level of the occipital protuberance, i.e.
the atlas.
[9] deep in the back muscles: Li Zhong-zi misquotes Neijing as saying fulü zhi
nei 伏 膂 之 內), where the word “nei” 內 is in fact “mai” 脉, an error intro-
duced by himself. The conduit lying deep in the back muscles is the Chong
conduit. So this sentence actually means 伏 膂 之 , deep-lying Chong
conduit.
[10] earlier by one day: Li Zhong-zi visualised the advance of the evil qi (the plas-
modium) going down inside the vertebral column at the rate of one vertebra
each day. Finally, it would reach the sacrum by the 26th day. From here, it
would come out of the vertebral column and drain into the Chong conduit
that lay in a bed of back muscles. Now without a physical hindrance, as when
moving from one vertebra to the next, the evil qi could travel much quicker.
It would take only nine days to reach the shoulder pit (supraclavicular fossa).
There is no reason to imagine that the evil qi actually moves at this rate, in
this direction or on this trajectory. It serves only a convenient way to explain
why, in the advancing phase of malaria, each attack comes later than the
previous one. On the contrary, during remission, each attack comes earlier
by one day. There are more explanations in this connection in the original
text which have not been quoted.
[11] cold malaria: There is no malaria without fever. But in algid malaria, there
are signs of exhaustion and shock, the skin is cold to the touch and there is
internal bleeding. The patient is in a state of extreme debility.
[12] warm malaria: Wennüe 溫 瘧. Malaria caused by Plasmodium vivax and ovale
are relatively mild. However, due to a para-erythrocytic stage in the liver, it
will relapse, making eradication difficult.
[13] icteric malaria: Dannüe 癉 瘧, malaria with not only fever, but also muscle
wasting. Malaria caused by Plasmodium malariae has only mild fever. It

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 Morbid Manifestations 353

occurs every fourth day as quartan malaria. However, it tends to run a

chronic course so that the patient is emaciated and jaundiced with a sallow
complexion. The character 癉 dan means “high fever”; it is also a homo-
phone of dan 疸, “jaundice”. This is often accompanied by splenomegaly. It is
surprising that swollen spleen and liver in malarial patients are never
mentioned in Neijing, but only later in Jingui yaolüe, although palpation is a
standard diagnostic method.
[14] quintan or nonan malaria: The explanation may not be valid, but Neijing
does note some types of malaria with a longer intermittency.
[15] stunned by heat: The Chinese word 爍 shuo means “metal melting”, hence
wasting, debilitating like the proverb “Prevalent rumours can melt gold
[distort the truth]” (zhong kou shuo jin 眾 口 爍 金). It explains the degree of
damage alone to the brain (stunned by heat) in cerebral malaria.
[16] resulting in chills: This is a vivid description of re-infection during the para-
erythrocytic stage.
[17] to express themselves: In modern parlance, from the hepatic stage to the
erythrocytic stage.
[18] muscle wasting: The same character 爍 shuo, see [15] above.
[19] chronic malaria: Zhang Zhong-jing recognised a kind of chronic malaria
with splenomegaly. The term nüemu[mei] 瘧 母〔痗〕, may mean simply
“mother of malaria”, i.e. a latent or carrier malaria. But annotators liked to
explain mu 母 (mother) as mei 痗 (disease); apparently they did not know
the natural history of malaria.

[Section 8.16] Suwen Chapter 38: On Tussis

《素問．咳論》曰：皮毛者，肺之合也。皮毛先受邪氣，邪氣以從其合也。
其寒飲食入胃，從胃（肺）脈上至於肺則肺寒，肺寒則外內合邪，因而客
之，則為肺咳。五藏各以其時受病，非其時各傳以與之。
人與天地相參，故五藏各以治時感於寒則受病，微則為咳，甚則為
泄、為痛。乘秋則肺先受邪，乘春則肝先受之，乘夏則心先受之。
肺咳之狀，咳而喘息有音，甚則唾血；心咳之狀，咳則心痛，喉中介
介如梗狀，甚則咽腫、喉痺；肝咳之狀，咳則兩胠下痛，甚則不可以轉，
轉則兩胠下滿；脾咳之狀，咳則右胠下痛，陰陰引肩背，甚則不可以動，
動則咳劇；腎咳之狀，咳則腰背相引而痛，甚則咳涎。

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 354 Neijing Zhiyao Yigu 內經知要譯詁

五 藏 之 久 咳，乃 移 於 六 府。脾 咳 不 已，則 胃 受 之。胃 咳 之 狀，咳 而

嘔，嘔甚則長蟲出；肝咳不已，則膽受之。膽咳之狀，咳嘔膽汁；肺咳不
已，則大腸受之。大腸咳狀，咳而遺矢；心咳不已，則小腸受之。小腸咳
狀，咳而失氣，氣與咳俱失；腎咳不已，則膀胱受之。膀胱咳狀，咳而遺
溺；久咳不已，則三焦受之。三焦咳狀，咳而腹滿，不欲飲。

此皆聚於胃、關於肺，使人多涕唾而面浮腫、氣逆也。

The body hair and skin are paired with the lungs. If the body hair and skin
were the first to be invaded by the evil qi, this qi would necessarily affect the
lungs with which they are coupled. If one consumes cold food and drink, the
coldness will rise up to the lungs via the pulmonary [not stomachic] conduit
[1]; the lungs are then afflicted by cold. With a cold lung, the evil qi from
outside and inside would conflate and stay in the lung, harming it; lung cough
[2] will ensue. The five zang-organs are susceptible to illness during their
corresponding seasons. If they are sickened outside their seasons, the disease is
probably passed on to the sick organ by other visceral organs [which have
become] diseased during their corresponding season.
Men live according to the rhythm of nature. Therefore when each of the
five zang-organs is afflicted by cold during its favourite season, a light
symptom is coughing, more serious symptoms can be diarrhoea and pain. In
autumn, the lungs are most likely to be affected by evil qi. By the same token,
in spring, the liver [will be affected]; in summer, the heart; in late summer, the
spleen [3]; in winter, the kidney.
The presentation of lung cough is coughing with noisy breathing, in more
severe cases, haemoptysis. In heart cough, the heart hurts when coughing; one
feels as if there is a lump stuck in the throat, and in more severe cases, there
will be pharyngeal swelling and laryngeal paralysis. In liver cough, the hypo-
chondrium hurts when coughing; it can be so bad that one is unable to turn
the waist. If one turns the waist, one feels swollen below the ribs. In spleen
cough, the side of the rib-cage under the right armpit hurts, and a dull pain
spreads to the shoulder blade. In more severe cases, one can hardly move at
all; any movement would bring on explosive coughing. In kidney cough, the
waist and back seem to pull together in a painful way, and in more severe
cases, one spits out saliva with coughing.
When the five zang-organs are coughing persistently, the symptoms
spread to the fu-organs. A chronic spleen cough will affect the stomach.

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 Morbid Manifestations 355

Stomach cough [4] is coughing with emesis, and in serious case, one vomits
up long worms [ascaris]. A chronic liver cough will affect the gall bladder. In
gall bladder cough, one vomits up bile juice. A chronic lung cough will affect
the large intestine. In large intestine cough, one defecates involuntarily when
coughing. A chronic heart cough will affect the small intestine. In small intes-
tine cough, one becomes flatulent when coughing; flatulence stops when
coughing stops. A chronic kidney cough will affect the urinary bladder. In
urinary bladder cough, coughing is accompanied by enuresis. If coughing [of
any visceral organ] persists, the three burners will be affected. Three burners
cough makes the abdomen feel full and there is loss of appetite.
All these symptoms are eventually related to the stomach, which in turn
affects the lung. They make one dribble tears and saliva and the face is swollen
[5]. This is because the flow of qi is reversed.

Explanatory Notes

Suwen Chapter 38: On Tussis is the last of the four chapters that constitute Vol.
10, the first two being devoted to malaria. Actually, Volumes 9 to 12 all involve
specific disease groups characterised by their corresponding symptoms; many
citations from these chapters form the susbstance of Chapter 8 in this book.
Yet Vol. 10 stands out as a particularly lucid example of clinical pathology
because the two groups of diseases, viz. malaria and tussis (coughing), are well
represented by characteristic symptoms. In malaria, the authors of Neijing
describe correctly the presentation of malarial fever; this is essentially identical
to what we know about malaria today, except for the pathogen. As to
coughing, the authors of Neijing point out correctly that not only the lungs
are involved in coughing, every visceral organ can be the ultimate cause of
coughing. The chapter actually began with Huangdi asking naively: “Why does
the lung cause coughing?” Qibo answers: “The five zang-organs and six
fu-organs could all cause coughing, not only the lung.” The rest of the chapter
tells us why.
Coughing is a reflex action that involves mainly the lungs. In lung diseases
like tuberculosis, pneumonia, or pulmonary oedema, the patient coughs.
However, one may cough in spite of healthy lungs and respiratory tract. For
example, one coughs when suffering from mitral stenosis, a disease of the heart
(see ref. 58). Another example is coughing due to gastro-oesophageal reflux

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 356 Neijing Zhiyao Yigu 內經知要譯詁

disease. This is a condition related to the stomach and in turn affects the
lungs. There is also drug-induced coughing, such as with the use of
angiotensin converting enzyme (ACE) inhibitors; these slow down the
breakdown of bradykinin, a vasodilator, the accumulation of which causes
coughing.
The main organ other than the lung that is involved with coughing is the
stomach. According to Neijing, indigestion in the stomach, with cold food and
drink reducing stomach activity, will cause coughing. The term stomach
cough (tussis stomachalis) actually occurs in medical dictionaries. Of course, it
is not the stomach that coughs; it is the aberrant functioning of the stomach
that causes the lung coughing. Stomach function must be considered together
with spleen function, for the two together provide the basis of intermediary
metabolism. Thus it would be fair to generalise that a diseased zang-organ
sends a distress signal to the lung, which then sounds the siren to warn the
macrosystem (i.e. the person himself) and his physician that something is
wrong inside. By the same token, the other symptoms: vomiting, flatulence,
incontinence, or diarrhoea for that matter, are other methods of “sounding
the siren”, prompting the patient to seek medical attention and the physician
to investigate.
In clinical Chinese medicine, the immediate cause of coughing can be
divided into two categories, viz. infection by external pathogens (waigan 外感)
and internal injury (neishang 內 傷). External pathogens cause infection of the
respiratory tract. There is fever and accumulation of mucus. Coughing is
productive, with thick yellow mucus. This is the “hot cough” in Chinese medi-
cine. The causative factor hits directly. Internal injury is due to diminished
activity of one or more visceral organs that leads to a weakened body. This
disease state is related to the lung and presents as coughing. There is no fever
and little accumulation of mucus. Coughing is not productive, or perhaps
some frothy white mucus is released with difficulty. This is the “cold cough” in
Chinese medicine. The ultimate causative factor acts indirectly. Thus if the
underlying cause of coughing is not known, over-the-counter products aiming
at symptom suppression by treating it with anti-tussives like codeine and
opioids, or palliative measures like demulcents, can only hide and aggravate
the true nature of the disease. Coughing must be taken seriously and in a
holistic manner: this is the message from Neijing. It is not surprising that with
this holistic view, Chinese medicine treats coughing with great success. The
same appraisal may extend to asthma.

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 Morbid Manifestations 357

Footnotes

[1] pulmonary conduit: This is the correct wording. Li Zhong-zi wrongly quotes
it as “stomachic conduit”.
[2] lung cough: All coughing related to an organ is construed to mean that it is
caused by a malfunction of that organ. It is not a particular organ that is
coughing, which is a function reserved for the lung.
[3] late summer: spleen: The term zhi yin 至 陰 can mean “reaching the yin”, or
“extreme yin”. In the case of spleen, the yin nature (handling of metabolic
substances) is active during all seasons, but more so during late summer
(chang xia 長 夏) when nature starts moving towards the yin domain. Suwen
Chapter 61: On Oedema and Febrile Diseases says: “The spleen has the most
yin because it is full of water [fully in charge of water distribution].”
[4] stomach cough: There is such an entry in Churchill’s Illustrated Medical
Dictionary (Churchill Livingstone, 1989). It is reflex coughing caused by
stomach trouble or dysfunction.
[5] face is swollen: This refers to the release of histamine during active
coughing.

[Section 8.17] Suwen Chapter 21: Further Discussion on

Conduits

《素問．經脈別論》曰：夜行則喘（惴）出於腎，淫氣病肺；有所墮恐（墜），
喘（惴）出於肝，淫氣害脾；有所驚恐，喘（惴）出於肺，淫氣傷心；度水
跌僕（撲），喘（惴）出於腎與骨。當是之時，勇者氣行則已，怯者著而為病
也。

When one walks at night feeling apprehensive [1], it affects primarily the
kidney. An intemperate qi [2] will then arise from the kidney that harms the
lung. When one falls from a high place [3], the fear arises from the liver;
this intemperate qi will be detrimental to the spleen. When one is frightened,
the fright arises from the lung; this intemperate qi will hurt the heart. When
one falls into water while fording a stream, the fright arises from the kidney
and bone. At this moment, a brave man will soon re-establish the smooth
flow of qi, while a faint-hearted person will stay in this state and disease will
ensue.

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 358 Neijing Zhiyao Yigu 內經知要譯詁

Explanatory Notes
Suwen Chapter 21 is the first of four chapters in Vol. 7 that discuss the adverse
effects of fear or fright on zang-organs. It would be more appropriate to have
them appear in Chapter 5 of this book, Visceral Organ Images in which
another section of Chapter 21 of Suwen has already been quoted (see above,
Section 5.7). By “further discussion”, the title implies that one could correlate
the relevant signs with pulse pattern, but the discussion is not based on
conduit itinerary. Indeed, Chapter 21 begins with Huangdi asking: “Where
one lives, one is apt to face various situations that are sedentary or ambulent,
brave or faint-hearted. Would one’s pulse pattern change accordingly?” This is
a simple and straightforward question, as everybody must have experienced a
racing heart when frightened. Qibo’s answer constitutes the substance of this
section. The next paragraph has already been quoted in Section 5.7. The same
line of thinking is elaborated in detail in Chapter 22, where seasonal changes
of pulse pattern and their corresponding diet are expounded. This constitutes
the essence of Chinese dietary culture, in which the properties of food will
necessarily affect zang-organ performance. The reasoning unavoidably follows
the “five elements” framework, but there is much of practical significance in
the theory that is totally valid up to this day. Chapter 22 introduces the
concept of “tonics” (bu 補) that is deeply ingrained in Chinese dietary culture.
The theoretical basis of applying tonics is clearly outlined in this chapter. Later
Wang Hao-gu 王 好 古 (ca. 1200–1308), in his Tangye bencao 湯 液 本 草
(Bencao for Decoctions), defined bu 補 as the property of food/medicine that
complements the corresponding zang-organ, whereas xie 瀉 refers to the prop-
erty of food/medicine that weakens the corresponding zang-organ. These
views were strongly endorsed by Li Zhong-zi in his Yizong bidu 醫 宗 必 讀
(Obligatory Reading on Principles of Medicine). Chapter 23 develops along
the same theme and the three chapters together (21–23) could be read as an
independant monograph on “Diet Therapy” (shizhi 食 治), to which Sun
Si-miao devotes one whole chapter (Chapter 26) in his One Thousand Gold
Prescriptions. There he strongly advocates dietary control prior to medication.
The last chapter (Chapter 24) is more concerned with acupuncture with
regard to the patient’s mental state. The paragraph on “the five emotional
states and physical constitution” (wu xingzhi 五形志) has been a guiding prin-
ciple in the joint, or alternate, administration of acupuncture and medication.
It leaves us with the conviction that at the time of Neijing, herbal medicine

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 Morbid Manifestations 359

was as well developed as acupuncture. Now we know that there was also diet
therapy.

Addendum by Dr. W. F. Pau

The message conveyed in this section is that systemic disease may be precipi-
tated by psychological as well as environmental factors.
The intemperate qi labelled as yinqi 淫 氣 may be construed to mean that
the body reacts to physical harm or psychological stress by the fright or flight
response, brought about by catecholamines secreted from the sympathetic
post-synaptic nerve endings in the organs mentioned: the kidney (which
embraces the suprarenals), the liver, the spleen (pancreas), the heart and the
lungs. One should allow for the inter-organ relationship hypothesised by the
Neijing authors, which must necessarily differ from that understood by
modern-day physicians/scientists.
Catecholamines of the sympathetic nervous system work on the cardio-
vascular system by increasing the heart rate, myocardial contractility and
conduction velocity at the junctional tissue, also by augmenting central
venous return, resulting in increased cardiac output. The biological cost to
such a response is increased oxygen consumption, which means that people
with decreased cardiac reserve may come to harm. There is a re-distribution
of the cardiac output, which is diverted to the brain, the heart and the skeletal
muscles from the skin, subcutaneous tissue, mucosa and the splanchnic and
renal beds. The intestines and the kidney are disadvantaged as a result.
The kidneys are inextricably involved in this fright response. Firstly, the
suprarenals pour out adrenaline, which enters the circulation to augment the
local action of catecholamines secreted by sympathetic nerve-endings in the
tissues. Secondly, catecholamines stimulate sodium reabsorption by a direct
effect on the renal tubules, and also act on the juxtaglomerular apparatus,
triggering the release of renin. Both mechanisms serve to conserve the extra-
cellular fluid volume.
With regard to metabolism, catecholamines mobilise stored fuel, in the
shape of glucose, free fatty-acids and lactate from the liver, adipose tissue and
muscle for local as well as distant consumption. They also act on the pancreas,
suppressing insulin and increasing glucagon production, thus reinforcing
hepatic glucose output. The effect of catecholamines on the lung is one of
stimulating bronchodilation.
As a result of stress, the organs are made to work harder, but at the end of

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 360 Neijing Zhiyao Yigu 內經知要譯詁

the day, provided that the compensatory mechanism stated above is intact,
health is restored in the majority of instances.

Footnotes

[1] apprehensive: According to Zhang Deng-ben (ref. 1), the character 喘 chuan,
(panting) was changed to 惴 zhui (apprehension, fear, worry),32 citing Sun
Ding-yi 孫 鼎 宜. The translation and interpretation of this paragraph is
based on this revision, which does make sense. While for coughing, it has
been reasonably explained that other zang-organs might also cause a cough,
it is hard to accept that the panting arises from the liver and affects the
spleen. There is no mention of zhui 惴 in Dictionary of Neijing (ref. 30).
However, in Taisu and Jiayi jing, the character 喘 chuan is written 揣 chuai,
which usually means “guess”, but also “shaking” or “struggling” in
compounds. Further on in the same paragraph, there is discussion of
sweating arising from the five zang-organs. Here again, sweating due to
perturbed heart and kidney (adrenal) function seems reasonable, but
sweating due to perturbed liver, spleen and stomach functions would be hard
to comprehend in the light of modern medical knowledge. Sun Ding-yi was
a typical example of a scholar turned physician (you ru ru yi 由 儒 入 醫). He
spent some time in Japan at the beginning of the twentieth century, and later
returned to his native Hunan to teach Chinese medicine. His collected works
were published in 1932. An independent manuscript written in 1909 and
entitled Huangdi Neijing zhangju 黃 帝 內 經 章 句 (Key Sentences from
Huangdi Neijing) in 18 volumes attested to his expertise in this field.
[2] intemperate qi: The term yinqi 淫 氣 means “excessive or abundant qi”. It
refers to the hyperfunction of zang-organs under the influence of a surge of
adrenaline out of fear. It is translated as “intemperate” here to distinguish it
from xieqi 邪 氣 (“pathogens”) and liu yin 六 淫 (the “six excessive climatic
factors”).
[3] falls from a high place: The term duo kong 墮恐 (falling and fear) in the orig-
inal text makes no sense. Zhang Deng-ben changed it to duo zhui 墮墜 (falling
down). The latter term appears in Lingshu Chapters 4 and 58.

32
《莊子．齊物論》︰「小恐惴惴。」

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 Morbid Manifestations 361

[Section 8.18] Suwen Chapter 40: On Abdominal Diseases

《素問．腹中論》曰：心腹滿，晝食則暮不能食，名為鼓脹。治之以矢
醴，一劑知，二劑已。

With a belly swelling up to the breast bone [sternum], one can only eat in the
morning and remains full in the evening. This is tympanites [1]. Treat it with
chicken dropping tincture [2]. It remits with one dose. By the second dose,
one will be cured.

Explanatory Notes
Suwen Chapter 40 is different from other chapters in Neijing in the sense that
it discusses abdominal diseases without reference to the conduits and the
treatment suggested is medication with drugs rather than acupuncture. It is
agreed that Neijing had multiple authors representing different schools of
thought and medical practice, of which the dominant group were believers in
conduits and practitioners of acupuncture (see ref. 44). This is simply due to
the fact that at the time Neijing was produced, the theory of conduits provided
a unifying concept that explained body function and disease. This does not
mean that other approaches to disease management, like herbal treatment and
physiotherapy, were not as efficient. The inclusion of this short paragraph in
this section only serves to illustrate the diverse origin of Chinese medicine.
Indeed, prior to the appearance of Neijing, detailed documents on herbal
treatments such as the Wushi’er bingfang 五 十 二 病 方 (Fifty-two Prescrip-
tions) and Wuwai Hanjian 武 威 漢 簡 (Wuwei Tablets of the Han Dynasty)
had already indicated the existence of the school of drugs. In Suwen Chapter
40, there were a number of diseases that presented with a swollen belly, hence
the title; they carried specific pathological terms like tympanites (guzhang 鼓
脹), anaemia (xueku 血 枯), oedema due to heart failure or nutritional dropsy
(fuliang 伏 梁) and cold limbs (jueni 厥 逆). These diseases were either treated
with drug decoctions, or not at all, but for some of them mineral or aromatic
drug treatments were prohibited. This showed the judicious attitude of
ancient pharmacists. Towards the end of the paragraph, there is one sentence
that refers to the detection of pregnancy at term. The indication was that the
patient felt uncomfortable but there was no sick pulse pattern. Perhaps this
served as a reminder that in spite of the advocacy of drug treatment in this

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 362 Neijing Zhiyao Yigu 內經知要譯詁

chapter, the conduit school always held sway. There are other citations relating
to detection (Section 4.13) and precaution in medication during pregnancy in
this book (Section 7.6).
According to Dr. W. F. Pau, this is a typical case of non-diagnosis of preg-
nancy at term in a patient who was thought to be suffering from tympanites.
Nowadays, medical students are taught to remember the five “F’s”: fat, fluid,
flatus, faeces and foetus, in the differential diagnosis of abdominal distension.
Now and then one does still hear of a woman giving birth at home without
having known that she was pregnant. There have also been cases of pseudo-
cyesis, in which a woman comes to the antenatal clinic repeatedly, insisting
that she is pregnant. These days, any uncertainty would be dispelled through
the use of ultrasound scanning. In Neijing times, it is fair that an intelligent
physician applying the four basic clinical methods of diagnosis should be able
to detect the foetal heart beat.
Actually the sentence “Zou shi ze mo bu neng shi” 晝食則暮不能食 describes
a tell-tale symptom of morning sickness in pregnancy.

Footnotes

[1] tympanites: The Chinese term 鼓 脹 guzhang refers to abdominal swelling

due to a number of causes, like cirrhosis of the liver, ascites, helminthiasis or
even tumour. The swelling refers to the “belly” of the drum (gu 鼓), rather
the surface of percussion.
[2] chicken droppings: Animal droppings are commonly used in Chinese medi-
cine, for example those of the sparrow (known as baidingxiang 白 丁 香), the
flying squirrel (wulingzhi 五 靈 脂), the hare (wangyuesha 望 月 砂) and the
silk worm (cansha 蠶 砂). While these droppings are still prescribed today,
chicken droppings are rarely used, maybe because they are too common.
There are other diuretics and laxatives, but this is a “two in one” that is rare.

[Section 8.19] Lingshu Chapter 35: On Bloating

《靈樞．脹論》曰：夫心脹者，煩心短氣、卧不安；肺脹者，虛滿而喘咳；
肝脹者，脇下滿而痛引小腹；脾脹者，善噦、四肢煩悗、體重不能勝衣、
卧不安；腎脹，腹滿引背央央然、腰髀痛。
胃脹者，腹滿、胃脘痛、鼻聞焦臭、妨於食、大便難；大腸脹者，腸

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 Morbid Manifestations 363

鳴而痛濯濯。冬日重感於寒，則飧泄不化；小腸脹者，小腹月真脹引腰而
痛；膀胱脹者，少腹滿而氣癃；三焦脹者，氣滿於皮膚中，輕輕然而不
堅；膽脹者，脅下痛脹、口中苦、善太息。
厥氣在下，營衛留止；寒氣逆上，真邪相攻。兩氣相搏，乃合為脹也。

When the heart is bloating [1], one feels dysphoric and short of breath, with
restless sleep. When the lung is bloating, one feels empty in the chest but looks
bloated, with a panting cough. When the liver is bloating, the hypochondrium
is full and pain is projected to the underbelly. When the spleen is bloating, one
tends to hiccup [2] with tired limbs; the body gains weight as if too big for the
clothing, and sleep is restless. When the kidney is bloating, the abdomen is
full, causing discomfort at the back; the waist and thighs are hurting.
When the stomach is bloating, the abdomen is full and the stomach hurts;
the nose detects a burnt odour, there are dysphagia [achalasia] and constipa-
tion. When the large intestine is bloating, the bowels rumble and there is colic
pain [borborygmus]. If this were compounded by exposure to cold in winter,
one would pass indigested grains. When the small intestine is bloating, the
underbelly is intensely full, with pain projected to the waist. When the urinary
bladder is bloating, the underbelly is full, with dysuria. When the three
burners are bloating, one feels as if there is air trapped under the skin, which
is light and non-resistant to the touch. When the gall bladder is bloating, the
hypochondrium hurts and the mouth detects a bitter taste; one tends to sigh.
A turbulent flow of qi remaining in the lower part of the body causes in
turn stagnant flow of the nutritive and defensive qi. When a surge of cold
moves upward, it clashes with the zhengqi. These two streams are fighting for
dominance; their combined effect results in bloating.

Explanatory Notes
First of all, it must be stated without ambiguity that the word “bloating” in
this section is not describing the swelling of any visceral organ in volume or
size. It is simply a figurative way of speaking about organ dysfunction that
produces in the patient a feeling of distension. The reference to the zang- or
fu-organ indicates location or function, rather than the organ per se. Thus in
Lingshu Chapter 35, Huangdi begins by asking what the pulse pattern at the
wrist is, if there is bloating. Qibo answers: “If the pulse is strong and hard but
hesitant (se 澀), it indicates bloating.” The curiosity of Huangdi is fired and he

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 364 Neijing Zhiyao Yigu 內經知要譯詁

asks a naïve question: “Since air gives rise to bloating, is this [air] in the blood
vessels or visceral organs?” Qibo tactfully deflects the question by saying that:
“It is possible in all three cases, but it is not actually the site of bloating.” He
goes on to explain that bloating is outside the visceral organs, it compresses
[pushes] the organs and expands the chest and hypochondrium. It makes the
skin feel as if it is swollen; that is why it is called bloating.
This is in essence a description of a dysfunctional state of those visceral
organs that are detected as bloating. It is particularly distinctive when
compared with tympanites (due to air) in the previous section, and oedema
(due to tissue fluid) in the following section. Such a fine distinction of clinical
situations not only reflected the keen observations of ancient clinicians, but
also the refinement in the theoretical basis of different kinds of swelling.
Perhaps this is the undeclared purpose of these three sections following one
another. In the next paragraph, Qibo explains about the visceral organs each
occupying a particular compartment in the chest and abdomen. They are
likened to different rooms and halls in a house and different quarters in a city.
In order to be a functional body, or a functional city for that matter, these
different compartments and quarters should be able to communicate with
each other. If these channels of communication were blocked, congestion
(bloating) would result. The remedy lies with discharging the congestion by
acupuncture. But a good clinician should be able to judge when to replenish
and when to discharge (bu xu xie shi 補 虛 瀉 實). This has become an apho-
rism of clinical practice, whether it concerns acupuncture, drugs or simply
food. The paragraph actually quoted in this section concerns the “shape of
bloating” (zhangxing 脹 形). As it has been explained above, this is actually not
an expansion of shape or form, but rather a feeling that a particular organ is
bloating. Later, in Section 8.32, there are discussions on multi-organ dysfunc-
tion syndrome that are moribund clinical situations not curable by replenish-
ment or discharge.

Footnotes

[1] bloating: Bloating is a kind of swelling that refers to a bloated face, or a

bloated dead body. It is translated here in this way to avoid specifying the
reason for it—e.g. the accumulation of air (tympanites) or fluid (oedema).
In any case, bloating in this case is not to be seen in changing volumes, but
rather feelings of expansion and congestion.
[2] hiccup: the Chinese word 噦 yue refers to the sound made when vomiting. It

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 Morbid Manifestations 365

can be actually vomiting (outu 嘔 吐), or retching (ganou 乾 嘔), or simply

belching (aiqi 噯氣). Here it is translated as “hiccup” (eni 呃逆), as it is more
likely to be a chronic symptom. All these signs can be ascribed to a weak
stomach, which in Chinese medicine is construed to mean weak spleen
function.

[Section 8.20] Lingshu Chapter 57: On Oedema

《靈樞．水脹篇》曰：窠上微腫，如新卧起之狀；其項脈動、時咳、陰股間
寒、足 脛腫、腹乃大，其水已成矣。用手按其腹，隨手而起，如裹水之
狀，此其候也。
膚脹者，寒氣客於皮膚之間， 然不堅、腹大、身盡腫、皮厚；按其
腹，窅而不起，腹色不變，此其候也。
鼓脹者，腹脹、身皆大，大與膚脹等也，色蒼黃，腹筋起，此其候也。
夫腸覃者，寒氣客於腸外，與衛氣相搏，氣不得榮，因有所系；癖而
內著，惡氣乃起，瘜肉乃生。此始生也，大如鷄卵，稍以益大；至其成，
如懷子之狀，久者離歲，按之則堅，推之則移；月事以時下，此其候也。
石瘕生於胞中。寒氣客於子門，子門閉塞，氣不得通，惡血當寫（瀉）
不寫（瀉）。衃以留止，日以益大，狀如懷子，月事不以時下。皆生於女
子，可導而下。

When the lower eyelid [1] is slightly swollen, as if one has just risen from bed,
with the neck [carotid] artery throbbing [2], occasional coughing, feeling cold
on the medial side of the thigh, a swollen shin [3] and distended abdomen,
oedema is well established. When palpating the abdomen, it rebounds when
the hand is lifted, as if pressing onto a bag of water. These are the signature
symptoms of oedema [4].
Peripheral oedema is due to the lodgement of cold evil qi under the skin;
it is tight but empty like a drum. The abdomen is distended and the whole
body is oedematous but the skin is compact [5]. When palpating the
abdomen, the depression remains after the hand is lifted but the skin surface
is unchanged. These are the signature symptoms.
In tympanites [6], the abdomen is distended and the body is enlarged,
similar to peripheral oedema. But the skin appears sallow, with marked veins.
These are the signature symptoms.

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 366 Neijing Zhiyao Yigu 內經知要譯詁

Intestinal polyps are due to the lodgement of cold evil qi outside the
intestine. There it confronts the defensive qi that loses its momentum. There-
fore the cold evil qi has the chance to dig in its heels and attaches itself to the
intestine. This becomes the causative factor of intestinal polyps. At the begin-
ning, the polyps are no larger than an egg. It keeps growing, as if one is preg-
nant. After a year or more, it hardens and is movable upon pushing. However,
menstruation continues. These are its signature symptoms [7].
Concretion of a stony consistence grows inside the uterus. The cold evil qi
is lodged in the cervix [8] blocking its patency. Therefore the menses cannot
pass through and remain inside. It accumulates over the days as if one is preg-
nant. Menstruation stops. These [two cases] happen only in women. This situ-
ation can be improved by draining and discharging the menstrual flow [9].

Explanatory Notes
This is the third section in a series in NJZY that discuss swelling, in this case,
exactly oedema as it is entitled. The primary purpose of this chapter in
Lingshu (Chapter 57) is to provide a guideline to distinguish between the
different oedematous states due to different causative factors. The causation
and the major symptoms are highlighted in the text in a definitive manner.
Huangdi asks: “What is the difference between oedema, peripheral oedema
[literally skin oedema], tympanites, intestinal mushrooms, stony concretions
and stony oedema?” Each of these cases is quoted in the text, except for the
last one, stony oedema (shishui 石 水), which is left unanswered. This is prob-
ably an omission, for the term “stony oedema” appears elsewhere in Neijing
(Lingshu Chapter 4, Suwen Chapters 7 and 48). It concerns a sinking pulse
[hard to detect] caused by kidney and liver dysfunction. This short chapter
ends with Huangdi asking: “Can peripheral oedema and tympanites be treated
by acupuncture?” Qibo proposes letting blood from the branching blood
vessels, before trying to regulate the principal conduits.
After references to the detection of pregnancy and medication during
pregnancy, this section discusses two clinical cases pertinent to gynaecology (jie
sheng yu nü zi 皆 生 於 女 子). One would think that women’s diseases are easy
to understand in the light of modern medicine, because they must necessarily
involve hormones, and the pathological sites are localised on the female repro-
ductive tract. The translation and annotation of this section was thus of
particular interest.

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 Morbid Manifestations 367

Ever since the Jesuits introduced anatomy and physiology to China in the
late Ming dynasty, there has been a trend to identify the “state of disease” (zheng
證) in Chinese medicine with a particular disease (bing 病) in Western medi-
cine. This trend gathered momentum around the turn of the twentieth
century, when Western medicine demonstrated its efficacy with chemotherapy
and surgery. By the 1930s, this development reached its climax when the then
nationalist government of China proposed to abolish traditional Chinese
medicine altogether. Although this draconian measure was aborted thanks to
nation-wide mass protest, (see Xie Guan in the Introduction), today it still
remains in the subconscious of many practitioners of Chinese medicine that if
a “state of disease” could be equated with a definite disease with identifiable
causation, then the diagnosis would be well established; otherwise, it might be
a case of signs and symptoms only. Hence most modern annotators of Neijing,
including Qin Bo-wei, Zhang Deng-ben and Wang Hong-tu, have identified
“intestinal mushrooms” with cystic ovary, though not without reluctance in
the case of Qin.
For such “mushrooms” (xun 覃 [=蕈], mushroom), early clinicians must
have had the opportunity to feel a palpable mass and realised that it was an
outgrowth attached to the intestine or Fallopian tube. In Neijing times, gynae-
cological examination may have been permissible, as Bianque (Qinyueren)
was accorded the title of a gynaecologist (dai xia yi 帶 下 醫, disease below the
belt). That would imply some particular physical examination pertaining to a
gynaecologist. As late as the Tang dynasty, Zan Yin, an army surgeon, wrote A
Treasure for Obstetrics of Proven Efficacy,33 first published in 847, and updated
in 897. A monograph on gynaecology written by the monks of the Bamboo
Grove Temple (Zhu Lin Si 竹 林 寺),34 in the prefecture of Xiaoshan, near
present day Hangzhou, was repeatedly updated after the fifth century. (See ref.
53, p. 224). All previous annotators have taken such “mushrooms” to be
ovarian cysts, which can grow to a palpable size and have a consistency like
that of a dermoid cyst. An ovarian cyst, irrespective of its size, does not inter-
fere with normal menstruation. However, it must be quickly pointed out that
an ovarian cyst is not the same as polycystic ovary. Polycystic ovarian
syndrome (PCOS) is characterised by anovulation and hyperandrogenism,

33
昝殷：《經效產寶》。
34
《蕭山竹林寺女科秘方考》。

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 368 Neijing Zhiyao Yigu 內經知要譯詁

and the presence of tiny cysts in one or both ovaries. PCOS would be incom-
patible with the statement that menstruation is regular (yue shi yi shi xia 月 事
以時下).
Since the text mentions polyps (xirou 瘜 肉), it would be tempting to
identify the “mushrooms” as intestinal polyps, duly stalked and capped like a
mushroom. Polyps are outgrowths on the mucosal surface, i.e., inside the
intestinal lumen, very much like a mushroom. They are rarely so large as to be
palpable, because in this case they would produce intestinal obstruction.
Intestinal polyps are basically of two kinds, one colorectal, which has a high
tendency to turn cancerous; the other, of the small intestine, which may bleed
and sometimes induces telescoping of one section of the intestine with
another (intussusception). Since none of these symptoms are mentioned,
intestinal polyps can be ruled out. Polyps occur in both sexes.
It seems unlikely that the text was actually describing an ectopic preg-
nancy. An ectopic pregnancy is rarely large enough to become palpable. It is
painful and amenorrhoeic, and neither of these symptoms is mentioned in the
text. But most importantly, an ectopic pregnancy would not last for over a
year (jiu zhe li sui 久 者 離 歲) and would not disappear with use of emmena-
gogues (dao er xia zhi 導 而 下 之). If it did not atrophy of its own accord, it
would rupture at a late stage, causing intense pain and internal bleeding. That
is not mentioned in the text. Even less likely is endometriosis, which is painful
and causes bleeding.
Xu Ling-tai 徐 靈 胎 (1693–1763) of the Qing dynasty confirmed that
“stony mushrooms” grew outside the uterus (or intestine) so that there was
still menstruation, whereas “stony concretions” were bad blood remaining
inside the uterus so that there was amenorrhoea. According to Dr. W. F. Pau,
this observation points to the presence of retained menstruation (cryptomen-
orrhoea). Due to an obstruction in the vagina or cervix, the menses can accu-
mulate in the vagina (haematocolpos), uterus (haematometra) or Fallopian
tube (haematosalpinx). Over time, the accumulated blood is inspissated and
turns semi-solid. This exactly fits the description of “stony concretion” in
every aspect except the fact that cryptomenorrhoea can only be positively
confirmed by physical examination (rectal, vaginal) of the patient. It is not
certain that Bianque was allowed to go that far in gynaecological examination.
If cryptomenorrhoea occurs in a young girl at the age of menarche, so that the
first period fails to arrive (惡血當瀉不瀉, “bad blood should pass through but
does not ”), then the phrase “menstruation does not arrive on time (月事不以

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 Morbid Manifestations 369

時 下)” can be taken as meaning that the menarche does not occur at the
appropriate age, rather than referring to amenorrhoea in mature women. This
argues in favour of the reference being to cryptomenorrhoea in young girls,
although the age factor is not mentioned in the text.
Zhang Zhong-jing in his Jingkui yaolüe Chapter 22: Miscellaneous Diseases
in Women actually describes blood retention in the uterus. He writes: “In post-
partum women, there might be a swollen underbelly like an ovoid container,
with some difficulty in passing urine but no thirst. This is due to coagulation
of water and blood in the blood chamber. This situation is rightly indicated
for Rhubarb—Euphorbia kansui decoction [a powerful diuretic].” However,
Chinese medicine takes note of vicarious or compensatory menstruation
(nijing 逆 經, daojing 倒 經, literally “reverse flow of menses”), a periodic
bleeding coincidental with menstruation. It is not difficult to extend this
notion to retained menstruation
The ensemble of these considerations revolve around a mass lesion and
its conjectural formation plus the presence/absence of menses, but none of
them permits us to pin it down to a particular disease. It might, therefore, be a
generalised description of these various diseases at different stages. The
purpose of this section is to provide a guideline for the diagnosis of different
presentations of abdominal distension, each stressing their respective signa-
ture symptoms. Inasmuch as the main symptom fits, treatment could be initi-
ated and changed until the problem is solved. It is not necessary to equate
“intestinal mushroom” with cystic ovary because after all, the authors of
Neijing were not relying on knowledge of ovaries and hormones to treat these
“mushrooms”.
The case of “stony concretion” has been identified with uterine myoma or
fibroids by all previous annotators. While there is no menstruation with
fibroids, uterine myoma can be menorrhagic and this contradicts the presence
of regular menses as indicated in the text. It could be argued that in mild and
occasional menorrhagia, the authors of Neijing were able to distinguish it
from a regular period, or the absence thereof. In this context, endometrial
cancer is ruled out because it could involve heavy bleeding.

Footnotes

[1] lower eyelid: The Chinese word 窠 ke means “bird’s nest”, or any other nests.
Thus muke 目 窠 means “the nest of the eye”, which is the eye pocket below
the lower eyelid. Here capillaries come near the surface and a black eye

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 370 Neijing Zhiyao Yigu 內經知要譯詁

pocket indicates lack of circulation. Sometimes it can be swollen due to stress

and lack of sleep. The eye pocket is an indicative sign of a person’s state of
health and it is a focus of attention in visual inspection. The idiom “not
falling into the nest” (bu luo ke jiu 不落窠臼) means one is not bound by the
old format or rules, and is clearly referring to an enclosure or depression.
The puffy eye pocket is described as a “crouching silkworm” (wo can  蠶),
which may mean a swollen lower eyelid. Wo can is also used to describe thick
and bushy eyebrows. Guan Yu 關 羽 of the Three Kingdoms period, an icon
of bravery and loyalty, is described as having “the eyes of a vermilion phoenix
and eyebrows like crouching silkworms ” (dan feng yan, wo can mei 丹鳳眼，
蠶眉).
[2] neck artery throbbing: This is clearly referring to the carotid artery that
throbs with increased blood volume in oedema. This is the acupoint renying
人迎 (ST-9).
[3] swollen shin: The Chinese word 脛 jing means the leg, more precisely the
part of the leg between the knee and the ankle. Thus the tibia is called jing-gu
脛 骨 because it is lying along the length of the leg. Dayu 大 禹 (ca. 2000 bc),
the legendary tribal leader who drained the central flood plain of China, is
said to have lost all the hair on his legs (jing bu sheng mao 脛不生毛) because
he frequently waded through marshes and had no time to return home, even
though he passed his gate three times. In oedema, the leg is swollen, but it
shows up more evidently on the shin than the calf. In clinical examination,
the doctor pinches the ankle to see if it is swollen.
[4] symptoms of oedema: In Taisu, Yang Shang-shan acknowledged these six
criteria of oedema but he placed all three sections together under “Oedema”
in Chapter 29: On Qi. He might have had good reason to do this, because
oedema could be due to lack of qi (heart performance).
[5] skin is compact: In peripheral oedema, there is expansion of extracellular
fluid under the skin, rendering it thin and translucent. It does not involve
abdominal distension.
[6] tympanites: In tympanites, there is accumulation of fluid in the abdomen
due to, e. g. cirrhosis of the liver; there is also increased peritoneal pressure.
Therefore, the skin is thin and the belly rebounds upon palpation. A sallow
countenance indicates liver dysfunction.
[7] signature symptom: The presence or absence of menstruation is the rule of
thumb to differentiate between “intestinal mushroom” and “stony concre-
tion”. The Chinese word 候 hou (sign, symptom, as in zhenghou 證候) is here

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 Morbid Manifestations 371

translated as “signature symptom” to emphasise this point. For the same

reason, all “symptoms” in this section are translated as “signature symptom”,
although it may be less well defined in the other cases.
[8] cervix: The Chinese term “foetal gate” (zimen 子 門) is clearly referring to the
uterine cervix. But if there is retention of menstrual blood inside the uterus,
it is more likely due to blockage in the vagina rather than the cervix. In this
context, the “foetal gate” can be construed to mean the birth canal.
[9] draining and discharging: If this is construed to mean the use of emmena-
gogues, it is hard to conceive how these drugs could remove outgrowths both
inside and outside the uterus. It is possible to drain a cryptomenorrhoea
with a catheter, but that would necessitate a surgical “cut”. Sun Si-miao
claimed to have drained retained urine with spring onion leaves as a catheter.
So the idea of a catheter was not new to Chinese medicine.

[Section 8.21] Suwen Chapter 18: On Normal Pulse

Patterns

《素問．平人氣象論》曰︰頸動疾喘，咳，曰水；目裹微腫，如蠶起之
狀，曰水；溺黃赤、安者，黃疸；已食如饑者，胃疸；面腫曰風；足脛腫
曰水；目黃者，曰黃疸。

When the neck blood vessel [1] is throbbing, with rapid panting [2] and
coughing, it is oedema. When the eyelid [3] is slightly swollen, like a crouching
silkworm raising itself, it is oedema. When the urine is reddish-yellow, but one
can still rest peacefully, it is jaundice [4]. When one still feels hungry after
meals, it is jaundice of the stomach [5]. When the face is bloated, it is “wind”
disease [6]. When the shin is swollen, it is oedema. When the eye is yellow, it is
jaundice.

Explanatory Notes
After the much-quoted Suwen Chapter 17, on the quintessence of sphyg-
mology (Sections 3.1, 4.1, 4.6 and 4.9), comes Chapter18—an important
chapter on normal pulse patterns that is based on adequate stomach function,
i.e. adequate energy supply. Chapter 18 has been cited three times in Chapter 4:
Pulse Diagnosis by Pulse-taking; the two chapters in Suwen Vol. 5 constitute an

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 372 Neijing Zhiyao Yigu 內經知要譯詁

independent monograph on sphygmology. (Vol. 6 also contains two chapters

on pulse-taking, but more on its clinical aspects.) What is quoted in this
section is a less important part of Chapter 18, in which the main idea is the
“genuine zang-organ pulse” (zhen zang mai 真 臟 ). The chapter begins with
a definition of the normal pulse rate, i.e. five beats per breathing cycle. A
normal pulse, it says, is the pulse of a normal person who is not sick (ping ren
bu bing 平 人 不 病). After this apparently naïve statement, it immediately goes
on to say that the basic principle in pulse-taking, as a rule, is to gauge the
pulse of a sick person by that of a normal person. Because the doctor is not
sick (yi bu bing 醫 不 病, “the doctor should not be sick [while on duty]”), he
evaluates the pulse rate of the patient with reference to his own. Now that the
(dynamics of ) a normal pulse is derived from stomach (function), a person
devoid of stomach qi (nutritive support) is said to be in an adverse condition
(ni 逆); an adverse condition could be fatal. Human life is based on water and
cereals; if these are denied, one will die. Similarly, a pulse without the
dynamics of stomach qi is also fatal. A pulse devoid of stomach qi will reveal
the genuine zang-organ pulse (zhen zang mai 真 臟 ). The idea of a “genuine
zang-organ pulse” was first introduced in Section 4.12, then again elaborated
in greater detail in Suwen Chapter 19 (not excerpted). The dynamics of
stomach qi is represented by a taut but pliant pulse; it serves to modulate all
other pulse patterns characteristic of each physiological system. The rest of the
chapter is devoted to discussion of the normal and pathological variation of
pulse patterns pertinent to each zang-organ (physiological system).
What is quoted in this section is a less important part of Chapter 18. This
paragraph is not actually about pulse pattern. It follows the same model as the
previous section, in giving a guideline to distinguish oedema from jaundice,
but towards the end of the paragraph, there is one sentence that was quoted
by Li Zhong-zi in Section 4.13 about the pulse pattern of pregnancy. Jaundice
may appear to be a simple case due to an accumulation of wetness and heat.
Wetness may mean an accumulation of metabolic products, while heat may
mean hyperfunction. Jaundice is due to hyperbilirubinaemia, that is the result
of increased production of bilirubin (haemolysis of red blood cells) and lack
of liver conjugation (wetness). It can be dealt with using agents to remove the
wetness and heat (qing re qu shi 清 熱 去 濕), plus one or two cholagogues
(Gardenia jasminoides, Artemisia capillaris). But jaundice, if not readily
removed, can be an early sign of pancreatic tumour and thus should not be
taken lightly.

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 Morbid Manifestations 373

Footnotes

[1] neck blood vessel: This is the carotid artery. See ibid. 8-20-2.
[2] rapid panting: The original text reads “neck blood vessel throbbing rapidly,
panting and coughing.” According to Taisu, it should read “neck blood vessel
throbbing, rapid panting and coughing.” The revision makes sense.
[3] eyelid: The term muguo 目 裹 (wrappings of the eye) is clearly referring to
the eyelids. If the eyelid is swollen like a silkworm rising up, this is most
likely talking about the upper eyelid. Li Zhong-zi, however, prefers to inter-
pret this as the lower eyelid. The same argument goes for ibid. 8-20-1, where
muke 目 窠 refers to the eye pocket, or even the whole eye socket, but not
particularly the lower eyelid.
[4] jaundice: This is simple jaundice without complications.
[5] stomach jaundice: It is hard to imagine how one can see the stomach turn
yellow. While dan 疸 usually refers to jaundice, it is also a synonym for dan 癉,
which means “fatigued, worn out”. Hence weidan 胃 疸 may mean a stomach
which is over-worked due to polyrexia. Rapid digestion of cereals and facile
hunger (xiao gu shan ji 消穀善飢) is an early sign of diabetes mellitus.
[6] “wind” disease: Disease due to exposure to wind (like fengzhen 風 疹, “rashes
upon wind exposure”). This is an acute allergic reaction involving massive
release of histamine that produces a bloated face and swollen limbs. In Suwen
Chapter 61, it is referred to as fengshui 風 水, which is not to be confused
with geomancy.

[Section 8.22] Suwen Chapter 39: On Pain

《素問．舉痛論》曰：經脈流行不止，環周不休，寒氣入經而稽遲，泣而不
行。客於脈外則血少，客於脈中則氣不通，故卒然而痛。

寒氣客於脈外則脈寒，脈寒則縮蜷，縮蜷則脈絀急，絀急則外引小
絡，故卒然而痛，得炅則痛立止；因重中於寒，則痛久矣。

寒氣客於經脈之中，與炅氣相薄則脈滿，滿則痛不可按也。

寒氣客於腸胃之間、膜原之下，血不得散，小絡急引，故痛。按之則
血氣散，故按之痛止。

寒氣客於俠脊之脈，則深按之不能及，故按之無益也。

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 374 Neijing Zhiyao Yigu 內經知要譯詁

寒氣客於沖脈，沖脈起於關元，隨腹直上，寒氣客則脈不通，脈不通
則氣因之，故揣（喘）動應手矣。
寒氣客於背俞之脈則脈泣，脈泣則血虛，血虛則痛。其俞注於心，故
相引而痛。按之則熱氣至，熱氣至則痛止矣。
寒氣客於厥陰之脈，厥陰之脈者，絡陰器，系於肝，寒氣客於脈中則
血泣脈急，故脅肋與少腹相引痛矣。
厥氣客於陰股，寒氣上及少腹，血泣，在下相引，故腹痛引陰股。
寒氣客於小腸、膜原之間絡血之中，血泣，不得注於大經。血氣稽留
不得行，故宿昔而成積矣。
寒氣客於五藏，厥逆上泄（壅）。陰氣竭、陽氣未入，故卒然痛死，不
知人。氣復反則生矣。
寒氣客於腸胃，厥逆上出，故痛而嘔也。
寒氣客於小腸，小腸不得成聚，故後泄腹痛矣。
熱氣留於小腸，腸中（痛）癉熱焦竭（渴），則堅乾而不得出，故痛而閉
不通矣。

There is a constant flow [of blood and qi] in the conduits [1], circulating
without ever stopping. When the cold evil qi enters the conduits and stays
there, the flow becomes hesitant [2]; it may even stop. If the cold evil qi resides
outside the conduits [3], the flow of blood is diminished. If the cold evil qi
resides inside the blood vessels, the flow of qi is blocked. Therefore, pain arises
abruptly [4].
If the cold evil qi resides outside the conduits, the latter feel cold and start
to contract. While contracting, the peripheral side branches are drawn tightly,
hence the abrupt pain. The pain will be relieved instantly when heat is applied
[5]. If one is exposed to cold while still feeling pain, this will turn into chronic
pain.
If the cold evil qi resides inside the conduits and confronts the warmth of
the blood therein, the conduits become full. Fullness hurts and becomes worse
when compressed [6].
If the cold evil qi resides among the stomach and intestines below the
pleuro-diaphragmatic space [7], blood will not spread [cannot be distributed].
The side branches are drawn tight; that is why it is painful. When compressed,
blood is dispersed; that is why the pain stops upon compression [8].
If the cold evil qi resides in the conduits alongside the spine [9], it cannot

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 Morbid Manifestations 375

be reached even by pressing deeply. In this case, it is useless [trying to relieve

pain] by compression.
If the cold evil qi resides in the Chong conduit, which starts from acupoint
guanyuan, it goes up the abdomen [10]. With the cold evil qi inside, the
conduit is blocked. Consequently, the flow of qi is interrupted. Therefore
muscles of the painful area can be felt twitching upon touching [11].
If the cold evil qi resides in the conduit on the back that carries the shu
acupoints [12], the [flow inside the] conduit becomes hesitant. When the flow
is hesitant, blood becomes deficient; pain arises. Because the shu acupoints
ultimately drain into [liaise with] the heart, therefore reciprocal traction [13]
between the heart and the back causes pain. Massaging this area generates heat
and the pain stops when heat reaches the afflicted site [14].
If the cold evil qi resides in the jue-yin hepatic conduit, which branches to
the external genitalia and links to the liver, it will cause the blood flow to
become hesitant and the conduit tight [constricted]. Therefore, the hypochon-
drium and the underbelly feel the pain through reciprocal traction [15].
If the reversed flow [of the cold evil qi] resides in the medial side of the
thigh, it will go up to reach the underbelly, causing hesitant flow of blood. As
these two afflicted sites are linked together [16], pain in the underbelly will
spread to the medial side of the thigh [17].
If the cold evil qi resides in the connecting branches, in between the small
intestine and pleuro-diaphragmatic space, blood flow becomes hesitant and
cannot drain into the principal conduits. As the flow of blood and qi becomes
stagnant, a mass concretion [18] will form over time.
If the cold evil qi resides in the five zang-organs, the reversed flow will
cause congestion [19]. Under these circumstances, the yinqi of the zang-organs
will become exhausted whilst the yangqi cannot replenish in time, an abrupt
pain occurs and it is so intense that one faints, losing consciousness. When the
yangqi returns, one regains consciousness.
If the cold evil qi resides in the gastro-intestinal tract, the reversed flow of
[the cold evil qi] will seek an outlet upwards. Therefore, there is pain and
vomiting.
If the cold evil qi resides in the small intestine, there is no absorption [20].
There will be diarrhoea and colic pain.
If the hot evil qi resides in the small intestine, the heat is intense [body
fluid is evaporated], resulting in parching thirst. The stool becomes dry and
compact and it is difficult to defaecate. There is pain and constipation [21].

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 376 Neijing Zhiyao Yigu 內經知要譯詁

Explanatory Notes
Suwen Chapter 39 is a short but important chapter, part of which has already
been quoted in Section 8.9, which discussed the uneven flow of qi as the ulti-
mate cause of all diseases, including painful ones. In this section, the discus-
sion focuses on a list of 14 painful conditions. With such a large number of
cases, it is possible to deduce some basic rules underlying the cause and diag-
nosis of pain. This is the purpose of the present section, and is reflected in the
title: On [a List of] Pain[s] (jutong 舉 痛, “listing pain”). Some annotators have
preferred to change the title to cutong 卒 痛 (abrupt or acute pain) because the
term zutong appears in the text. But it is clear that not all the 14 cases are acute
pain, some are chronic pain or diffused pain (referred pain).
Arbitrarily changing the text of the classics to suit the purposes of anno-
tation is not recommended, unless there is compelling evidence to do so, e.g.
new findings in archaeology. There is another example in this section on rear-
ranging two sentences for rhetorical purposes. Before elaborating on the
substance of this section, it might be useful to note a very interesting intro-
ductory remark in this chapter, which is after all rare in the literary style of
Neijing.
Huangdi asked: “Those who talk knowingly about nature must find
corresponding events in human life. Those who talk knowingly about ancient
times must find corresponding events in present-day life. Those who talk
knowingly about human behaviour must have similar experiences of their
own.35 [A similar statement is made in Suwen Chapter 66, and again a more
elaborate statement could be found as the concluding remarks of Suwen
Chapter 69; both are widely thought to be additions by Wang Bing, or
comments by him which were later incorporated into the text as if they had
been in the original]. In this way, the Great Way (dao 道) will seem no longer
confusing and it becomes accountable. This is comprehension. Now I ask you
respectfully, how can I make my words comprehensible, my subject [of
interest] visible and tangible and how can I verify it myself so as to enlighten
myself and free myself from confusion [jiehuo 解 惑, “disentangle the bewil-
derment”. See Han Yu below]. Can you tell me something about this matter?”
Qibo was nonplussed by this question. So he bowed his head again

35
「善言天者，必有驗於人；善言古者，必有驗於今；善言人者，必有驗於
己。」

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 Morbid Manifestations 377

deferentially and said: “What kind of great way are you asking about?”
Huangdi said: “I wish to know what brings abrupt pain to the five zang-organs.
What kind of qi is involved?” Thus the answer of Qibo unfolded at the begin-
ning this section. The answer to what kind of qi was involved was quoted in
Section 8.9.
We all know that Suwen, the “plain questions”, was not in fact a transcript
of a dialogue between Huangdi and Qibo on medical problems. By asking
suggestive questions, Huangdi defined the context of the answers. This is a
way to introduce a lecture in dialogue form, as it was often the case with the
great Confucian masters. The words announced by Huangdi can be found
verbation in Xunzi (荀 子, ca. 313–238 bc),36 the great Confucian philosopher
of the late Warring States period following closely to Mengzi 孟 子 (ca.
372–289 bc) but not entirely endorsing the latter’s teaching. Based on these
words, Dong Zhong-shu 董 仲 舒 (179–104 bc) developed the thesis of
empathy between heaven and men (tian ren gan ying 天 人 感 應) as the main
thrust to drive the apotheosis of Confucianism for the service of Han Wudi
漢武帝 (reigned 140–87 bc).
Han Yu 韓 愈 (768–824), standard bearer of Confucianism in the mid-
Tang dynasty, defined the duty of the teacher. “The [duty of the] teacher is to
pass on the [knowledge of] the Great Way (chuan dao 傳道), to bestow profes-
sional knowledge (shou ye 授 業) and to disentangle bewilderment (jie huo 解
惑).”37 Indeed, Suwen Chapter 58: On Acupoints, a fairly technical discourse on
clinical acupuncture, begins with a rather comic description of Huangdi
humbly seeking enlightenment from Qibo. Qibo, who is still withholding
information, nevertheless declares that “The sages are easy to talk with, just as
a good horse is easy to ride.”38 This makes Huangdi even more humble. He
says: “I am not that easy to teach, I have been seeking enlightenment and to
rid myself of bewilderment (fa meng jie huo 發 蒙 解 惑), please tell me all you
know.” The last chapter of Suwen, nominally on ophthalmology, begins with
Leigong seeking instruction from Huangdi. Leigong says: “I have been given
tuition on etc. Is there anything that is missing and not recorded in the clas-
sics?” Here the term shou ye 授業 (to deliver professional know-how) might as

36
《荀子．性惡》︰「善言天者，必應於人；善言古者，必驗於今。」
37
《韓愈．師說》：「師者，所以傳道，受業，解惑」。
38
聖人易語，良馬易御 (sheng ren yi yu, liang ma yi yu).

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 378 Neijing Zhiyao Yigu 內經知要譯詁

well be translated as “to receive tuition” (shou ye 受 業). The affinity between
the authors of these passages in Neijing and Confucian writings is quite
evident from these two references. It had the tacit endorsement of Wang Bing,
himself an adept of Daoism, who left these words unchanged in his edition of
Neijing (cizhu 次 注). It is true that Daoists contributed a great deal to Chinese
medicine, and Wang Bing introduces himself with a Daoist title, Qixuanzi 啟
玄子 (Master of Revealing the Metaphysical). But Daoist pursuits tended to be
introspective and self-centred, whereas Confucianists tended to adopt a
worldly mission to proselytise the Great Way. Without the Confucian scholars,
and their privileged position in the establishment as a result of the initial
efforts of Dong Zhong-shu, it would have been hard to perpetuate and
promote Chinese medicine. This is a somewhat similar to the situation with
Buddhism, which has two sects as Mahayana (the Great Vehicle saves the
world) and Hinayana (the Small Vehicle saves one’s soul), with the former
adopted and promoted by the state in China on many occasions. Before
further digression, it is fair to say that this long and unusual introduction in
Suwen Chapter 39 sets the background for the diagnosis of pain, which is
conceived of as a morbid sign that is visible, tangible and perceptible. It also
puts Neijing into a more worldly perspective, indicating that after removing
the mythical coat of the Yellow Emperor, it is simply a standard form of peda-
gogy in the Confucian tradition.
Pain is an unpleasant sensation that calls for action. Acute pain produces
reflex actions. Chronic pain will change life-style and mental state, and even-
tually make the patient depressed. Just like fever, or any other symptom for
that matter, it is not enough to suppress pain, e.g. with the use of analgesics. It
is imperative to find out which part of the body is hurting and why. In this
context, we have to recognise that pain is a subjective manifestation, tinged
with emotional undertones and influenced by previous experience and envi-
ronmental circumstances, as well as ethical, cultural and religious factors. It
also depends on personal loss or gain in announcing pain. Without removing
the source of pain, the disease may advance until it is too late for treatment; by
then it is terminal (e.g. cancer). In Chinese medicine, there is no lack of choice
of analgesics, e.g opioids, but in clinical practice, it is the qi, and its stagnant,
reversed or turbulent flow, which is seen as causing pain (bu tong ze tong 不 通
則 痛), and the management of pain boils down to the re-establishment of a
smooth flow of qi. Qi is construed to mean nervous stimulation, blood circu-
lation, muscular tone, sympathetic tone or whatever driving force is needed to

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 Morbid Manifestations 379

maintain homeostasis in the afflicted area. Initially, Qibo tries to briefly

explain the genesis of pain as the attack of the cold evil qi on the conduits,
disturbing the smooth flow of qi. Here cold evil qi should not be equated with
cold exposure as one of the six pathogenic evil qi (hanxie 寒 邪). It simply
means that the hesitant, sluggish flow of blood, or even total stoppage, is
tantamount to a cold situation, one of the eight cardinal states in diagnosis
(bagang bianzheng 八 綱 辨 證). Huangdi is not satisfied with such a concise
answer, however. He names 14 kinds of pain, each of which has a different
presentation. Today, we know that pain can be acute or chronic, dull or sharp.
But Qibo thrashes out a detailed classification plan for pain; he artfully identi-
fies the site of each of these types of pain and their main symptoms in diag-
nosis. The primary cause in 12 cases is cold evil qi (inadequate circulation).
Although one case is ascribed to reversed flow (厥氣 jueqi) and one to hot evil
qi (reqi 熱 氣), Li Zhong-zi, in his original annotation, argues that the primary
cause was still inadequate circulation (butong 不 通). While the neural func-
tion of pain perception and transmission is totally ignored in this section, it
has nevertheless highlighted the dynamic nature of pain in specifying the role
of cold evil qi in pain genesis. Pain classification in Neijing can be rearranged
in tabular format as follows:

Presentation and Afflicted Site Pathogenesis

diagnosis
Abrupt pain Contraction of conduit Cold outside conduit, heat
relieving
Incessant pain Contraction of conduit Exposed to cold while still
painful
Compression- Cold inside contracting Conduit is full
resistant conduit
Compression- Stomach and intestine, Blood and qi dispersed upon
relieving below (outside) compression
mesentery
Compression- Deep-lying conduit along Cannot be reached by
inactive the spine compression
Muscle twitching Chong conduit Blockage of qi flow
pain

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 380 Neijing Zhiyao Yigu 內經知要譯詁

Referred pain in Urinary bladder conduit Hesitant flow and lack of

heart/back where lie the shu acupoints blood, compression relieving
that drain into the heart
Referred pain in Hepatic conduit, Hesitant blood flow and
hypochondrium/ branching to genitalia and contracting conduit
underbelly linking to liver
Referred pain in Abdominal pain spreads Cold reaches underbelly,
abdomen/medial to medial side of thigh hesitant blood flow
side of thigh
Chronic pain Cold lodged in small Stagnant blood in afflicted site
intestine and mesentery cannot drain into principal
conduit
Pain leads to loss of All five zang-organs Depletion of yinqi and absence
consciousness (non-arrival) of yangqi result
loss of consciousness
Pain leads to Stomach and small Reversed flow of qi
vomiting intestine
Pain leads to Small intestine Lack of peristalsis, abdominal
diarrhoea pain and diarrhoea
Pain leads to Heat resides in small Loss of body fluid, compact
constipation intestine stool

The diagnostic significance of compression and heat is interesting. Today,

it is still common practice in clinical examination. The use of a heat-pad or
ice-pad, depending on the case, often brings relief. It is natural that one
kneads the brow or massages the belly, hoping to bring relief. The origin of
these manipulations can be found in Neijing.
Of these 14 cases, 12 of them are due to the cold evil qi. This is definitely
not one of the six excessive climatic factors (liuyin 六 淫). It is also hard to
imagine how an internal site can be afflicted by cold, since the internal envi-
ronment is thermostatic. So cold evil qi as a cause of pain may mean inade-
quate circulation, muscle atony or even tissue atrophy. In Chinese medicine,
pain is generally divided into two groups, pain of deficiency or pain of excess
(xushi 虛 實). On top of that, it can be further divided into pain of a hot or
cold nature (hanre 寒 熱). Deficiency and cold can be reasonably taken to

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 Morbid Manifestations 381

mean hypofunction, and the reverse is true for excess and heat. The inclusion
of the fourteenth case as a result of an attack by the hot evil qi clearly indicates
this point.
Following this long list, Huangdi asks if pain can be visible and tangible.
To this, Qibo answers in the affirmative. He tells Huangdi that black is the
colour of pain, and hard and blood-engorging concretions can be felt by
running the hand over the site. This completes a short but informative guide
to the clinical approach to pain.

Footnotes

[1] conduits: Jingmai usually means conduits where qi flows. In this section,
jingmai or simply mai, is actually referring to blood vessels. Blood flows in
blood vessels (xue mai 血 ), and qi is the driving force provided by the
heart. In the translation, it remains “conduits” (mai ).
[2] flow becomes hesitant: The Chinese word 泣 qi (sobbing or crying in a low
voice), is also a synonym for se 澀 (astringent, hesitant). This is a figurative
way of describing a sluggish blood flow (Suwen Chapter 10: “When blood
stagnates in blood vessels, its flow becomes hesitant” (xue ning yu mai zhe wei
qi 血 凝 於  者 為 泣.) From the same source, eating too many salty [foods],
the [flow in the] blood vessels becomes stagnant and hesitant[see above]; it
changes colour. (Suwen Chapter 10: Duo shi xian, ze mai ning qi er bian se 多
食 咸，則  凝 泣 而 變 色.) This refers to hyper-osmolarity in blood, which
causes hypertension, a fact that we have only learned fairly recently. A similar
situation has been described in Section 8.6, when the cold remains in the
chest. Se is also a pulse pattern (see ref. 53, Section 6.4.1.5).
[3] cold evil qi outside the conduits: The tissue usually irrigated by local circula-
tion is now lacking blood, possibly due to vasoconstriction. This can be the
result of intrinsic constriction (atherosclerosis) or extrinsic compression by
tumour or bony prominence. Anginal pain is caused by atherosclerotic
narrowing, leading to intermittent claudication. By the same token, cold evil
qi inside the blood vessels may mean thrombosis or embolism; in the coro-
nary blood vessels, it would cause a heart attack (myocardial infarction), in
the mesenteric vessels, gangrene of the bowel, with acute pain.
[4] pain arises abruptly: Acute pain triggers avoidance action by reflex. But if the
pain lies deep inside the body, it is imperative to locate the afflicted site first
before anything can be done to relieve the pain. Because the section begins
with acute pain (cutong 猝 痛), some annotators have changed the chapter

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 382 Neijing Zhiyao Yigu 內經知要譯詁

title to reflect this, but it is not necessary, as later in the text there are also
chronic pain, referred pain and compression-relieving pain and compres-
sion-resistant pain, pain that can be relieved by heat etc.
[5] heat is applied: The Chinese character 炅 jiong means a brightly-lit heat
source, and could perhaps also mean trying to get warm (to relieve pain)
over a brightly burning fire. Jiong appears twice in this chapter. The only
other occurrence of it is in Suwen Chapter 62, where it explains the genesis
of “internal heat” (jiongzhong 炅 中) as due to blood being sequestrated in
the yang domain and qi in the yin domain. Pain that can be relieved by heat
is most likely somatic pain, like leg cramps or the pain of fibrositis.
[6] worst when compressed: Compressing the pain area (an 按, “press with the
palm”) to see if the pain subsides or increases is a diagnostic step in pain
management. Compression in diagnosis is different from massage (anmo 按
摩), where there is movement of the palm and fingers, and also different
from men 捫 (groping to feel). An can also be an element of palpation
(qiezhen 切 診) in the four methods of diagnosis. This kind of pain is ascrib-
able to that of inflammation. Fullness may be interpreted to mean tissue
engorgement. One example is gout, which is extremely painful at the slightest
touch.
[7] pleuro-diaphragmatic space: The term muyuan 膜/募/幕 原 is ill-defined
because it cannot be correlated with any anatomical structure; it actually
describes the pleuro-diaphragmatic space. It is best known as the reservoir
of malarial parasites that reside in “the mesenteries linking the stomach
and the intestines”. (ibid. 8-15-5. See also Lingshu Chapter 66 quoting
mesenteries of the stomach and intestine (chang wei zhi mu yuan 腸 胃 之 募
原). Muyuan was made famous by the popular Dayuan yin 達 原 飲 from Wu
You-xing’s 吳 有 性 On Epidemics (Wenyi lun 瘟 疫 論), published in 1642.
Wang Bing believed it to refer to the diaphragm, the origin of the mesenteries
(gehuang 鬲 肓). Zhang Yin-an said it was the adipose membrane linking the
stomach and intestine. Tamba Genkan made it very specific: it was the
hanging tissue extending from the diaphragm, attaching to the 7th thoracic
vertebra. Although muyuan is identified as the mesentery, the latter does not
possess such profound physiological function as it was described. The
mesentery is a fold of the peritoneum, as is the omentum; the latter is draped
across the small and large intestines, as described in Neijing. But up to this
day, muyuan, like the “three burners”, remains a functional concept without a
structure. The mesenteries are full of blood vessels irrigating the small

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 Morbid Manifestations 383

intestine. The omentum has many lymph nodes that may play a role in
immuno-defence.
[8] pain stops upon compression: Gao Shi-zong took the liberty of moving the
two sentences at [14] to here, in order to explain why compression can be
pain-relieving. Tamba Genkan found this an excellent rearrangement, but
even though it seems very sensible, there is no evidence that the ancient
script as seen by Wang Bing should be altered. Unless there is evidence which
pre-dates Wang Bing, it is unwise to change ancient texts at will to suit
modern-day purposes.
[9] blood vessels along the spine: This is taken to mean the urinary bladder
conduit, which goes down both sides of the spinal column. Zhang Jie-bin
suggests that this is the deepest-lying of the branches from the urinary
bladder conduit penetrating the back muscles (fu chong zhi mai, fu lü zhi mai
伏 沖 之 ，伏 膂 之 ). But this has nothing to do with the Chong conduit
that runs on the ventral side.
[10] goes up the abdomen: The Chong conduit (see Section 6.2) starts from
acupoint qijie (on both sides of the pubic hair area) whereas the Ren conduit
starts from acupoint guanyuan (three Chinese inches below the navel). They
merge before entering the navel. So the Chong conduit is also considered to
start from acupoint guanyuan.
[11] muscle twitching upon touching: The word chuan 喘 (panting) should be
changed to chuai 揣 (struggle, writhe). Thus, it describes a pain that is sensi-
tive to the touch, like a raw nerve ending. Lingshu Chapter 66: For chronic
pain (ji 積) that occurs in the Chong conduit (伏 沖 之 =太 沖 ) feels the
muscles twitching with pain when the afflicted area is touched (chuai zhi
ying shou er dong 揣之應手而動).
[12] the shu acupoints: The five shu acupoints (wu shu xue 五 俞 穴) of the five
zang-organs all lie on the back, on both sides of the spinal column (Lingshu
Chapter 51). Because these shu acupoints are linked to (drain into) the heart,
the pain felt on the back is an expression of heart pain. This reminds us of
back pain in some cases of cardiac infarct. As the heart does not feel pain,
this is referred pain (xiang yin er tong 相 引 而 痛) described as traction
between the two afflicted areas. The shu acupoints may refer to the
dermatomes, which are linked to the dorsal root of the corresponding
vertebra. The shu acupoints lie in a cluster on the urinary bladder conduit.
Thus any reference to the conduit carrying the shu acupoints means this
conduit. However, it is not known that massaging the back can relieve angina

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 384 Neijing Zhiyao Yigu 內經知要譯詁

pain. Instead, to relieve such pain, the current practice in acupuncture today
is to try needling the acupoint shenmen 神 門 on the wrist. In any case, rest
helps.
[13] reciprocal traction: As explained above, the heart does not feel pain. But
before or during infarct, pain is felt on the medial side of the upper arm, or
the back below the scapula. These are referred pains. Thus “traction” causing
pain between the [dorsal] urinary bladder conduit [carrying the shu
acupoints, including xinshu, 心 俞] is actually describing a referred pain.
There are two more cases of referred pain which follow this one.
[14] These two sentences explain why compression-generated warmth was pain-
relieving. It would be more relevant to move this to [8], although such a
move cannot be justified without supporting documents. It is futile to
compress the back, and it is not possible to compress the heart. According to
Gao Shi-zong, this sentence complements the “relief of pain upon compres-
sion”. It is followed by a comment on the futility of trying to soothe back
pain by massage in the next paragraph. The rearrangement makes sense, but
it is not necessarily the case in ancient pre–Wang Bing versions of Neijing, if
ever one existed. In modern neurophysiology, compression can stimulate the
same dermatome as that of pain, activating the A-beta fibres (mediating
touch), which fire more rapidly than the C-fibres (mediating pain), thus
restricting the transmission of pain to the brain.
[15] reciprocal traction: This may not be traction involving muscle contraction.
Lesions in the liver and gall bladder are radiated to the hypochondrium
through the jueyin hepatic conduit and are felt as pain.
[16] two afflicted sites are linked together: They are linked through the Chong
conduit and the three podogenic yin conduits passing through the medial
side of the thigh to enter the lower abdomen.
[17] medial side of the thigh: This may refer to the inguinal ligament linking the
anterior superior iliac spine and the pubic tubercle, providing a structural
basis for the pain of traction. According to Dr. W. F. Pau, this may also mean
a strangulated inguinal or femoral hernia leading to intestinal obstruction,
for herein lies the traction between the incarcerated bowel segment and the
rest of the gut, which jeopardises the mesenteric circulation and ultimately
leads to gangrene of the bowel. Hernia was as common in ancient times as it
is now.
[18] mass concretion: Stagnant blood among the mesenteries points to obstruc-
tion of the portal circulation. Over time, the spleen enlarges (splenomegaly).

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 Morbid Manifestations 385

This is one possible explanation for chronic pain due to “retained circula-
tion” (xue qi xi liu 血氣稽留).
[19] congestion: The character 泄 xie (discharge, leak, drain) should here be
changed to 壅 yong (block) as it is unlikely that the reversed flow of qi would
seek an outlet upwards. It is more likely that by going against the normal
flow direction, it causes congestion. Wang Hong-tu recommended this
change, citing two references. By limiting blood circulation among the
visceral organs, compounded with acute pain, one may loose consciousness.
Fainting could be a result of hitting the solar plexus where the splanchnic
nerves of the sympathetic division end.
[20] no absorption: Literally “not gathering together”, this describes malabsorp-
tion in the small intestine, leading to diarrhoea, for example steatorrhoea.
[21] constipation: According to Lee Jin-yong (ref. 43), the first tong (pain) should
be removed; that was the case in Taisu. When it is cold, there is pain as
described in all the above cases except the last one. In this case, when there is
heat, there is also pain, due to loss of body fluid, and thus accumulation of
harmful metabolites. The word ke 渴 (“thirst”) should be interpreted as jie
竭 (“empty, exhaust”), as in Lüshi chunqiu: Yixiang 呂 氏 春 秋．義 賞: “to
empty the pond to get the fish” (jie ze er yu 竭 澤 而 漁). Lack of fluid in the
guts gives rise to compact stool, hence pain and constipation. Li Zhong-zi
argued that the pain is caused by constipation, which is a hot situation. So it
still fits with the broad concept of bu tong 不通 (not patent), which is prima-
rily a cold situation.

[Section 8.23] Suwen Chapter 43: On Numbness

《素問．痺論》曰：風寒濕三氣雜至，合而為痺也，其風氣勝者為行痺，寒
氣勝者為痛痺，濕氣勝者為著痺也。

肺 痺 者，煩 滿、喘 而 嘔；心 痺 者，脈 不 通、煩 則 心 下 鼓、暴 上 氣 而

喘、嗌乾、善噫，厥氣上則恐；肝痺者，夜卧則驚、多飲、數小便、上為
引如懷；腎痺者，善脹、尻以代踵、脊以代頭；脾痺者，四肢解（懈）惰、
發咳、嘔汁、上為大塞（寒） ；腸痺者，數飲而出不得、中氣喘爭、時發飧
泄；胞痺者；少腹、膀胱按之內痛，若沃以湯，澀於小便，上為清涕。

痛 者，寒 氣 多 也。有 寒，故 痛 也。病 久 入 深，營 衛 之 行 濇，經 絡 時

疎，故 不 痛；皮 膚 不 營，故 為 不 仁，陽 氣 少，陰 氣 多，與 病 相 益，故 寒

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 386 Neijing Zhiyao Yigu 內經知要譯詁

也；陽氣多，陰氣少，病氣勝，陽遭陰，故為痺熱。其多汗而濡者，此其
逢濕甚也。陽氣少，陰氣勝，兩氣相感，故汗出而濡也。
凡痺之類，逢寒則急，逢熱則縱。

With the concurrent attack of the three evil qi, namely wind, cold and wet,
numbness [1] will result. When the wind evil qi is predominant among the
three, it will be migratory numbness [2]. When the cold evil qi is predominant
among the three, it will be painful numbness [3]. When the wet evil qi is
predominant among the three, it will be resident numbness [4].
With numbness in the lung [5], one feels dysphoric and [there is] chest
congestion; one pants and tends to vomit. With numbness in the heart, the
conduits are not patent, one feels dysphoric and has palpitations [6]. There is
also a sudden upward surge of qi with panting, dry throat, belching, and
apprehension [7], due to the reverse flow of qi. With numbness in the liver,
sleeping at night is interrupted by frequent [feelings of] fright; there is poly-
dipsia but frequent urination. One feels an epigastric traction like being preg-
nant [8]. With numbness in the kidney, one tends to become oedematous [9].
One has to move while sitting on one’s buttocks [10] as if they are the heels.
At the same time, one’s nape is seen above the head [11]. With numbness in
the spleen, one feels listless in the limbs, coughing frequently, regurgitating
clear liquid [gastric juice] with serious epigastric congestion [12]. With numb-
ness in the intestine, one drinks frequently but experiences dysuria, borbo-
rygmus [13] and passage of undigested food. With numbness in the urinary
bladder, there is pain in the underbelly and urinary bladder upon compres-
sion, as if they are being filled with hot water. However, passing urine is
painful and a clear discharge dribbles from the nose.
When there is predominance of cold evil qi, there will be pain. With cold,
one feels painful. If the disease becomes entrenched, the flow of nutritrive qi
and defensive qi becomes hesitant. If the conduits are sometimes decongested
[14], there is no pain. However, if the nutritive qi cannot nourish the skin, it
will lose sensation. This is complicated by lack of yangqi and excess of yinqi
and one feels aversion to cold. On the contrary, if there is excess of yangqi and
deficiency of yinqi so that yangqi overpowers yinqi, there will be febrile numb-
ness [15]. In those who are sweating profusely with a wet skin, this is due to
repeated exposure to wetness. As there is lack of yangqi, yinqi dominates, and
the latter confronts the wet evil qi; hence it is sweating and wet.
For all kinds of numbness, it contracts when cold and relaxes when warm [16].

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 Morbid Manifestations 387

Explanatory Notes
Suwen Chapter 43: On Numbness (pi 痺) is one of the four speciality chapters
grouped together in Volume 12; the other three chapters are Wind(-induced
diseases, feng 風), Atrophy (wei 痿) and Turbulent Flow of Qi (jue 厥). This
arrangement indicates that these conditions all belong to a group of interre-
lated diseases, which is different from pain. However, in NJZY, the section on
“Numbness” followed immediately after that on “Pain”, suggesting that Li
Zhong-zi considered numbness was as important as pain, though it lacked a
unified theoretical framework such as “where qi is not flowing, pain arises” (bu
tong ze tong 不 通 則 痛). Pi (numbness, or loss of sensation ) is the generic
name for a disparate group of diseases characterised by loss of sensation,
inflammation, pain and progressive structural lesion (of the connective
tissues). Numbness is only the most obvious denominator among them, and
frequently occurs without the other symptoms. It is described as a “lack of
sensation” (ma mu bu ren 麻木不仁, “lack of sensation like hemp and wood ”),
and is often due to exposure to cold or lack of circulation in the limbs. It is
actually a pins-and-needles sensation, short of total anaesthesia. But this state
of numbness is painless and transient and is not considered a disease per se.
Numbness as a disease must have external causative factor(s) like wind/
draught (feng 風), cold/chill (han 寒) or wet/damp (shi 濕), that produce
inflammation (swelling), pain and structural damage, as defined in this
section. For these environmental insults to take effect, the patient is prone to
have an auto-immune response, a reaction not known at the time of Neijing,
but which actually constitutes the immediate cause of structural damage. With
these preliminaries in mind, numbness in Neijing encompasses rheumatism,
rheumatoid arthritis, peripheral neuropathy, fibrositis or inflammation of the
connective tissues in general. All these symptoms may worsen due to changes
in the weather, or after a period of inactivity; they are alleviated by massage or
light exercise and application of a warm compress.
Several sections of NJZY Chapter 8 discuss various groups of diseases
with a major symptom such as fever, tussis, pain, periodic fever and chills
(malaria), and now numbness, to be followed later by atrophy. These are
concrete examples of nosology with the schematic outline presented in
Section 8.1. Having familiarised the reader with the basic principles of medi-
cine in the first seven chapters, Li Zhong-zi then put 40 per cent of the weight
of NJZY in Chapter 8: Morbid Manifestations (Bing Tai 病 能). The ultimate

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 388 Neijing Zhiyao Yigu 內經知要譯詁

purpose of medicine is, after all, the treatment (and prevention) of disease,
with demonstrable benefits. To do this, it is imperative to understand the
disease itself, and its congeners by way of comparison, before any methods of
treatment can be implemented. In other words, as we have stated already in
Section 8.14, if the doctor does not know what or where the problem is and
why it has occurred, how can he/she initiate any treatment? Therefore, these
few sections with well-defined symptom complexes, are examples of nosology
which are loosely comparable to programme music against a background of
harmony and counterpoint. If the concept is right (if one has mastered
musical theory), the treatment cannot be far wrong (the composition is tech-
nically correct).
While translating these “programmed” sections, the author has been
amazed by the similarity between traditional Chinese medicine and modern
western medicine. This is not coincidental, because both are based on keen
observation of clinical cases; they only differ in the language used. The simi-
larity is most evident in this section on numbness. This may be because
numbness, or rheumatism, is easy to observe and whatever macroscopic infor-
mation modern diagnosis can glean from a rheumatic patient, ancient clini-
cians of Neijing times would also have detected from visual inspection. It is
not only the similitude in clinical detail that is surprising, it is particularly
rewarding to note that the conceptual framework of the whole section on
numbness is based on a coherent idea of how rheumatism presents as a
disease, from its pathogenesis to its treatment and prevention. Although Li
Zhong-zi excerpted the most essential paragraphs from Suwen Chapter 43, it
is necessary to view the chapter as a whole so as to appreciate its conceptual
framework as a paradigm in nosology.
The textual information in Suwen Chapter 43 is structured in tiers, one
leading to the other in increasing depth of insight. The reader is able to
witness how the disease evolves, its multi-faceted presentation, its treatment
(mainly by acupuncture) and its prevention (change in life-style).
Huangdi begins by asking Qibo how numbness arises, and Qibo replies: “It
is due to the concurrent arrival [zazhi 雜 至, literally “mixed arrival”; or jizhi
集 至, “arriving together”] of the three evil qi, viz. wind, cold and wet. The
joint result [he 合] is numbness.” Numbness is then categorised as migratory,
painful or resident, according to the secondary symptoms. This leitmotif in
numbness is excerpted.
Huangdi then asks: “Then why are there five kinds of numbness [for the

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 Morbid Manifestations 389

same group of causative factors]?” Qibo explains that these five manifestations
of numbness vary according to the season. In winter, there is numbness in the
bone; in spring, it is in the sinews; in summer, in the spleen; in long summer,
in the muscles and in autumn, in the skin.
Without waiting for an answer, Huangdi asks: “As the ailment penetrates
and resides in the five zang-organs and six fu-organs, what is the qi involved?”
Qibo replies: “The five zang-organs have their corresponding [body parts] [合
he]. If the disease [symptom] stays, it will penetrate inside [the body] and
reside in the corresponding organ. Therefore, when numbness in the bone is
not remitting, and at the same time exposed to the evil again (fu gan yu xie 復
感 於 邪), it will become resident in the kidney.” By the same token, from the
sinews it will go to the liver; from the blood vessels to the heart; from the
muscles to the spleen; and from the skin to the lungs. Here the key sentence is:
“As to what is called numbness, each of its presentations is due to repeated
exposure (chong-gan 重 感) to the wind, cold or wet evil qi according to the
season (ge yi qi shi 各 以 其 時).” Qibo is talking about numbness in the five
body parts (wuti pi 五 體 痺), which were considered external relative to the
zang-organs inside the chest and peritoneal cavities. According to Qibo, it is
clear that environmental insults (repeated exposure to the three evil qi) would
first cause numbness in the external/surface body parts according to the
season, then penetrate into the zang-organs to become fully established numb-
ness. This is numbness in the five zang-organs (wuzang pi 五 臟 痺). This
important paragraph was not excerpted in Neijing. As it appears in Section
8.23, numbness in the zang-organs is introduced abruptly, without any prelim-
inaries. The reader therefore is not informed of the serious consequences of
articular rheumatism that develops into non-articular rheumatism. While
articular rheumatism is painful and disabling, it is non-articular rheumatism
in the visceral organs that brings system failure.
Qibo goes on to explain that: “Yangqi [physiological compensation] will
be conserved when one is calm, dissipated when one is restless. Abusive eating
and drinking will hurt the stomach and intestine. When the evil qi causes
panting, numbness is gathering in the lung. By the same token, with worrying
it gathers in the heart; with incontinence, in the kidney; with exhaustion, in
the liver; with muscle fatigue, in the spleen. All kinds of numbness, if not
cured, will aggravate by moving inside [the body]. If the wind evil qi is
predominant, it is easy to cure.”
Huangdi asks: “Why is numbness sometimes fatal, sometimes chronic and

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 390 Neijing Zhiyao Yigu 內經知要譯詁

sometimes easy to cure?” Qibo answers: “That which penetrates the zang-
organ is fatal. That which loiters in the joints produces chronic pain. That
which remains on the skin is easy to cure.” This is the prognosis for
rheumatism.
Huangdi asks: “What about [numbness] resident in the six fu-organs?”
Qibo tells him: “This is also due to diet and habitat, the ultimate causes of the
disease. Each of the six fu-organs has its shu acupoint [favourable acupoint for
treatment of rheumatism]. When the wind, cold and wet evil qi strike these
shu acupoints, and there is a corresponding carelessness in diet, the [evil qi]
will penetrate through the shu acupoints and become resident in the
fu-organs.” This is the second time the causal relationship with life-style is
mentioned. Without knowing anything about auto-immunity in rheumatism,
Neijing was keenly aware that besides environmental factors, there was an
idiopathic element in the pathogenesis of rheumatism. This is ascribed first to
diet, then in addition, to habitat. Ever since the time of Neijing, it has been
common practice to improve the habitat, or take a break in another more
favourable environment (e.g a mountain resort, or spa) as a cure for
rheumatism.
Huangdi asks: “How about acupuncture treatment?” Qibo replies: “The
five zang-organs have shu acupoints, and the six fu-organs have he acupoints
[favourable acupoints for treatment of gasto-intestinal troubles]. According to
the subdivisions of the conduits, each has its own expression. Treat those that
are in excess, and the disease will be cured.” This paragraph says nothing about
how to treat rheumatism, but it does emphasise two salient points. Firstly,
rheumatism can be cured by acupuncture. Secondly, if the doctor knows
where and what the trouble is, he/she should treat it accordingly with
acupuncture. This statement reconfirms the medical thinking of Neijing in its
clinical approach: if one knows the nature of the disease, one can cure it.
Huangdi wants to know the part played by the defensive and the nutritive
qi in rheumatism. Qibo replies wisely that while they may aggravate or lessen
the morbid manifestations, they will not act jointly with the three evil qi, and
thus would not produce numbness. In this paragraph, Qibo describes in detail
the characteristics of the defensive qi and the nutritive qi. This serves as the
most penetrating insight into the modus operandi of these two important
functions and also distances them from any involvement in the pathogenesis
of rheumatism. This discussion leads on to a paragraph on non-painful rheu-
matism, rheumatic fever and other variations in the presentation of

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 Morbid Manifestations 391

rheumatism that could be modulated by the defensive and/or nutritive qi.

This paragraph is excerpted.
Finally, Huangdi asks about non-painful rheumatism. Qibo replies:
“Numbness in the bone renders one sluggish. In the blood vessels [it leads to]
stagnant flow. In the sinews, to inflexible joints. In the muscles, to loss of
sensation. In the skin,to feeling cold. In these five cases, there is no pain. [Under
all circumstances], numbness as a group [of diseases] will aggravate when
cold, and remit when warm.”
This is a fine monograph on rheumatology.
With a typical example of a specialty like rheumatology and others, it is
fair to say that Neijing was intended to be a collectively authored textbook of
medicine. It encompassed all the medical knowledge of its time, but more
importantly, it defined the epistemology in medical study that permitted the
establishment of a self-explanatory corpus medicum. It is a pity that, after
initial attempts to study body structure, especially in Lingshu, anatomy was
taken out of the equation, due to socio-ethical constraints. Without a struc-
tural basis, physiological function became conjectural or inferential and did
not permit validation by experimentation. Neijing remains the ultimate para-
digm of traditional Chinese medical knowledge, and there has been no need
for a new textbook or a new author. All later efforts to further medical knowl-
edge have been in the realm of annotation and interpretation. This constitutes
another fundamental limitation in the evolution of Chinese medicine.
In closing, it is fair to conclude that the authors of Neijing were keen
observers of symptom manifestations. They had noted every minor detail but,
in the absence of experimental intervention, they had no way to confirm the
disease entity. Thus they invented the broad and non-committal concept of
wuti pi 五 體 痺 to cover different cases of end-organ failure. Today, we know
that some organs, such as the lung and kidney, react with a narrow range of
pathological changes, such as small intestine vasculitis, fibrinoid necrosis and
fibrosis, to a wide variety of insults like infection, allergens, occupational
exposure, radiation or prolonged circulatory failure. Seen from this perspec-
tive, wuti pi becomes more tangible.

Footnotes

[1] numbness: “Numbness (pi 痺) is closure (bi 閉); the flow of blood and qi is
stagnant and hesitant.” (pi, bi ye. xue qi ning se bu xing ye 痺，閉 也。血 氣
凝 澀 不 行 也。 ) Thus begins the exegesis of Suwen Chapter 43 in Direct

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 392 Neijing Zhiyao Yigu 內經知要譯詁

Interpretation of Huangdi Suwen (Huangdi Suwen zhijie 黃 帝 素 問 直 解,

preface 1695) by Gao Shi-zong 高士宗 (also known as Shi-shi 世栻, 1637–?).
This is an example of the phonological approach to annotation which
became very common during the Qing dynasty. Gao had been a student of
Zhang Zhi-cong 張 志 聰, also known as Yin-an 隱 庵, for ten years. Zhang
had written, together with his students including Gao, the Collective Compi-
lation and Annotation of Huangdi Neijing (Huangdi Neijing Suwen jizhu 黃 帝
內經素問集註, prefaced 1670). Jizhu 集註 means “collective effort from the
editorial team” and was largely based on the reciprocal support of citations
from Suwen and Lingshu, a typical example of “interpreting a scripture with
another scripture” (yi jing jie jing 以 經 解 經). Gao found this version some-
what hard for beginners to digest and made a new attempt to interpret
Neijing in a more straight forward manner, hence “direct interpretation” (zhi
jie 直 解). For each chapter, he began with a short but concise exegesis that
captured the quintessence of the chapter. Born in the last years of the Ming
dynasty, Gao witnessed a period of the exuberance of the Qing dynasty, when
Emperor Kangxi (reigned 1612–1722) fell in love with Chinese culture, and
literature in particular. But soon came ruthless persecution of the ethnic
Chinese literati who tended, albeit in veiled literary terms, to criticise the
autocratic rule of the Manchu overlords. Thus began the notorious “prison
of letters” (wenzi yu 文 字 獄). Any ambivalence in writing could be inter-
preted as lèse-majesté that could cost the life of the author. Scholars found
that the only safe pursuit was literary criticism (kaozhengxue 考 證 學, a tech-
nical aspect of hermeneutics), and in this endeavour, nothing was safer than
phonological studies (shengyunxue 聲 韻 學). Pi 痺 sounds similar to bi 閉,
and it is due to the blockage of blood flow, or sensory input, for simple
reasons like the application of a tourniquet, there is loss of sensation.
[2] migratory numbness: Numbness, in the context of rheumatism, can be
simply osteoarthritis. The large joints flare up one at a time, or stiffness in
the morning disappears but reappears later in other joints. This is literally
called “walking numbness” (xingpi 行 痺); it may not carry other non-artic-
ular features like in rheumatism. Its primary cause, the wind evil qi, is also a
description of the sudden onset and/or the migratory nature of the pain.
[3] painful numbness: In tongpi 痛 痺, the pain is intense and localised in one of
the joints. It involves the musculo-skeletal juncture or the bursa. Its primary
cause is the cold evil qi, which is taken to mean the lack of blood circulation.
[4] resident numbness: In zhuopi 著 痺, there is a pain that stays put. It is not so

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 Morbid Manifestations 393

painful, but it is disabling because of numbness in the muscles. It is a kind of

myalgia or fibromyalgia.
[5] numbness in the lung: Numbness in the five zang-organs is probably non-
articular rheumatoid arthritis. It is called wuzang pi 五 臟 痺, but wuzang
should be extended to include all internal organs, like the intestines and
urinary bladder, which are fu-organs that are described in this section. It
would be easier for an uninitiated reader to follow if the previous paragraph
on articular (or external/surface) rheumatism (wuti pi 五 體 痺) had also
been excerpted. There the transmission of rheumatism from an external/
surface body part to the internal visceral organ is explained. This targeted
transmission was based on the “five elements” concept of body part/visceral
organs affinity and may seem artificial. But the cause of non-articular rheu-
matism, i.e. repeated environmental insult, sums up the causal relationship
between articular and non-articular rheumatism. How ancient clinicians
could have detected rheumatoid affliction of an internal organ remains a
mystery.
[6] dysphoric and has palpitations: The Chinese term is literally “drumming
under the heart” (xin xia gu 心 下 鼓). This describes vividly not just palpita-
tions (xinji 心悸), but actual fibrillation or flutter.
[7] apprehension: This is describing serious fibrillation, as if the heart is jumping
out of the throat (reverse flow of qi) with a sensation of impending death,
that is why the patient is apprehensive, as in acute cardiac infarction. This
happens to most cardiac patients with a history of cardiac attack.
[8] like being pregnant: This is no ordinary abdominal swelling, as hinted at by
the word wei (shang wei yin 上為引, “as if drawn from the upper region”). Li
Zhong-zi interpreted this phrase as “water retention in the upper belly”
(shang wei yin yin 上 為 引 飲). Gao Shi-zong, citing Lingshu Chapter 10: The
Conduits, argued lamely that in liver shang wei yin yin disease, there was
scrotal hernia in men, and swollen underbelly in women. This was “drawn
from the upper belly” not because of polydipsia but oliguria (and hence
water retention). Zhang Deng-ben saw this as traction from the upper belly
extending to the underbelly. If numbness in the liver is construed to mean
rheumatoid liver, epigastric traction may actually refer to inflammation of
the mesentery (arteritis) at the level of the liver (epigastric). The liver is
suspended by the falciform ligament, the free border of which, the round
ligament (ligamentum teres), extends from the liver to the umbilicus. This
connection is easy to understand because the round ligament is the remnant

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 394 Neijing Zhiyao Yigu 內經知要譯詁

of the umbilical vein of the foetus. In adults, the round ligaments are bands
of fibrous connective tissues between the layers of the paired broad ligaments
which are outfolds of the peritoneum and attach the uterus to either side of
the pelvic cavity. With this anatomical structure in mind, it is not hard to see
why discomfort in the liver is perceived as a traction leading from the upper
belly, as if a pregnant uterus is “tugging” at the liver. This feeling may be
accentuated during wretching in early pregnancy. Thus the expression “like
being pregnant” may refer to this situation. Since there was no way doctors at
the time could know of this structural connection, any annotations could
only be conjectural. That is why the term is translated as epigastric traction
here: the upper belly becomes drawn tight (wei yin 為 引), like being preg-
nant (ru huai 如 懷). Dr. W. F. Pau thinks that this interpretation is most
unlikely, however, because the round ligament is too thin to produce much
sensation.
[9] oedematous: This is more likely oedema in renopathy than abdominal
swelling.
[10] buttocks as heels: This is knuckle-walking, with the buttocks trailing on the
ground. This describes vividly the movement of a paraplegic. The word kao
尻 is actually the sacrum, otherwise know as digu  骨. This severe form of
skeletal deformity may be seen in children with inherited renal tubular disor-
ders (vitamin D-resistant rickets), or adults suffering from osteomalacia
secondary to renal insufficiency, which is described as “numbness in the
kidneys” (shen pi 腎痺) in the text.
[11] nape above head: The 7th cervical vertebra has a prominent spinous process.
It becomes more visible when the head is drooping.
[12] epigastric congestion: The word sai 塞 (congestion) is sometimes considered
a misprint of the word han 寒 (cold). In either case, it means gastric inaction
(sai) or hypofunction (han). For coughing due to spleen/stomach malfunc-
tion, see Section 8.16.
[13] borborygmus: This is simply borborygmus, but is presented in the text as the
confrontation of the zhengqi with the evil qi in the intestines. Numbness in
the intestine could be enteropathic arthritis involving ulcerative colitis.
[14] conduit decongested: This explains why the defensive qi and the nutritive qi
can become modulators of numbness manifestation but are not causative
factors per se. It is clear that numbness, i.e. rheumatism, involves other causa-
tive factors than the capacity of the body for physiological compensation.
[15] febrile numbness: This is rheumatic fever. It is a result of group A

Neijing.indb 394 2010/2/26 6:59:42 PM

 Morbid Manifestations 395

streptococcal pyrogen infections that affect the joints as well as the heart and
other tissues. The text can be perceived as a description of progressive bacte-
rial infection, but there is no indication that the heart is involved, a signature
symptom in rheumatic fever.
[16] relaxes when warm: This is a concise and very appropriate conclusion for the
presentation of rheumatism from the patient’s point of view. Anyone
suffering from rheumatism will know that the disease aggravates with a
change in the weather, and this is as accurate as a barometer. In daily prac-
tice, sometimes an ice-pack is used to suppress inflammation, but a heat
pack to improve circulation and to alleviate the pain.

[Section 8.24] Suwen Chapter 44: On Atrophy and Organ

Dysfunction

《素問．痿論》曰：肺熱葉焦，則皮毛虛弱急薄，著則生痿躄也。
心氣熱，則下脈厥而上，上則下脈虛，虛則生脈痿，樞折（不）挈、脛
縱而不任地也；肝氣熱，則膽泄口苦、筋膜乾，筋膜乾則筋急而攣，發為
筋 痿；脾 氣 熱，則 胃 乾 而 渴、肌 肉 不 仁，發 為 肉 痿；腎 氣 熱，則 腰 脊 不
舉、骨枯而髓減，發為骨痿。
肺者，藏之長也，為心之蓋也。有所失亡，所求不得，則發肺鳴，鳴
則肺熱葉焦。
大經空虛，發為肌（脈）痺，傳為脈痿。
思想無窮，所願不得，意淫於外，入房太甚，發為筋痿，及為白淫。
有漸於濕，以水為事，若有所留；居處相濕，肌肉濡漬，痺而不仁，
發為肉痿。
有所遠行勞倦，逢大熱而渴，渴則陽氣內伐，內伐則熱舍於腎。腎
者，水藏也。今水不勝火，則骨枯而髓虛，故足不任身，發為骨痿。
治痿者獨取陽明，何也？陽明者，五藏六府之海，主潤宗筋，主束骨
而利機關也。沖脈者，經脈之海也，主滲灌谿谷，與陽明合於宗筋。陰陽
總宗筋之會，會於氣街，而陽明為之長，皆屬於帶脈而絡於督脈，故陽明
虛則宗筋縱，帶脈不引，故足痿不用也。

The pulmonary lobes are parched by the hot evil qi, rendering the skin debili-
tated. If this situation persists, one becomes quadriplegic [1].

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 396 Neijing Zhiyao Yigu 內經知要譯詁

With hot evil qi prevalent in the cardiac conduit [2], blood flows from the
lower part of the body to the upper. When this happens, blood vessels in the
lower part of the body will be empty; it will cause vascular atrophy [3]. The
joints are dangling limply as if dislocated [4]; the legs are loose and cannot be
put to the ground [5]. When the hot evil qi is prevalent in the hepatic conduit,
the bile juice spills [out of the gall bladder], leaving a bitter taste in the mouth.
The sinew membranes [6] become dry, therefore the tendons contract and
becomes spastic, and this will develop into teno-atrophy. When the hot evil qi
is prevalent in the spleenic conduit, the stomach is dry and one becomes
thirsty. The muscles will then lose sensation, and this will eventually develop
into muscle atrophy [7]. When the hot evil qi is prevalent in the renal conduit,
the waist and spinal column cannot support the body [to stand upright] [8],
the bones dry up and the bone marrow is diminished. This will eventually
develop into bone atrophy [9].
The lung is the senior among the zang-organs [10], the canopy of the
heart [11]. If there are unfulfilled aspirations, and one does not obtain what
one pines for, the lung starts wheezing. A wheezing lung has parched lobes [12].
When the principal conduits are empty, muscular numbness occurs [13]
and presents as vascular atrophy.
With wild thoughts, unrealised wishes and unbridled lust compounded
by sexual indulgence [14], teno-atrophy occurs [15]. There is also excessive
whitish discharge [16].
Frequent exposure to wetness or working in an aquatic environment will
foster a lingering wet evil qi. If this is compounded by a damp habitat, the
muscles are gradually eroded by humidity; they become numb and lose sensa-
tion. Consequently, muscular atrophy occurs [17].
When exhausted by a long journey and confronted with hot weather, one
becomes thirsty. When thirsty, the yangqi turns introvertive, cornering the hot
evil qi in the kidney. Now, the kidney is the zang-organ responsible for water
[fluid balance], and when water is overcome by fire, the bones wither and the
bone marrow is depleted. Therefore the legs cannot support the body [to
stand up]; bone atrophy occurs.
To treat atrophy, focus on the [podotelic] yang-ming [gastric conduit].
Why is that? The yang-ming [conduit] is the sea [reservoir of nutrients] for
the five zang-organs and the six fu-organs. Its primary function is to nourish
the progenitorial ligament [with nutrients]. The progenitorial ligament serves
to rein in the bones and facilitate the joints [18]. The Chong conduit is the sea

Neijing.indb 396 2010/2/26 6:59:42 PM

 Morbid Manifestations 397

[reservoir of blood and qi] of the conduits; it seeps into the creeks and valleys
[spaces between large and small muscles]. It joins the yang-ming conduit,
merging into the progenitorial ligament. All the yin and yang conduits
converge towards the progenitorial ligament [19] and meet at qijie [20]. Of
these, the yang-ming conduit is the leader [because it is full of blood], through
which all other conduits are linked to the Dai conduit and branch into the Du
conduit. That is why when the [blood in] the yang-ming conduit is dimin-
ished, the progenitorial ligament becomes loose and the Dai conduit cannot
rein in the other conduits. Consequently, the legs become flaccid and useless.

Explanatory Notes
Suwen Chapter 44: On Atrophy follows the previous chapter on numbness. It
must always be reviewed together with Chapter 43: On Numbness. Together
with Chapter 42: On Wind and Chapter 45: On Turbulent Qi Flow, these four
chapters form a “cluster” with interrelated symptoms in Volume 12 of Neijing.
According to Qin Bo-wei (ref. 2), numbness and atrophy are actually two
concepts with a great deal of similarity but also contrast between them. As a
generic group of diseases, atrophy is hot evil qi–induced disease with subse-
quent debility of body response. It is due to perturbations of emotion, work
habits and environment. Its presentation is loss of somatic function and
reduction in size of body parts. Its transmutation is from zang-organ to affili-
ated body parts. The basic management plan for it involves clearing and nour-
ishing. Its treatment by acupuncture is focused on the xing and shu of the five
potency level acupoints. On the contrary, numbness is cold evil qi–induced
disease with consequent excess of body responses. It is due to the attack of the
wind, wet and cold evil qi (environmental factors). It presents as pain and loss
of sensation. Its transmutation is from the body parts to the affiliated zang-
organ. The basic management plan for it involves warming and unblocking
the conduits. Its treatment by acupuncture is focused on the shu and he of the
five potency level acupoints. To sum up this comparison, it is apt to point out
that chronic numbness can turn into atrophy. Although this is twice referred
to in the text as loss of sensation in the muscles, it can be safely assumed that
it applies to all five zang-organs (systems). There is no statement to the
contrary, i.e. that atrophy can turn into numbness.
The whole of Chapter 43 is structured like a lecture leading the audience
from one highlight to another; that is why it was translated almost verbatim in

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 398 Neijing Zhiyao Yigu 內經知要譯詁

the explanatory notes of the previous section. In Chapter 44, the structure is
more concise, probably benefiting from the format in the previous chapter.
There are only four main blocks. The chapter begins with an explanation of
zang-organ atrophy (system dysfunction) and its causation (shi 使). The
second paragraph explains the pathogenesis (de 得). The third paragraph, a
short one, highlights the colour differentiation (bie 別) and lesions in body
parts relevant to the five zang-organs. The last paragraph proposes a guideline
for treatment (zhi 治) with acupuncture and the rationale for it. This strongly
reminds us of the classical literary style in essay-writing or poetry that was
also governed by four key words, viz. (qi cheng zhuan he 起承轉合; qi—begin-
ning, i.e. introduction; cheng—receiving, i.e. extension; zhuan—turning, i.e.
subplot; he—closing, i.e. conclusion). Although this literary style did not
appear in writing until the Yuan dynasty, one can trace its embryonic origin in
Suwen Chapter 44, which was clearly intended to be a coherently structured
essay capable of standing on its own. Thus with the four key words (causation,
pathogenesis, differentiation and treatment), a reader would have no difficulty
in following the line of thinking of the author of Neijing and arriving at a
holistic view of atrophy and its treatment.
If this information is recast in tabular form, one can immediately see the
didactic value of the structure of the text.

Relationship between cause and symptom in each zang-organ

Zang-organ Causation Presentation Symptoms
Lung not getting what is paraplegia weakness in skin
desired
Heart main blood vessels vascular atrophy legs cannot stand
are empty firm
Liver licentious and sexual teno-atrophy contraction of
indulgence tendons, impotence
Spleen exposure to wetness muscular atrophy loss of sensation in
in work and habitat muscles
Kidney fatigue and thirst bone atrophy waist and spine
cannot support
body

“Comparing similar phenomena and grouping them according to their

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 Morbid Manifestations 399

common features” (qu xiang bi lei 取 象 比 類) is a basic approach when

learning Chinese medicine. Suwen Chapter 76: Shi cong yong lun 示 從 容 論
actually uses the term ji yu bi lei 及 于 比 類. This stems from the time-
honoured method of Confucian learning: to learn by categorisation (ge wu zhi
zhi 格 物 致 知).39 Taking these two consecutive chapters as a whole, one can
readily appreciate that Neijing is not just a collation of medical writings. It
emerged, subsequent to the efforts of Wang Bing, as a self-contained corpus
medicum of enormous didactic value, with which Wang Bing could allay the
fears that it would dissipate among the ignorant (san yu mo xue 散 於 末 學)
through a lack of qualified teachers (jue bi shi zi 絕 彼 師 資). Novices in
Chinese medicine can learn their profession directly by reading Neijing. It is a
pity that not every practitioner of Chinese medicine does so today.

Footnotes

[1] quadriplegic: Weibi 痿 躄, literally “limping legs”, but used in a generic

context to describe lame limbs, i.e. quadriplegia. Atrophy refers to reduction
in muscle mass due to disuse or denervation. Dystrophy refers to loss of
locomotor or systemic function due to lack of nutrient supply, endocrine
regulators or auto-immune reaction. Much of the atrophy, wei 痿, described
in this section is actually dystrophy or dysfunction.
[2] cardiac conduit: Meaning physiology of the cardiovascular system, not only
the heart. It applies likewise to all other zang-organs, hence the chapter title
“Organ Dysfunction”.
[3] vascular atrophy: Maiwei 脉 痿, actually atrophy of tissues due to lack of
blood supply, not atrophy of the vessels themselves.
[4] as if dislocated: Here the character 不 bu is missing. It should read bu qie 不
挈, “not lifting”. Section 1.2: “immortals who could master the laws of
nature, 提 挈 天 地”, literally “lift the (law) of heaven and earth”. The adage “ti
kang qie ling” 提綱挈領, “lifting the main rope (of the net) and the collar (of
a fur coat)”, comes from Xunzi (《荀子．勸學篇》︰「若挈裘領 ……。」)
[5] cannot be put to the ground: i.e., paraplegia.
[6] sinew membranes: Jin 筋 is loosely translated as “sinew”, meaning muscle
and tendon, or under specific circumstances as “tendon”, connecting the
muscle to the bone. Hence jinmo 筋膜 can be the fascia, the tendon sheath or

39
《大學》︰「致知在格物，物格而後知至。」

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 400 Neijing Zhiyao Yigu 內經知要譯詁

even the aponeurosis. In the present context, it is most likely to be the tendon
sheath. In a broad sense, jin is applicable to tendons, muscles or nerves. In
alcoholic polyneuropathy, the limbs are loose due to loss of neural control.
But in Neijing times, it would not have been possible to distinguish whether
this was due to tendons, muscles or nerves.
[7] muscle atrophy: In extreme case, myasthenia gravis, an auto-immune disease
attacking the cholinergic receptors, which Chinese medicine treats with some
success. The primary cause is ascribed to spleen dysfunction. In Chinese
medicine, the spleen also stands for the immune system.
[8] to stand upright: In Duchenne muscular dystrophy, the patient cannot stand
up or climb steps. But this disease is genetically linked. It starts early and the
patient dies young. It has nothing to do with renal function.
[9] bone atrophy: This could be osteoporosis, bone cancer, or bone tuberculosis.
In Chinese medicine, avascular necrosis of the femoral head can be treated
with some success by topical medication, installation of a drain and even
removal of the dead tissue. Orthopaedic intervention, in spite of the taboo
on invasive surgery, has always been practised in Chinese medicine.40
[10] senior among the zang-organs: There is no reason to believe that the lung is
more important than the other four zang-organs. Since all the conduits
converge towards the lung (fei chao bai mai 肺 朝 百 脉), perhaps this means
the lung supplies oxygen, the primary substance in metabolism.
[11] canopy: The lungs indeed hang over the other organs like the canopy of a
chariot. But the social implication is that only important dignitaries or the
king can employ a canopy. Two new acquaintances met in the traffic and
engaged in an intimate conversation such that the canopies of their chariots
were overcasting each other canopy.41
[12] parched lobes: In the original text, this sentence continues as “because (gu 故,
“therefore”) the pulmonary lobes are parched, paraplegia develops; that is
what it means”. Most annotators expanded on this statement and placed the
parched lung as the primary cause of all kinds of atrophy (weibi 痿 躄). The
sentence “parched pulmonary lobes” (fei re ye jiao 肺 熱 葉 焦) appears three
times in this chapter, but the third time was not excerpted by Li Zhong-zi.

40
See Wei Yi-zong 韋 以 宗, Zhongguo guke jishu shi 中 國 骨 科 技 術 史 (History of
Chinese Orthopaedics) (Shanghai: Shanghai keji wenxian chubanshe, 1983).
41
See《史記．鄒陽傳》︰「傾蓋如故。」(qing gai ru gu).

Neijing.indb 400 2010/2/26 6:59:43 PM

 Morbid Manifestations 401

When first cited, at the beginning of the chapter, it included the character 故
gu (because of, therefore), but this was not excerpted by Li. This is odd
because the character 故 gu makes it a subordinate clause, with the main
clause nowhere to be found. When cited the third time, it again began with
故 gu, but the whole sentence was not excerpted by Li, as explained above.
Some other annotators considered that the third statement (the one not
excerpted) was actually part of an annotation and was transcribed here as an
unintentional insertion. Even then, some rearrangement is necessary to
accommodate the first occurrence of the character 故 gu. If the first para-
graph ending with [1] were transferred here, to dovetail the sentence ending
at [12], the subordinate nature of the first paragraph would become obvious.
This move also renders the third statement redundant. (The new arrange-
ment reads as follows: ming ze fei re ye jiao… gu fei re ye jiao ze pi mao 鳴 則
肺 熱 葉 焦 …… 故 肺 熱 葉 焦 則 皮 毛 …… ). In this context, atrophies of all
zang-organs are of equal status, although the lung is cited as an example.
They are the sequelae of the numbness in the corresponding organ, but not a
transmutation from other zang-organs. This argument makes sense (ref. 43).
[13] muscular numbness occurs: According to Taisu, this should be vascular. This
amendment makes sense and echoes the same statement below on muscular
atrophy. This and the following paragraph are extracted from Benbing 本 病
(On Individual Disease), an ancient medical text contemporaneous with
Neijing. Li Zhong-zi omitted the origin of this quotation, which is vital to
show that Neijing was not the only medical literature of its time (There are
other ancient medical texts like《揆 度》、《奇 恆》etc. see ref. 29). Benbing
was quoted only once in Suwen. Later quotations of this ancient script could
be spurious (as in Suwen Chapter 73, apocryphal).
[14] sexual indulgence: Literally “entering the chamber too often”. Purely out of
modesty, most annotators did not pin down these lustful wishes and
thoughts of lust. But it is clear that the entire statement is a description of
licentiousness.
[15] teno-atrophy occurs: The word 筋 jin here is construed to mean zongjin 宗筋,
the progenitorial ligament that is the penis. In this context, teno-atrophy of
the progenitorial ligament is a precise description of impotence.
[16] whitish discharge: Spermatorrhoea or leucorrhoea.
[17] muscular atrophy occurs: This is a definitive statement that chronic numb-
ness turns into atrophy, not the other way round. It applies to all zang-
organs. This statement is extracted from Xiajing 下 經. It and Shangjing 上 經,

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 402 Neijing Zhiyao Yigu 內經知要譯詁

apparently Volumes I and II of the same title, are quoted several times in
different chapters of Suwen (Shangjing: Chapters 46, 69 and 77; Xiajing:
Chapters 34, 44, 46 and 77.) There must have been a period when Shangjing,
on men and their environment, Xiajing on the body and diseases, Neijing
內經 (a medical handbook for the doctor’s personal use) and Waijing 外經 (a
medical handbook for public perusal) all co-existed. Only when they were
later incorporated into Neijing was the latter entitled “Huangdi Neijing” to
confirm its supremacy. According to Zhang Can-jia (ref. 29), there are no less
than 40 references cited in Suwen and Lingshu. It is a pity that none of these
ancient scripts exist today. Perhaps they did exist in Neijing times,42 but offi-
cial compilers in the Qin court gingerly conserved the most important
bamboo tablets and incorporated them into a prototype of Neijing while
destroying the rest, as the order of the Emperor of the time was to destroy all
books except those of a utilitarian nature (see ref. 43).
[18] facilitate the joints: Chinese medicine sees all ligaments of the body as
converging towards the penile shaft, so as to permit its penetrative function.
In this context, the progenitorial ligament means the major ligaments, not
exactly the external genitalia. The joints are conceived as mechanical
contraptions (jiguan 機關) that open and close.
[19] progenitorial ligament: According to Li Zhong-zi, these are the nine conduits,
including the three podogenic yin conduits (tai-yin spleenic, shao-yin renal
and jue-yin pulmonary) plus the podotelic yang-ming gastric conduit, the
podotelic shao-yang gall bladder conduit, the Chong, Ren, Du conduits and
the inner-connecting (qiao) conduits.
[20] qijie: Qijie 氣 街 refers to the femoral artery at the groin by the side of the
pubic hair region. It can serve as an acupoint but is not assigned to one of
the regular conduits. Qijie, literally “thoroughfare of qi”, refers to the conflu-
ence of major arteries where the pulse can be felt throbbing. There are four
qijie in other parts of the body, but it refers often to the one at the groin, also
called acupoint qichong (氣沖穴).

42
《史記．扁鵲倉公列傳》︰「意受其書上下經 ……」

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 Morbid Manifestations 403

Addendum by Dr. W. F. Pau

Regarding the first two citations of「肺 熱 葉 焦」as in [12],43 it is fair to
conclude that the clinical condition is bronchial asthma, wheezing being its
dominant symptom.
According to a long-held belief among Chinese scholars, people could air
their grievances by speaking their mind. To wheeze is to give vent to one’s
pent-up grievances, or unfulfilled aspirations, as suggested in the translation.
This implies that the ancient physicians were not aware of the allergic nature
of asthma. The hyperinflated state of the lung and the thorax conforms to the
description yi fen tian ying 義 憤 填 膺 (a sense of righteousness filling the
chest), which means the same as bu ping ze ming 不 平 則 鳴 (speak out when
feeling that something is unjust). However, the inflammatory changes in the
asthmatic’s lung are catarrhal in nature, unlike the suppurative processes that
are hallmarks of pneumonia. The asthmatic’s lungs are neither parched nor
blackened, unless the patient is a smoker, which cannot have been the case in
the Neijing era as tobacco was not introduced to China until the Ming dynasty.
This is the first incongruity.
In modern medicine, there is no known chest disease that leads to skin
atrophy or debilitation. Since both the lung and the skin are organs of respira-
tion and perspiration (《素問．陰陽應象大論》︰「肺生皮毛」(fei sheng pi
mao), “the lung generates skin and body hair”.《素問．五藏生成》︰「肺之
合 皮」(fei zhi he pi), “that the lung is affiliated with the skin”), it was reason-
able for people to infer that a morbid state of one might affect the physiology
of the other.44 But there should not be hair-loss or thinning of the skin. This is
the second incongruity.
The observation that if the hot evil qi dwelt in the lungs, the outcome was
quadriplegia is not borne out by facts. There is no way that any lung disease
could lead to quadriplegia. During an asthmatic attack, the patient may be
unable to walk, not because he is suffering from motor paralysis of the limbs
but because he is breathless. There is neither damage to the nerve trunks in

43
Author’s note: which was independently proposed by Dr. Pau without access to the
entire chapter of Suwen.
44
Author’s note: Pi mao xu, yi gan mao 皮 毛 虛，易 感 冒 (“when the skin is weak,
one easily catches a cold”).

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 404 Neijing Zhiyao Yigu 內經知要譯詁

the spinal cord, nor wholesale muscle atrophy in the limbs. This is the third
incongruity.
There has to be an alternative interpretation of the relation between
parched lung and atrophy, but none has yet been found.
On Footnotes [2] and [3]: The literary description is that blood flows in
reverse, from the lower part of the body to the upper, which would render
blood vessels in the lower part of the body “empty”. Such a phenomenon is
observed in two diseases that affect the cardiovascular system of the body.
They are:

A. Coarctation of the aorta: in this condition, a constricted segment of the tho-

racic aorta exists, commonly at a point distal to the origin of the left subclavian
artery, near the insertion of the ligamentum arteriosum (ductus arteriosus in the
foetal circulation). The brachial and radial pulses are full, whereas pulsation in
the femoral artery is absent or markedly diminished. There is hypertension in
the arms but unobtainable blood pressure in the lower extremities. The develop-
ment of collateral vascular channels around the chest wall is characteristic of co-
arctation of the aorta; notching of the ribs is a signature radiographic sign. The
direction of blood flow in the collateral circulations conforms to the description
xia mai jue er shang 下脈厥而上.
B. Diabetic vasculopathy: macrovascular disease is a common complication of
diabetes mellitus. Progressive obliteration of the lumen of arteries supplying
the lower extremities, known as peripheral vascular disease, leads to intermit-
tent claudication and gangrene of the feet. The degree of arterial stenosis can be
gauged by measuring the Ankle-Brachial Index (ABI), which is the ratio between
the systolic pressure of the posterior tibial artery at the ankle and that of the
brachial artery. A ratio of less than 0.9 is abnormal, a prediction of triple vessel
disease in the heart, gangrene of the feet and other circulation failure.

Experts in pulse-taking (an mai 按脈), keen adepts of san bu jiu hou 三部
九候 (“three sites and nine modes of pulse-taking”), should be able to observe
these differences in the pulses in the respective vessels mentioned above.45

45
Author’s note: Lingshu Chapter 48: On Interdiction. The ratio between the pulse
pressure at the carotid artery (renying 人 迎) and the wrist (cunkou 寸 口) can vary
from one fold to four folds, the former being the stronger. Depending on this ratio,
it is possible to diagnose where the disease lies, and decide on its treatment and
prognosis. This information is so important that it is listed in this chapter which
means literally interdiction (jinfu 禁 服) to divulge this knowledge outside a closed
circle of sworn brotherhood sealed with blood.

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 Morbid Manifestations 405

Either of these two conditions will lead to gross cardiovascular dysfunc-

tion, which meets the description of mai wei 脈痿 (vascular atrophy), but only
diabetes mellitus could explain the morbid state which follows, where “the
joints are dangling limply as if dislocated; legs are loose and cannot be put to
the ground.”
Among the many complications of diabetes mellitus (DM) are:

(1) diabetic polyneuropathy––loss of sensation in the weight-bearing joints such

as the knees and the ankles accelerates damage to these joints by wear and tear
and ultimately leads to gross osteo-arthropathy, deformity and dislocation, the
so-called Charcot’s joint.

(2) diabetic amyotrophy is manifested by weakness of the large muscles of the

pelvic girdle and upper legs. This matches the description in the text: “legs are
loose and cannot be put to the ground.”

If this assumption is correct, although it is at best a rough estimate, the

above answer begs the question: what is “xin qi re” 心 氣 熱 (“hot evil qi” prev-
alent in the cardiac conduit)? It cannot be interpreted as DM. One may ques-
tion the wisdom of the authors of Neijing in creating such a diagnostic jigsaw
puzzle for readers of future generations, much as Nostradamus lay down his
great prophecies for future generations to decipher.46
Lay people may question the competence of their doctor if he misses DM
and confuses it with some other disease. In the past, from the beginning of the
sixteenth century to the time penicillin was invented, syphilis was known in
the West as the “great imitator”. Nowadays, DM has this distinction. It may be
disguised as xin qi re etc. (xin qi re, shen qi re, gan qi re 心 氣 熱，腎 氣 熱，肝
氣熱) or one of these kinds of numbness, and can be the cause of “atrophy” of
almost any tissue or organ in the body.47
On Footnote [6]: This is about hot evil qi prevalent in the hepatic
conduit. It is fair to accept that people in Neijing times could not distinguish
between the tendons, muscles and nerves, which were called all summed up
under the term jin 筋. So where is the connection between liver dysfunction (to
the extent of jaundice) and atrophy of tendons, muscles or nerves, or all three?
One may venture to cite alcoholism as the bridge between them. Alcoholism is

46
Author’s note: cf. tui bei tu 推 背 圖. First appeared in early Song dynasty, it is an
ambiguous graphic story forecasting the future social events to come.
47
Author’s note: For syphilis in Chinese medicine, see ref. 53, p. 159.

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 406 Neijing Zhiyao Yigu 內經知要譯詁

the principal cause of deranged hepatic function in Western societies. It might

be true as well that alcoholism was also prevalent in some ancient Chinese
communities. In Shuihu zhuan 水滸傳 (The Water Margin), which dates from
the late Song dynasty, the heroes consumed alcohol in huge amounts on a
daily basis.48
Alcoholic cirrhosis of the liver would serve to explain the spilling of bile
juice. One of the clinical manifestations of chronic alcoholism is polyneurop-
athy, which begins with paraesthesia of the feet, then foot drop, then weakness
of the leg muscles spreading proximally to the thigh. There is a parallel paraes-
thesia and weakness of the hand, and wrist drop as well. Surely, alcohol and
the effect it has on body function, must be regarded as an exogenous evil qi,
capable of invading the body.
As tendons and muscles work in unison, weakness of one leads to weak-
ness in the other. Alcoholic polyneuropathy will progress to severe atrophy of
the leg muscles over a period of time.
This might be an answer to the purist who insists on calling a tendon a
tendon.49 There are only two tendon diseases commonly known in Western
medicine, which are covered in passing in textbooks. They are:

1. Dupuytren’s contracture, which begins with a thickening at the ulnar side

of the palmar aponeurosis, developing into contracture of this part of the
tendon sheath, ultimately leading to flexion deformity of the ring and small
fingers.
2. Volkman’s ischaemic contracture, which is contracture of the flexor tendons
of the wrist, secondary to interference of the circulation of the forearm. It
is induced by fracture of the lower end of the humerus.

It transpires that Dupuytren’s contracture is a frequent complication

among alcoholics. This contracture affects mainly fair-haired northern Euro-
peans, and a study in a Nordic country, showed that among cirrhotic patients
in a liver unit, only those whose liver cirrhosis was alcoholic in origin suffered
from the tendon contracture.

48
Ponds of wine, see “mood enhancers” in ref. 53, p. 166.
49
There is no lack of purist in ancient China such as the School of Logicians (ming jia
名 家). See J. Needham, Science and Civilisation in China, Vol. 1, p. 95, and Vol. 2,
Ch. 11; 呂思勉：《經子解題》、《史記．太史公自序》︰司馬談論六家要旨。

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 Morbid Manifestations 407

How the authors of Neijing could know of this relationship between liver
dysfunction and a tendon contracture in the hand, truly a tendon atrophy, is
completely unknown,
On Footnote [7]: This is on hot evil qi prevalent in the spleen. The same
interpretation as for [6] applies here, since liver and spleen are often paired.
(See ref. 53, p. 71.) The symptoms of dry stomach and thirst can again be
attributed to alcoholism, with associated chronic atrophic gastritis. In Chinese
medicine, the principal function of the spleen is the transformation of water
and cereals (pi zhu yun hua 脾主運化, see ref. 53, pp. 50–51), and the spleen is
said to govern the blood (pi tong xue 脾統血). There is little to suggest that the
spleen governs the health of the muscles, except from the nutrient supply
point of view. This is a malnutrition issue, as distinct from specific muscle
diseases like myasthenia gravis, or Duchenne muscular dystrophy. Neither
gastric atrophy nor muscular numbness are a feature of myasthenia gravis.
Only chronic alcoholism can explain these two manifestations.
On Footnotes [8] and [9]: This is about bone atrophy. It is much easier to
reach a consensus on bone atrophy, as the end result of chronic renal failure.
The term for kidney-related bone disease is renal osteodystrophy. The ailing
kidney fails to synthesise the hormone 1,25-dihydroxy-vitamin D3 from
precursors; this hormone stimulates absorption of calcium from the gut. The
ailing kidney also causes retention of phosphorus, and thus hyper-phospha-
taemia, which reduces the serum ionised calcium level to keep the calcium-
phosphate product constant. The hypocalcaemia sets off a compensatory
hyperparathyroidism, which increases bone reabsorption. Such abnormal
metabolism will result in rickets and osteomalacia in the growing child,
osteomalacia in the adult, and osteomalacia plus osteoporosis in the elderly.
Patients with chronic renal failure will suffer from a combination of protein-
calorie malnutrition, osteomalacia, osteoporosis, proximal myopathy and
peripheral neuropathy, so it is hardly surprising that they cannot stand
upright. It is unusual to find the extreme degree of skeletal deformity
mentioned in Suwen Chapter 43, on kidney numbness. Aseptic necrosis of the
femoral head can occur, as well as multiple fractures. That the marrow is
diminished means there will be anaemia. Erythropoiesis is suppressed in
uraemia because the kidney is not producing enough erythropoietin.
The authors of Neijing preferred to blame physical exhaustion from long
journeys and dehydration for “setting the kidney on fire”. This reflects
changing disease patterns down the centuries. In the twentieth century, the

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 408 Neijing Zhiyao Yigu 內經知要譯詁

leading causes of chronic renal failure were hypertension, diabetes, lupus

erythematosis, immune-mediated glomerulonephritis, obstructive uropathies
and drug-induced nephropathies.
On Footnote [13]: This is a repetition of the theme that has already been
dealt with in [3]. If it can be accepted that da jing 大經 (major conduit) means
a major blood vessel, which after all, is a conduit for the flow of qi, the
following interpretation would make sense. Uneven distribution of blood
supply, as alluded to in the second paragraph of this section, results in under-
perfusion of some territories, such as the heart, the brain or the extremities. A
typical example is coronary insufficiency, which produces muscle numbness,
and that is angina pectoris, with progression (chuan wei 傳 為) to acute coro-
nary syndrome, cardiac failure or sudden cardiac death.

[Section 8.25] Lingshu Chapter 80: On the Great

Bewilderment

《素問．逆調論》曰︰不得卧而息有音者，是陽明之逆也。足三陽者下行，
今逆而上行，故息有音也。
陽明者，胃脈也。胃者，六府之海。其氣亦下行。陽明逆，不得從其
道，故不得卧也。胃不和則卧不安，此之謂也。
《靈樞．邪客》曰︰厥氣客於五藏六府，則衛氣獨衛其外，行於陽，不得入
於陰。行於陽則陽氣盛，陽氣盛則陽蹻滿（陷）
；不得入於陰，陰虛，故目
不瞑。調其虛實，以通其道而去其邪。飲以半夏湯一劑，陰陽已通，其卧
立至。以流水千里以外者八升，揚之萬遍，取其清五升煮之，炊以葦薪，
火沸，置秫米一升，治半夏五合，徐炊令竭一升半，去其滓，飲汁一小
杯，日三，稍益，以知為度。故其病新發者，覆杯則卧，汗出則已矣；久
者，三飲而已也。

Suwen Chapter 34: On Turbulent Qi Flow

There are times when the patient cannot lie down quietly [1] and the
breathing is noisy [laryngeal stridor]. This is due to turbulent qi flow [2] in
the yang-ming [gastric] conduit. The three podotelic yang conduits course

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 Morbid Manifestations 409

downwards. If they reverse the flow of qi by going upward, this gives rise to
noisy breathing.
The yang-ming conduit governs the stomach, which is the sea [of nutri-
ents] for the six fu-organs. Its direction of qi flow is downward. But if qi is not
travelling along its tract, one cannot sleep [peacefully]. “When the stomach is
restless, sleep is restless”. [3] [This statement from Xiajing 下 經] is actually
referring to this situation.

Lingshu Chapter 71: External Evil Qi

When the external evil qi [4] resides in the five zang-organs and the six
fu-organs, the defensive qi, being unable to enter the yin [visceral, inner]
domain, can only travel in the yang domain, guarding the body surface. This,
in turn, causes the inner-connecting upstanding yang conduit (yangqiao) to
become full [5]. Not being able to reach the yin domain, it becomes deficient
in yin; therefore the eyes will not close [in sleep] [6]. Adjust the state of defi-
ciency or excess and restore the patency of the tracts for the defensive qi;
[subsequently] the evil qi can be dispelled. Now take a dose of the Pinellia
Decoction [7]. Since [the defensive qi] can commute between the yin and
yang domains, sleep will ensue promptly. Fetch eight sheng [8] of water from a
stream that has been running for one thousand li [9], toss it ten thousand
times [10] and remove five sheng of the clear supernate. Bring it to boil with
reed fire [11], then add one sheng of millet [12] and five ge [13] of processed
Pinellia tuber. Simmer until it is reduced to one and a half sheng. Remove the
marc, drink a small cup of the juice three times a day. Increase the dose as
needed so as to feel the beneficial effect [of the decoction]. If this is a new case,
[the patient] will sleep as soon as the cup is emptied [14]. One feels much
better with some sweating. For a chronic case, three doses will do.

Explanatory Notes
Suwen Chapter 34 deals with a number of rare diseases that are caused by
turbulent flow of the nutritive and defensive qi, as well as thermoregulation
and the balance between yin and yang in terms of water (metabolites in body
fluid) and fire (rate of metabolism), i.e. homeostasis. This is the last of the
four chapters on febrile diseases in Volume 9; the other three chapters are

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 410 Neijing Zhiyao Yigu 內經知要譯詁

partly quoted in Section 8.11 (Chapter 33), Section 8.13 (Chapter 32) and
Section 8.14 (Chapter 31). Gao Shi-zong began his annotation of Chapter 34
with an exegetic definition of these rare diseases. “When heat and cold are not
harmonious, there is dysphoria and ‘fuming’ fever [dan re 癉 熱]. When water
and fire are not harmonious, there is ‘muscle grilling’ [rou shuo 肉爍, myositis]
and spasm. When the defensive qi and the nutritive qi are not harmonious,
there is inanition and muscle wasting [rou ke 肉 苛]. When the qi flow among
the zang-organs is not harmonious, there is noisy breathing.” Of these four
cases, Li Zhong-zi only picks up “restless sleep due to restless stomach”, which
was co-presented with noisy breathing. It is exactly in this context that he
mixes up the chapter title, which he ascribes to Lingshu Chapter 80: On
the Great Bewilderment (Da huo lun 大 惑 論). The two chapters are indeed
comparable in style, as Lingshu Chapter 80 also covers rare cases like
phobias about high places, forgetfulness, facile hunger with no appetite and,
most relevant to Suwen Chapter 34, sleep disturbance. The last item is subdi-
vided into restless sleep (bu de wo 不 得 , “cannot lie down”) and somno-
lence (duo wo 多 , “frequently lying down”). A confusion of this kind is
inexcusable, because NJZY was intended to be a first text for the beginner.
Nevertheless, it is a much lesser error when compared with Section 8.7, which
did not form part of the authentic text of Neijing. In Section 8.7, we might not
hold Li Zhong-zi responsible for this error, as the current version of NJZY was
only resurrected by Xue Xue (in 1764), a century after its first publication by
the author (in 1642). There was no indication that Xue was handling the orig-
inal version. The same excuse applies to this section.
The second part of this section is cited from Lingshu Chapter 71: External
Evil Qi. Li Zhong-zi made a double mistake by putting this together with
Suwen Chapter 34 and including them under the chapter title of Lingshu
Chapter 80: On the Great Bewilderment. The only excuse is that all three of
them, two excerpts and one chapter title, are partly dealing with sleep distur-
bance, which is the purpose of this section. Having said that, Lingshu Chapter
71 deserves special attention. To begin with, this is a dialogue between
Huangdi and Bogao 伯 高, not Qibo. Bogao was an expert in acupuncture. He
is quoted in Lingshu Chapter 14: Bone Measurements and Chapter 32: Gut
Content. The latter chapter title actually refers to the amount of gut content
that would allow the common folk to survive starvation; it deals with meas-
urements of the digestive tract. From these two chapters, it is immediately
apparent that Bogao was an anatomist; that befits truly his expertise in

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 Morbid Manifestations 411

acupuncture. In the current chapter (Lingshu Chapter 71), Bogao is presented

as an expert on herbal drugs, as it includes one of the 13 prescriptions in
Neijing and it gives detailed instructions as to its preparation. Immediately
after this excerpt, in the paragraph that follows but is not cited in NJZY, Bogao
gives a colourful discourse on the correspondence between the gross anatomy
of the human body and landmarks in nature, in order to justify “the inherent
affinity between body function and the movement of natural events” (ren yu
tian di xiang ying 人與天地相應). Such a universal anthropomorphic outlook
was first announced in Zuozhuan, Duke of Chao 32nd year: “There are three
stars in heaven, five elements on earth, left and right side in the body; they
each have their consorts.”50 It was later finely elaborated by Dong Zhong-shu
董 仲 舒 (179–104 bc) during the reign of emperor Han Wudi, leading to the
apotheosis of the absolute monarch. Since then, Confucianism had become
the dominant ethics of monarchical rule and the empathy between men and
nature became one of the central tenets of Chinese medicine. Bogao, together
with Shaoshi 少師 in Chapter 72 and other names like Leigong 雷公, Guiyuqu
鬼 臾 區, and Shaoyu 少 俞, believed to be ministers of health at the court of
Huangdi, represented probably different schools of medical practice contem-
poraneous with Qibo, who prevailed over others to produce the main
substance of Neijing. (See ref. 44). The rest of Lingshu Chapter 71 belongs to
Qibo, who talks about fine control of the needle (chi zhen zong she 持針縱舍)
to dispel the invading evil qi.

Addendum by Dr. W. F. Pau

Snoring has generated great interest in recent years because it is a sign of
obstructive sleep apnoea syndrome. On further analysis of the symptoms
described in this section, it can be concluded that whereas snorers can lie
down fully, a patient suffering from either bronchial or cardiac asthma has to
sit up in bed because his/her breathing is laboured. Cardiac asthma is espe-
cially dangerous, as it indicates left-side heart failure with pulmonary oedema.
The snag in this assumption is that it is the cheirotelic shao-yin conduit that
governs the heart, not the yang-ming conduit. That leaves open which
acupoint the therapist will choose to cure the noisy breathing.

50
天有三辰，地有五行，體有左右，各有妃耦。

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 412 Neijing Zhiyao Yigu 內經知要譯詁

Footnotes

[1] lie down quietly: There are subtle nuances in the term “sleep”: wo , “lie
down”; ming 瞑, “close the eyes”, not necessarily to sleep; mei 寐, “a brief
sleep, cat-nap”; shui 睡, “rest with eyes closed”; mian 眠, “sleep quietly”, or
“deep sleep”; wu 寤, “wake up from sleep”. In this case, wo means “lie down
to sleep”.
[2] turbulent qi flow: The term ni 逆 means “reverse, flow against the stream”. In
this case, it means uneven flow or turbulent flow.
[3] sleep is restless: this is a quotation from Xiajing 下 經 that Li Zhong-zi
omitted to mention. More importantly, this sentence might well be an inser-
tion, as indicated by the phrase “that is what it means” (ci zhi wei ye 此 之 謂
也), a colloquial style fitting for an annotation. (See ibid. 8-24-12).
[4] exogenous evil qi: The term jueqi 厥氣 refers to a recrudescent disease due to
turbulent flow of qi such that the yin-yang balance is upset. Here the result
becomes the cause, as disturbance of directional qi flow is brought about by
external evil qi. This is implied by the chapter title Xie Ke 邪 客, “an evil
visitor”, i.e. a visit (invasion) of external noxious elements that enters the
body and resides therein. The body reacts accordingly and the ensemble is
called jueqi, hence the translation of the chapter title. This is different from
jueni 厥 逆 or jueleng 厥 冷 where qi flow, and blood circulation, is totally
obstructed, causing cold limbs and even syncope.
[5] (yang-qiao) is full: The correct word should be man 滿 (full), not xian 陷
(collapse). The same wording occurs in Taisu and Lingshu Chapter 80; the
corresponding word is sheng 盛 (bountiful). For the inner-connecting yin-
qiao conduit, the corresponding words are sheng and man in reverse order,
implying that the two words are equivalent in meaning.
[6] eyes will not close: It is firmly believed in Chinese medicine that when the
defensive qi travels in the yang domain, one remains awake. When the defen-
sive qi enters the yin domain, one is somnolent. This is exactly the action of
melatonin released by the pineal gland. Here day or night is merely the signal
that triggers the release of melatonin, not the time factor. Defensive qi is
ascribed to the circulating granulated white blood corpuscles that become
sequestered in the spleen at night. Nowadays, some other regulatory mole-
cules must also be taken into consideration.
[7] Pinellia Decoction: Also called Pinellia and Millet Decoction (Ban xia shu mi
tang 半夏秫米湯) that indicates the two ingredients, processed Pinellia tuber
and glutinous millet. It is in fact a thick soup of glutinous millet medicated

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 Morbid Manifestations 413

with Pinellia tuber (fabanxia 法 半 夏, often abbreviated to faxia, which has

been cooked with ginger juice and alum). Pinellia has multiple pharmaco-
logical actions with respective identifiable active substances, mainly as an
anti-emetic and a mucolytic. However, Pinellia has a profound stabilising
effect on the parasympathetic system. It is the main ingredient in Er chen
tang 二 陳 湯, from the Song dynasty official formulary (Ju Fang 局 方), later
enriched to become Wen dan tang 溫  湯. The latter is good at calming a
disturbed mental state, spasmolysis, dysphoria and insomnia, besides its
usual anti-emetic effect. Today, Wen dan tang is often used as an anxiolytic,
like diazepam.
[8] sheng: The conversion between ancient and modern measurements is a
vexing issue, because there are several concurrent explanations that are all
seemingly valid. As far as this section is concerned, we devote our attention
to volumetric measures. In Hanshu 漢 書 (Annals of the Han Dynasty) the
units of volumetric measure shao 勺, ge 合, sheng 升, dou 斗 and shi 石 are
metric. They were codified according to official standard containers of the
Qin imperial court; one sheng was equal to 200 ml. Later, it was argued that
one sheng equalled about 500 ml, with one shao equal to 1/10th of a ge and
1/100th of a sheng. Shao 勺 is the homonym of shao 杓, a wooden spoon;
with 5 ml for one spoonful, it makes sense. However, during the long period
between the Han and Tang dynasties, the current practice was that one sheng
was equivalent to only two ge. This is evidently not applicable to the Pinellia
Decoction. With five sheng of water (one litre) to boil with one sheng of
millet (about 200 g) and five ge (two and a half sheng, i.e. 500 g) of Pinellia,
there can hardly have been sufficient water to cook the millet al dente. One
more complication lies in the fact that during the long period between the
Zhou and Qin dynasties, there was a kind of medical sheng (yaosheng 藥 升),
a special measure for the profession of the time but which became obsolete
later. The sheng in Neijing should be considered as a Qin dynasty measure-
ment. Since the Han dynasty adopted the legislation of the Qin, we can
adhere to the metric relation between sheng and ge, with one sheng equal to
200 ml. If 5 sheng of water (1 litre of water, equal to the metric litre, gong
sheng 公升) are used to cook one sheng (about 200 g) of millet, plus 5 ge (half
a sheng, about 100 g) of Pinellia tuber and reduced to one and a half sheng
(about 300 ml) of juice, this is still a very thick soup.51

51
See ref. 32, Vol. 14,《中藥學》，顏正華主編。

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 414 Neijing Zhiyao Yigu 內經知要譯詁

[9] one thousand li: In Neijing times, i.e. during the Zhou dynasty, one li 里 was
a distance of 300 steps, about 200 metres, so in this case, the water needs to
be coming from 200 km upstream. Li Zhong-zi called this oxygenated water
ganlanshui 甘 瀾 水 (sweet rippling water), a term not found elsewhere. Xie
Guan 謝 觀 in his gargantuan Encyclopedia of Chinese Medicine (1926)
recorded the term but it did not mention its source.
[10] toss it ten thousand times: The purpose of these efforts was to obtain fully
oxygenated water. But when the water was first brought to the boil before
adding the medicinal ingredients, there was little oxygen left in the hot water.
In his famous Cha jing 茶 經 (Canon on Tea), the first of its genre, Lu Yu 陸
羽 (733–804) recommended fetching water from a running source. When
boiling water, it should be used only at the first sign of ebullition.
[11] reed fire: A vigorously flaming fire made by burning dry reeds, so that the
water boils quickly.
[12] millet: This refers to the glutinous variety of millet (Panicum miliaceum 黍),
the small yellow rice (xiao huang mi 小 黃 米) because of its grain size and
colour. It can also apply to the glutinous variety of ji 稷 (Panicum), or even
liang 梁 (sorghum). In any case, shu 秫 must be glutinous. Today, the small
grain millet (xiao mi 小 米) is used to prepare this decoction, and it is
believed, by health food enthusiasts among others, to have a cooling effect.
[13] five ge: Ten ge make one sheng. Here we better keep to the metric relationship
between ge and sheng. Five ge will give 500 g, an enormous dose by today’s
standards. This seems more unlikely when considering that in the old days,
the absolute weight for dosage seems to have been even smaller.
[14] the cup is emptied: Some annotators preferred to interpret wo as simply “lying
down covered up” (to promote sweating). Whether wo implies sleep or not,
lying down soon after medication shows the rapid action of this viscous
decoction; as a result of such rapid action, tachyphylaxis [drug resistance]
promptly develops. There are a number of standing prescriptions to treat
insomnia, like the Glycyrrhiza—wheat—Jujube Decoction (Gan mai da zao
tang 甘 麥 大 棗 湯); they are all directed towards the ultimate cause of sleep
disturbance rather than merely dulling the senses.

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 Morbid Manifestations 415

[Section 8.26] Suwen Chapter 80: On the Normal Practice of

Diagnosis

《素問．方盛衰論》曰：肺氣虛，則使人夢見白物，見人斬血籍籍；得其
時，則夢見兵戰。腎氣虛，則使人夢見舟船溺人；得其時，則夢見伏水
中，若有畏恐。肝氣虛，則夢見菌香生草；得其時，則夢伏樹下不敢起。
心氣虛，則夢救火陽物；得其時，則夢燔灼。脾氣虛，則夢飲食不足；得
其時，則夢築垣蓋屋。

When the pulmonary qi is deficient [1], one dreams of white objects; one can
see with the mind’s eye gory scenes of massacre [2]. If such dreams occur [in
autumn], which is the prevalent season [for the lung] [3], one dreams of
soldiers engaged in battle. When the renal qi is deficient, one dreams of people
falling overboard and being drowned. If it occurs [in winter] [4], one dreams
of lying under water as if hiding from a threatening object. When the hepatic
qi is deficient, one dreams of mushrooms sprouting in the meadows [5]. If it
occurs [in spring] [6], one dreams of crouching under a tree, not daring to
stand up. When the cardiac qi is deficient, one dreams of dousing fire ignited
by lightning [7]. If it occurs [in summer] [8], one dreams of conflagration.
When the spleenic qi is deficient, one dreams of being deprived of food. If it
occurs [in long summer] [9], one dreams of putting up walls and installing a
roof.

Explanatory Notes
Suwen Chapter 80 is one of the last three chapters in Volume 24, at the end of
Neijing. Together these chapters cover a wide range of subjects that are basic
concepts in the practice of medicine. Chapter 80, for example, is entitled:
Measuring [gauging, comparing] the Abundance and Dearth of Qi. It is actually
a guide to the normal practice of diagnosis at the time of Neijing and before
the “Four Methods of Diagnosis” (sizhen 四 診) were established as an integral
procedure. In this chapter, the standard protocol in diagnosis is “Five Targets
of Diagnosis and Ten Measurements” (wuzhen shiduo 五 診 十 度). This is
similar to the evolution of pulse-taking, that began with “three locations and
nine modalities” (san bu jiu hou 三 部 九 候) and ended up with “taking the
pulse at the wrist only” (du chi cun kou 獨持寸口).

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 416 Neijing Zhiyao Yigu 內經知要譯詁

In Chapter 80, the five targets are the five zang-organs, whether they are
operating in a normal, hypo- or hyper-functional state. The excerpt cited by Li
Zhong-zi describes an indirect method of gauging the functional state of the
zang-organs by interpreting the significance of dreams when one of these
organs is deficient. The reasoning is entirely based on the “five elements” cate-
gorisation. Evidently, at the time of writing, the three sites of the wrist (cun 寸,
guan 關, che 尺), with their respective zang-organ affinities, had not yet been
established. Nevertheless, interpreting dreams (shuomeng 說 夢, yuanmeng 圓
夢) has been a standard practice in Chinese psychoanalysis since long before
Freud. We know today that dreams are expressions of the subconscious during
deep sleep (with rapid eye movement). The reality lies in the fact that what-
ever we are dreaming must have occurred to us in our thoughts sometime
before.52 If we extend this notion to the affinity between dreams and organ
function, it would not be difficult to appeciate that with a weak adrenal func-
tion (broadly speaking, renal function in Chinese medicine), one becomes
apprehensive, always feeling a sense of doom. Or with a weak spleen (digestive
function), one dreams of food, and in the worst-case scenario, suffers hunger-
induced hallucinations.
Zhuangzi described how one dreamt of drinking wine but wept upon
waking. This was because there are dreams within dreams and one would
never know whether one is actually dreaming or awake (《莊 子．齊 物 論》).
Zhuangzi repeated this argument in his famous parable about dreaming of
being a butterfly. He wondered whether actually the butterfly was dreaming
about being Zhuangzi itself (hence the famous idiom “Zhuang Zhou meng die”
莊周夢蝶).
With regard to the practice of wuzhen shiduo, the excerpt should continue
as follows: “These are all due to deficiency in the five zang-organs. There is an
excess of yangqi and a deficiency of yinqi. Match this observation with the
signs derived from the five zang-organs (he zhi wu zhen 合 之 五 診), adjust the
balance between yin and yang. This is expounded in the book Jingmai 經 脉.
Hence the term wuzhen 五 診. It then continues: “There are ten measurements
in diagnosis, viz. measuring the pulse, the zang-organ, the flesh, the ligaments
and the shu(-acupoints) of the visceral organs [i.e. the flux of qi]”. Hence the

52
What we think in daytime, we dream of it at night. (ri you suo si, ye you suo meng 日
有所思，夜有所夢).

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 Morbid Manifestations 417

term shiduo 十 度 (duo, “to measure”) echoes the chapter title fang 方 (to
measure, compare). But according to the text, there are only five parameters to
be measured, as indicated above. There are several explanations for this. The
simplest is to say that there are two measurements, for example a left and a
right pulse pattern in each of these five parameters. Other annotators,
however, have tried hard to find five other parameters. Gao Shi-zong favoured
the sentence “assess the impact of social status, whether the patient is a
commoner or a nobleman”. This forced interpretation of ten measurements
may not be convincing, but the consideration of socio-ethical variants in diag-
nosis is a valid approach to gain a complete picture of the physical and mental
state of the patient under examination. Indeed, towards the end of this
chapter, the clinician was warned never to lose sight of personal particulars
even in an all-inclusive diagnosis (zhen ke shi quan, bu shi ren qing 診可十全，
不失人情).
It is noteworthy that these three chapters in Volume 24 represent a
dialogue between Leigong 雷 公 and Huangdi, with the former asking the
questions, and the lord Huangdi now lecturing to his subject. Yamada Keiji (ref.
44) believes that these three chapters were probably culled from writings of
the school of Leigong and were significant enough to merit an independent
volume, because they contained great substance but did not totally conform to
the style of the Qibo-Huangdi dialogues. There are gems of medical thinking
between the lines. For example, the paragraph leading to Section 4.5 begins
like this: “When highlighting what is in excess, be aware of what is deficient”. (qi
suo you yu, zhi suo bu zu 起所有餘，知所不足). Such a “dialectic” attitude in
assessment of the disease state pervades every corner of clinical practice in
Chinese medicine.
This section should be compared with the next section, on dreams due to
organ hyperfunction. Such contrasts in ideas were discussed in more detail in
the section on numbness versus atrophy.
There is another quotation from Chapter 79 in Section 8.34.

Footnotes

[1] pulmonary qi is deficient: Assessing the qi of a zang-organ (zangqi 臟 氣) is

an appreciation of the functional state of that organ. Suwen Chapter 22: On
Seasonal Changes of Visceral Organ Functions (Zang qi fa shi lun 臟氣法時論)
highlights the affinity of zang-organ functions, and their morbid manifesta-
tions, with seasonal climatic conditions. It begins with the key sentence: “In

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 418 Neijing Zhiyao Yigu 內經知要譯詁

conformity with the body parts, abide by the laws of the four seasons and
five elements for treatment of diseases.” (he ren xing yi fa si shi wu xing er zhi
合人形以法四時五行而治). At the end of this chapter, there is also a para-
digm of an ideal diet based on observing the taste of food that favours a
particular zang-organ “Diseases in the five zang-organs vary according to
season, treat them with food of an appropriate taste” (si shi wu zang, bing sui
wu wei suo yi 四 時 五 臟，病 隨 五 味 所 宜). This chapter is actually a short
and concise monograph on normal physiology and pathology. It is to be
regretted that Li Zhong-zi did not include it in NJZY. The excerpt in Section
8.26 is the main substance, relating as it does turbulent qi flow (jue 厥) to an
abundance of qi as well as to a dearth of it. When a particular zang-organ
(physiological system) is weak, it gives rise to a particular pattern of dreams.
This serves as an alternative basis of diagnosis to pulse pattern.
[2] gory scenes of massacre: The lung is in the metal category, and its colour is
white. Metal objects are above all sharp weapons, hence the image of massa-
cres and battle scenes. Autumn was also the time for capital punishment
(qiujue 秋 決) in China and is seen as a sad season. Song Yu 宋 玉 (ca. 300
bc): “What a lamentable season autumn is.” (bei zai qiu zhi wei qi 悲 哉 秋 之
為氣).
[3] prevalent season (for the lung): If a disease of the lung occurs in autumn, at
a time of the year when the lung is most vigorous, it is particularly suscep-
tible to the attack of damaging factors. Therefore, the lung bears the brunt of
the harsh autumn weather. Besides seasonal prevalence of the five elements,
within each season, each pair of days stipulated according to the ten “terres-
trial branches” denomination, is also ascribed to a prevalent element. It
begins with the day jia-yi 甲 乙, and the prevalent element is wood; subse-
quently, there are bing-ding 丙 丁, fire; geng-xin 庚 辛, metal; wu-ji 戊 己,
earth and yen-gui 壬 癸, water. This habit of thinking is deeply ingrained in
Chinese culture, thus a literate person might use the phrase: “Consign it to
bing-ding.” (fu zhu bing ding 付 諸 丙 丁, “burn it, burn down, consume by
fire”). At the prevalent moment when the relevant element is dominant, the
corresponding zang-organ is particularly vulnerable. Suwen Chapter 22: “The
five elements … are what determine the state of qi in the five zang-organs.”
(wu xing zhe … ding wu zang zhi qi 五行者 …… 定五臟之氣)
[4] see [3] above.
[5] mushrooms in the meadows: the word jun 菌 means “mushroom”, hence jun
xiang 菌 香 means “aromatic mushroom”, or what is called xiang xun 香 蕈

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 Morbid Manifestations 419

today. Liver is in the wood category, which can also be said to include grass.
So a mushroom should not be considered as a proper plant, like trees and
grass. Some annotators have argued somewhat feebly that because the
heptaic qi is weak, one cannot possibly dream of a full-strength tree, hence
only of mushrooms growing on rotten wood in a meadow. Some quoted
Quan Yuan-qi 全 元 起, the first annotator of Neijing (fl. end of fifth to mid-
sixth century). Quan’s work has been lost but fragments found their way into
later editions. He predated Yang Shang-shan 楊 上 善 (ca. 575–670), who left
us the Taisu, which was a re-classification, assuming that Quan’s version was
in a different format. Wang Bing was indisputably the first annotator of
Neijing in its present format. He must have been able to consult both Quan’s
and Yang’s works while undertaking his colossal task of editing and
sequencing the chapters of Suwen (cizhu 次 注). On “mushrooms”, Wang
noted that Quan preferred to interpret jun 菌 as qun 箘, as in the term
qungui 箘 桂 (cinnamon tree), in the sense that qun is a near-homonym of
xun 薰 (sweet fume), referring to the sweetish odour of the cinnamon. The
word xun 蕈 means “mushroom”, as in the combination xunjun 蕈 菌 (edible
macrofungi). That left cao 草 (grass) unaccounted for. Having considered all
these interpretations, the present translation is deemed adequate.
[6] see [3] above.
[7] ignited by lightning: The orginal text used the term yangwu 陽 物 (“the yang
object”, or anything representative of the male sex). Zhang Yin-an saw the
dragon as the ultimate icon of maleness (as compared to the phoenix as the
icon of the female) because of its thundering roar. He translated “douse the
fire ignited by the male object” into “fire ignited by lightning”. However, it
should be pointed out that yangwu is also the male organ, sometimes known
as yangju 陽具 (the male tool). It is artfully rendered as “linggen” 靈根 (from
the Sanskrit lingam, “the spiritual root”). Zuozhuan, Duke of Zhao first year:
“Women attach to the male and render their service at night” (nü yang wu er
hui shi 女陽物而晦時).
[8] See [3] above.
[9] See [3] above.

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 420 Neijing Zhiyao Yigu 內經知要譯詁

[Section 8.27] Lingshu Chapter 43: Dreams and the

Disturbed Mind

《靈樞．淫邪發夢篇》曰：陽氣盛，則夢大火而燔灼；陰陽俱盛，則夢相
殺。上盛則夢飛，下虛則夢墮。甚（盛）飢則夢取，甚飽則夢予。肝氣盛則
夢怒，肺氣盛則夢恐懼、哭泣、飛揚，心氣盛則夢喜笑恐畏，脾氣盛則夢
歌樂、身體重不舉，腎氣盛則夢腰脊兩解不屬。

厥氣客於心，則夢丘山烟火；客於肺，則夢飛揚，見金鐵之奇物；客
於肝，則夢山林樹木；客於脾，則夢見丘陵大澤、壞屋風雨；客於腎，則
夢 臨 淵、沒 居 水 中；客 於 膀 胱，則 夢 游 行；客 於 胃，則 夢 飲 食；客 於 大
腸，則夢田野；客於小腸，則夢聚邑沖衢；客於膽，則夢斗訟自刳；客於
陰器，則夢接內；客於項，則夢斬首；客於脛(頸)，則夢行走而不能前及居
深地窌苑中；客於股肱，則夢禮節拜起；客於胞月直，則夢洩便。短蟲多，
則夢聚眾；長蟲多，則夢相擊毁傷。

With abundant yangqi, one dreams of blazing and glowing fire [1]. With both
yangqi and yinqi in abundance, one dreams of killing one another. If qi is
abundant in the upper part of the body, one dreams of lifting up in the air; if
qi is deficient in the lower part of the body, one dreams of falling down from a
high place. When feeling very hungry [2], one dreams of grabbing [food];
when very full, one dreams of giving away [food]. With abundant qi in the
liver, one dreams of getting angry. With abundant qi in the lung, one dreams
of fear, sobbing and lifting into the air [3]. With abundant qi in the heart, one
dreams of hilarious or frightening events. With abundant qi in the spleen, one
dreams of joyful singing or a heavy body that is hard to lift. With abundant qi
in the kidney, one dreams of being bisected at the waist so that the two parts
of the body are separated.
With the jueqi sequestered [4] in the heart, one dreams of smouldering
fire over the hills. [If it is] in the lung, one dreams of flying, or queer metal
objects. If in the liver, one dreams of forests and woods. If in the spleen, one
dreams of undulating hills and immense marshes, or storms demolishing
buildings. If in the kidney, one dreams of overlooking an abyss, or drowning
in water. If in the urinary bladder, one dreams of wandering [5]. If in the
stomach, one dreams of gorging and bingeing [6]. If in the small intestine, one
dreams of communities and thorough fares. If in the gall bladder, one dreams
of litigation and self-mutilation [7]. If in the genitals [8], one dreams of sexual

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 Morbid Manifestations 421

intercourse [9]. If in the neck, one dreams of being decapitated. If in the leg
[10], one dreams of failing to step forward, or living in underground caves, or
deep in private gardens [11]. If in the arms and thighs [12], one dreams of
bowing deeply and ceremoniously. If in the bowels [13], one dreams of incon-
tinence. In helminthiasis with short worms [14], one dreams of flocking
together; with long worms [15], one dreams of striking others and inflicting
wounds.

Explanatory Notes
For a better grasp of Lingshu Chapter 43, it should be read together with
Suwen Chapter 80. Indeed the two chapters are both talking about the same
subject, dreams, with the same causative factor, uneven flow of qi (jueqi 厥氣).
Although the Lingshu chapter is concerned with the abundance of qi, and the
Suwen chapter with the dearth of it; sub-optimal qi flow, whether excessive or
deficient, is an appreciation of aberrant organ function. They are both called
jueqi. When the zang-organs suffer, the content of the dreams is more or less
the same in both cases, as it is determined by the “five elements” categorisa-
tion. The Lingshu chapter also discusses the fu-organs. The suggested meaning
of the dream is interpreted in footnotes, but there is no need to take them
seriously as signs for diagnosis, which is also the purpose of the Lingshu
chapter. Qin Bo-wei rightly summed up all these dreamland experiences as
manifestations of neurasthenia, while the discomfort associated with a partic-
ular organ is only the immediate precipitating factor. More important from
the perspective of medical history is the fact that Suwen and Lingshu each
devoted one chapter to dreams and their intepretation. The first authors of
Neijing were not far from the period when witchcraft began to be dissociated
from medicine. Bianque declared there were six kinds of recalcitrant patient
(六不治 liu bu zhi, “the six incurables”) [16]. One of them was “placing confi-
dence in witches rather than physicians”.53 A similar statement is found in
Suwen Chapter 11: “Those who are bound by their belief in the spirits cannot
be enlightened with the supreme virtue. Those who abhor treatment with
acupuncture cannot appreciate the fine technique [that heals]. Those who will
not allow medical intervention will certainly die; it is futile even to make an

53
《史記．扁鵲倉公列傳》︰「信巫不信醫。」

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 422 Neijing Zhiyao Yigu 內經知要譯詁

attempt to treat them.”54 Confucius, while not daring to show disrespect for
the spirits, recommended to keep them at a safe distance.55
Nevertheless, vestiges of witchcraft still persisted in obsolete corners of
Chinese medicine in some forms of psychiatric counselling. Suwen Chapter
13: On Invocation begins with the statement: “Treatment of diseases in ancient
times relied only on displacing the essence (yi jing 移 精, “changing the
mood”) and changing [the flux of] qi (bian qi 變 氣). Back then people lived a
simple life without stress; they never suffered from serious diseases. Therefore
it sufficed to displace the essence and invoke [the cause of disease] (zhu you 祝
由). Now that [by the time of Neijing] people live a stressful life, minor
ailments will turn into serious diseases and serious diseases are often terminal,
and invocation is no longer effective.” As late as the Qing dynasty, Zhao
Xue-min 趙學敏 (ca. 1719–1805) was credited with the authorship of Zhuyou
luyan 祝由錄驗 (Validated Records of Invocation).56 This reference could not
be confirmed with a second source. However, it seems quite acceptable that
Zhao’s authorship is genuine. Born into a rich family, Zhao devoted his time
to recording hitherto unnoticed facts and findings in medicine. He was most
famous for his Bencao gangmu shiyi 本 草 綱 目 拾 遺 (Addendum to Bencao
gangmu), in which he added 716 new items not known to Li Shi-zhen. He
also compiled a long list of empirical methods and prescriptions from a
personal friend, an itinerant physician, and entitled it Chuanya 串 雅 (Listing
the Elegant Practice). So it is not surprising that he also noted the practice of
invocation. Even today, there are still traces of these obsolete practices in
metropolitan cities. In Hong Kong, for example, there are some old women
who are employed by clients to engage in the ritual of beating a paper figurine
(da xiao ren 打 小 人), with the hope of bringing relief to the instigator. The
use of the planchette (fuji 扶 乩) is also not uncommon. Today, invocation has
been replaced by counselling. There are many who believe that this is prefer-
able to the use of anxiolytics and psychotropic drugs.

54
《素問．五臟別論》︰「拘於鬼神者，不可以言至德。」
55
《論語．雍也》︰「敬鬼神而遠之。」
56
See Shi Zhong-xu 史仲序, Zhongguo yixue shi 中國醫學史 (The History of Chinese
Medicine) (Taipei: Guoli bianyi guan 國立編譯館, 1984).

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 Morbid Manifestations 423

Footnotes

[1] glowing fire: Other versions of Neijing than the one quoted by Li Zhong-zi
used the character ruo  instead of zhuo 灼. The word ruo /爇 indicates a
slow-burning fire like a censer, or the burning of downy mugwort leaves in
cauterisation.
[2] very hungry: The correct character should be 甚 shen as in the next sentence,
not sheng 盛.
[3] fear, sobbing and lifting: These are properties associated with the lung.
[4] sequestered: Literally “a visitor”or “to visit”, this means an invasion of the evil
qi that causes obstruction of qi flow (jueqi 厥氣), like a visitor who refuses to
leave.
[5] wandering: Apparently looking for a place to relieve oneself.
[6] gorging and bingeing: The text just has “eating and drinking”, but the “dream”
is interpreted as the process of gorging and bingeing, or the uncomfortable
feeling of having gone through that process.
[7] self-mutilation: The term ziku 自刳 means “to scoop empty”, or more exactly,
“to cut open one’s own belly”, as in harakiri (fuqie 腹 切) in Japanese culture.
It was also a capital punishment in ancient China. Zhuangzi mentioned
disembowelment (《莊子．胠篋》).
[8] genitals: Literally the “covered objects” (yinqi 陰 器), this is a reference to the
genitals, without indicating of which sex.
[9] sexual intercourse: Literally “received inside”, this means erotic dreams. It is
often interpreted as intercourse with demons (meng yu gui jiao 夢 與 鬼 交),
especially for women. In Western culture, it takes the form of an incubus, or
succubus.
[10] in the leg: The correct word is jing 脛 (leg), not jing 頸 (neck), a typographic
error by Li Zhong-zi.
[11] private gardens: Generally speaking, the word yuan 苑 indicates more than a
garden. It is often an immense domain of exotic plants and animals, a
guarded hunting ground, like the extravagant Shanglin Yuan 上 林 苑 of Han
Wudi.
[12] arms and thighs: The thigh (gu 股) and arm (gong 肱) are the more impor-
tant parts of the limbs, hence references such as in Zuozhuan, Duke of Zhao
9th year: to “ministers of thighs and arms [who provide staunch support]”. (gu
gong zhi chen 股肱之臣)
[13] the bowels: The term baozhi 胞 月直 means the bladder and the large intestine.
[14] short worms: For example, liver fluke. Large numbers of worms may cause

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 424 Neijing Zhiyao Yigu 內經知要譯詁

obstruction, hence the discomfort which triggers a dream.

[15] long worms: For example, ascaris. Obstruction as above.
[16] the six incurables: They are: 1) an arrogant patient that cannot be brought to
reason; 2) a miser who values money more than his health; 3) a patient with
an unsuitable life style; 4) a patient in whom unstable conditions prevail in
connection with yinqi and yangqi and the visceral organs; 5) a patient whose
constitution is too weak to take any medication; 6) a superstitious patient
who would rather believe in the spirits. (From Shiji: Biographies of Bianque
and Chang-gong.)

[Section 8.28] Lingshu Chapter 81: On Carbuncles and

Furuncles

《靈樞．癰疽篇》曰：血脈營衛，周流不休，上應星宿，下應經數。寒邪客
於經絡之中則血泣，血泣則不通，不通則衛氣歸之，不得復反，故癰腫。
寒氣化為熱，熱勝則腐肉，肉腐則為膿，膿不寫則爛筋，筋爛則傷骨，骨
傷則髓消，不當骨空，不得泄寫，血枯空虛，則筋骨肌肉不相榮，經脈敗
漏，薰於五藏，藏傷故死矣。

癰發於嗌中，名曰猛疽。猛疽不治，化為膿；膿不寫，塞咽半日死。
其化為膿者，寫則合（含）豕膏，無冷食，三日已。

發於頸，名曰夭疽。其癰大以赤黑。不急治，則熱氣下入淵液，前傷
任脈，內熏肝肺，十餘日而死矣。

陽氣大發，消腦留項，名曰腦爍。其色不樂、項痛而如刺經（以）針、
煩心者，死不可治。

發於肩及臑，名曰疵癰。其狀赤黑，急治之。此令人汗出至足，不害
五臟。癰發四五日，逞焫之。

發於腋下，赤堅者，名曰米疽。治之以砭石，欲細而長。（數）砭
之，涂以豕膏，六日已，勿裹之；其癰堅而不潰者，為馬刀挾纓，急治之。

發 於 胸，名 曰 井 疽。其 狀 如 大 豆，三 四 日 起。不 早 治，下 入 腹；不

治，七日死矣。

發於膺，名日甘疽。色青，其狀如穀實、瓜蔞，常苦急熱。急治之，
去其寒熱。不及治（按守山閣本据甲乙經改）十歲死，死後出膿。

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 Morbid Manifestations 425

發 於 脅，名 曰 敗 疵。敗 疵 者，女 子 之 病 也，灸 之；其 病 大 癰 膿，治

之，其中乃有生肉，大如赤小豆。剉陵、翹草根（及赤松子根，按守：甲
改）各一升，以水一斗六升煮之，竭，為取三升，則強飲，厚衣，坐於釜
上，令汗至足，已。
發於股脛，名曰股脛疽。其狀不甚變，而癰膿搏骨。不急治，三十日
死矣。
發於尻，名曰銳疽。其狀赤堅大，急治之。不治，三十日死矣。
發於股陰，名曰赤施，不急治，六十日死。在兩股之內，不治，十日
而當死。
發於膝，名曰疵癰。其狀大癰，色不變，寒熱。如堅石，勿石，石之
者死。須其柔，乃石之者生。
諸癰之發於節而相應者，不可治也。發於陽者，百日死；發於陰者，
三十日死。
發於脛，名曰兔齧。其狀赤至骨，急治之。不治，害人也。
發於內踝，名曰走緩。其狀癰也，色不變。數石其輸而止。其寒熱，
不死。
發於足上下，名曰四淫。其狀大癰，急治之，百日死。
發 於 足 傍，名 曰 厲 癰。其 狀 不 大，初 如 小 指。發，急 治 之。去 其 黑
者，不消輒益。不治，百日死。
發於足指，名曰脫癰。其狀赤黑，死不治；不赤黑，不死；不衰，急
斬之，不則死矣。
營衛稽留於經脈之中，則血泣而不行，不行則衛氣從之而不通、壅遏
而不得行，故熱，大熱不止。熱勝則肉腐，腐則為膿。然不能陷，骨髓不
為焦枯，五藏不為傷，故命曰癰。
熱氣淳盛，下陷肌膚，筋髓枯，內連五藏，血氣竭，當其癰下，筋骨
良肉皆無餘，故命曰疽。
疽者，上之皮夭以堅，上如牛領之皮；癰者，其皮上薄以澤。

The defensive qi and the nutritive qi travel with the blood all round the body
incessantly. Their itineraries correspond to the constellations in heaven and
principal waterways [1] on earth. When the cold evil qi resides in the conduits,
blood flow becomes stagnant. Stagnant blood will cause obstruction, seques-
tering the defensive qi, preventing it from circulating; boils ensue [2]. Eventu-
ally, the [sequestered] cold evil qi provokes a febrile response. When the fever

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 426 Neijing Zhiyao Yigu 內經知要譯詁

persists, ulceration begins, and then suppuration follows. If the pus cannot be
drained, the sinews become necrotic. With necrosis in the sinews, the bones
are eroded. With bone erosion, the bone marrow will dissipate. If the marrow
is not filling up the bone cavities, [and thus blood circulation by-passes the
rotten bone], [the pus] cannot be drained away. Consequently, blood supply
dwindles and debility prevails; the sinews, bones and muscles become
malnourished because blood circulation fails. When the febrile state spreads
to the five zang-organs, their functions are compromised and death is to be
expected.
The carbuncle (yong) that develops in the pharynx [3] is called a malig-
nant furuncle (ju) [4]. If not treated in time, it will turn purulent. If the pus is
not drained [5], the throat will be blocked and the patient dies in half a day. If
it is purulent, drain the pus and hold some [processed] pork fat [6] in the
mouth. Avoid cold food [7]. With this treatment, one will recuperate in three
days.
The furuncle (ju) that develops at the neck is lethal [8]. The boil is large
and dark red. If not treated promptly, the hot evil qi will move downward to
acupoint yuanye [9]. It will damage the Ren conduit that is running in front as
well as the liver and lung deep in the body. The patient will die in a fortnight.
When yangqi [in the tai-yang conduit] is exuberant, it wears out the brain
[10] and remains in the neck. The boil thus formed is called “brain wasting”
[11]. It is of a dull colour; the neck hurts as if it is being pricked with a needle.
If the patient is dysphoric, it is incurable and death is expected.
The nevo-carbuncle [12] develops at the shoulder and upper arm. It looks
dark red. Treat it promptly. It will cause sweating all over the body down to
the feet, but it will not harm the five zang-organs. By the fourth or fifth day,
promptly treat it with cauterisation [13].
The grainy furuncle [14] develops under the armpit; it is red and firm. It
is amenable to treatment by stone needle [15]. The stone needle should be
long and thin, applied repeatedly [16], then smear [the inflicted area] with
[processed] pork fat, and use no dressing; it will heal in six days. If the swelling
yong [carbuncle] [it has been referred to as a carbuncle in the text] is firm and
not ulcerative, it is called a “sabre tassel” [17].
The deep-seated furuncle [18] appears on the chest. It is the size of a pea.
If it is not treated during the first three or four days, it spreads down to the
belly. If still not treated, the patient will die in seven days. [19]
The sweet-tasting furuncle [20] develops in the greater pectoral muscle

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 Morbid Manifestations 427

[21]. Its colour is blue-green; it looks like the seed of the paper-bark tree [22]
or gualou [23]. The patient suffers repeatedly from alternating attacks of chill
and fever. Treat it promptly to get rid of these symptoms. If the disease lasts
for ten years, death is inevitable. Post mortem [examination] reveals suppura-
tion [24].
The rotting mole [25] that develops on the costal region occurs only in
women. If it is [wrongly] treated by cauterisation, it will develop into a large
purulent abscess. If treated properly, tissue buddings [granulation] the size of
small red beans [26] will appear inside the boil. Chop one sheng [27] of
Forsythia root [28]. Boil with 16 sheng [29] of water and reduce to three sheng.
While the decoction is still hot, drink as much as possible. Sit on top of a [hot]
cauldron, thickly dressed to promote sweating all over the body. This will cure
it [30].
The femoral-cum-crural furuncle does not show much change [on the
surface] [31] but its pus invades the bone [32]. If not treated, the patient will
die within a month [33].
The sharp furuncle [34] occurs on the sacral region [35]. It is large, firm
and red. Treat it promptly, if not, death will occur within thirty days.
The red-spreading [furuncle] (chishi) occurs on the groin [36]. If not
treated promptly, [the patient] will die within 60 days. If it occurs bilaterally,
the patient could not survive for more than 10 days.
The nevo-carbuncle [37] that develops on the knee is a large boil without
any abnormal colour changes. The patient suffers from chills or fever. If the
boil is hard like stone, do not lance it with a stone needle. Wait till it is soft,
then lacerate it with a stone needle. The patient will survive.
Carbuncles may occur on the corresponding joints [on both sides of the
body] [38]. If they occur in the itinerary of the yang conduits [39], the patient
can survive up to 100 days. If they occur on the itinerary of the yin conduits
[40], the patient will die within 30 days.
The “rabbit-gnawed” [boil] [41] develops in the shin. It is reddish
[inflamed] from skin to bone. Treat it promptly, otherwise, it could be lethal.
The “slow-walking” [boil] [42] develops on the inner ankle [medial
malleolus]. It looks like a carbuncle but without any change in outward
appearance. Lance frequently with a stone needle on the sore spot [43]. If the
patient starts to have chills or fever, he may survive.
The boils that develop on the instep or sole are called the “four excesses”
[44]. They look like large carbuncles. Treat promptly, [otherwise] the patient

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 428 Neijing Zhiyao Yigu 內經知要譯詁

cannot last more than 100 days.

The ferocious carbuncle [45] develops on the side of the feet. It first
appears the size of a small toe. Should it occur, treat it promptly. Try to remove
the dark discoloration; if not successful, it will grow even bigger. If it does not
respond to treatment, one cannot last more than 100 days.
The detaching carbuncle [46] develops in the toes. It looks dark red and
becomes lethal if not treated. If the affliction is not dark red, it is not lethal. If
the affliction is not regressing, cut it off promptly, otherwise, death is
unavoidable.
When the defensive qi and the nourishing qi are withheld [from circula-
tion] in the conduits, blood circulation becomes stagnant and not free-
flowing. While not flowing freely, the blood [circulation] entraps the defensive
qi with it so that [the conduits] are not patent. The blockage engenders heat;
there will be unremitting fever. When fever is overpowering, and flesh starts to
rot; rotten flesh becomes purulent. However, as this evil qi does not penetrate
deep into the body, the bone marrow will not be scorched and wilting, the five
zang-organs are not harmed; suppuration caused by such evil qi is called yong
[carbuncle] [47].
When heat is overbearing, it penetrates deep into the muscles, so that the
bone marrow and sinews are wilting. In this case, the five zang-organs are
affected; blood and qi are exhausted [claudication of the blood vessels]. Below
the carbuncle surface, there are no healthy tissues left. That is why it is called
ju [deep-seated carbuncle] [48].
The surface of a deep-seated carbuncle is hard [induration] and darkish,
like the hide from the nape of a cow [49]. The surface of a carbuncle is thin
and lustrous.

Explanatory Notes
This is the last chapter in Lingshu; it lists 19 types of boils, each characterised
by a specific name. Of these, one is a subtype (“sabre tassel”) and two carry
the same name but are located in different places (nevo-carbuncle, on the
knee or the shoulder and arm). As the chapter title implies, the names are first
of all divided into two main categories, the carbuncles and furuncles. There
are definitely seven kinds of carbuncle, and six kinds of furuncles. Between the
two, there are two ambivalent cases, which are first introduced as a “carbuncle”,
but later given the specific name “furuncle” (malignant and lethal). There is

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 Morbid Manifestations 429

also a carbuncle that is actually an abscess (rotting mole). There remain three
cases that are described only by vernacular names which indicate their most
distinguishing features (brain-wasting, rabbit-gnawed, slow-walking). Each
type is first identified by its location, then a specific name. This is followed by
a brief description of the most distinctive features that, in some cases, rein-
force the meaning of the specific names. These descriptions involve location,
appearance (e.g. red, dark, discoloured, normal), size/shape, consistency (soft/
firm), and malignancy (lethal, harmful, incurable, curable); these parameters
help to identify the boils and reveal their nature. It then remains to pronounce
the prognosis and method of treatment, if applicable. A list of these 19 types
will find that they will fall neatly into a tabular format.
This chapter begins with a brief introduction to the pathogenesis of
carbuncles and “boils” in the context of visible, topical skin lesions. Although
they are deemed to be the result of an uneven flow of the nutritive qi and
defensive qi, none of them is associated with a certain regular conduit, except
the “sabre tassel”, which is mentioned in Lingshu Chapter 10: The Conduits.
The chapter concludes with a remark which distinguishes between carbuncles
and furuncles. The obvious absence of conduit theory in this chapter, (likewise
in Sections 18–20 on bloating/oedema) and its position as the last chapter of
Lingshu, suggest that the source of this chapter may have been adepts of the
school of topical medicine (yangyi 瘍 醫); they later became the peripatetic
doctors roaming from village to village, who were known as “bell-doctors”
(lingyi 鈴醫, see above, Zhao Xue-min 趙學敏, Chuan ya 串雅). Topical medi-
cine was not new to Chinese medicine. As early as the Zhou dynasty, there
were six specialties in the imperial court medical service, one of which was
topical medicine (yangyi 瘍醫, see Liji: Rites of Zhou, Tianguan 禮記：周禮．
天 官). This department concerned itself with the treatment of weapon
wounds and bone fractures, as well as boils and ulcers due to secondary infec-
tion. These services were later subdivided and refined, as a tributary stream
flowing into the mainstream of Chinese medicine that is internal medicine.57
It is precisely because of this obstinate adherence to internal medicine that all

57
See Zhongyi waike xue 中 醫 外 科 學 (Surgery in Chinese Medicine), vol. 4 of
Advanced Research References in Chinese Medicine Series, 1994, and Zhongyi gushang
kexue 中 醫 骨 傷 科 學 (Orthopaedics and Traumatology in Chinese Medicine), vol.
15, from ref. 32, reprinted in Taipei, 1998.

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 430 Neijing Zhiyao Yigu 內經知要譯詁

skin lesions were considered an expression of internal problems. We can, of

course, hardly blame the ancient physicians, or any other system of traditional
medicine before the advent of microbiology, for being ignorant of the pres-
ence of bacteria and their virulence. In fact, these 19 kinds of “boils”, covered a
broad range of skin diseases and lesions other than what are now known as
carbuncles and furuncles.

Location Nomenclature Distinguishing Prognosis Treatment

feature
pharynx malignant throat- if purulent, processed pork
furuncle blocking heals in 3 days fat
neck lethal furuncle large, dark red 10 days, if not n.a.
treated
neck/brain “brain- dull colour, incurable, if n.a.
wasting” neck hurting dysphoric
shoulder/arm nevo- profuse not harmful cauterisation
carbuncle sweating
armpit grainy red and firm heals in 6 days laceration and
furuncle pork fat
armpit “sabre tassel” firm/ not treat promptly n.a.
ulcerative
chest deep-seated pea size, 7 days, if not n.a.
furuncle spreads to treated
belly
pectoral sweet-tasting blue-green, 10 years, if n.a.
muscle furuncle seed- like, treated
chills/fever
costal region rotting mole large, puru- curable herbal and
lent, occurs in sweating
female
thigh/ inguinal femoral-cum- tipless, pus one month, if n.a.
region crural reaches bone not treated
furuncle
sacral region sharp furuncle large, firm, red one month, if n.a.
not treated

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 Morbid Manifestations 431

medial side of “red- name implies 10/60 days, on n.a.

thigh spreading” a reddish one/both
spread thighs
knee nevo- large, firm, curable lacerate when
carbuncle chills or fever soft
joints carbuncle corresponding 30/100 days incurable
joints
shin “rabbit- red to the not harmful, if n.a.
gnawed” bone treated
promptly
inner ankle “slow- carbuncle not lethal laceration
walking” looking
instep/sole “four excesses” large 100 days n.a.
carbuncle
side of foot ferocious small, 100 days, if n.a.
carbuncle discoloration darkening
toe detaching dark red lethal, if not excision
carbuncle treated

NB: While these boils are all observable on the surface of the body, Suwen
Chapter 46 also mentions a kind of gastric boil (weiwanyong 胃脘癰, “ulcer of
the gastric body”); it is described as due to the accumulation of heat [inflam-
mation] at the gastric sphincter (weikou 胃 口, which generally refers to both
sphincters, but more precisely, the pyloric) (re ju yu wei kou er bu xing 熱聚於
胃口而不行). This is almost a description of Helicobacter pylori in the pyloric
antrum, the immediate cause of chronic gastritis and ulcer. The Australian
scientists Warren and Marshall won the 2005 Nobel prize for medicine for this
discovery, without having read Neijing.
Under the apparently regular format of carbuncles and furuncles, these
19 kinds of boils cover a broad range of bacterial infections that include
Corynebacterium (diphtheria), Streptococcus (cellulitis), Staphylococcus
(carbuncles and furuncles), Clostridium (gangrene), Haemophilus (chancroids)
and Mycobacterium (tuberculosis). Although none of these infective microor-
ganisms can be identified with certainty on the basis of only a brief descrip-
tion, their location, malignancy and prognosis strongly suggest that they were
not as simple as either carbuncles or furuncles that develop from infection of

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 432 Neijing Zhiyao Yigu 內經知要譯詁

hair follicles. Their treatments, however, were limited to the techniques of the
time. The text indicates lancing, moxibustion and herbal decoctions for
special cases; the other cases that called for prompt treatment were presum-
ably treated by acupuncture. Suwen Chapter 55 provides a clinical guideline
for treating carbuncles with needles. This chapter begins with the words
“Acupuncturists do not need to diagnose the cause of disease.” (ci jia bu zhen
刺 家 不 診). There follows a list of ten diseases that present obvious outward
symptoms, including leprosy. However, Liu Juanzi’s 劉涓子 Guiyi fang 鬼遺方
contains a whole armamentarium of herbal prescriptions plus other surgical
methods.58 A similar plenitude of treatments is mentioned in Qianjin yifang
千金翼方 by Sun Si-miao 孫思邈 and Zhouhoufang 肘後方 by Ge Hong 葛洪.
All three authors lived within a period of three centuries. Today, without
targeting specific bacteria with antibiotics, the treatment of boils in Chinese
medicine is based on three basic approaches, i.e. xiao 消, tuo 托 and bu 補.
Xiao means “anti-flammatory”, which could include bacteriostatic action; it is
applied at the early stage of boil development. Tuo is more specifically for boils
and occurs in the expression tuoli 托裡, “to enhance”, literally “lifting up” (tuo),
the immunodefence mechanism, particularly during suppuration. Bu is used
to encourage regeneration of tissues when the pus is drained. Boils are much
less frequent nowadays, with improved standards of hygiene, and their treat-
ment is much more efficacious with the use of bacteriostatic agents (beginning
with sulfonamides) and especially antibiotics. This final chapter in Lingshu
demonstrates the unrelenting efforts to keep healthy outside the theoretical
framework of the conduits and “five elements”.
Qin Bo-wei attempted to amplify the description of these 18 kinds of
boils (apart from the “sabre tassel”) using information from Waike xinfa 外 科
心 法 by Xue Ji 薛 己 but added little to the way they are understood in the
modern medical context. Xue Ji lived close to the time of Li Zhong-zi, who
showed much respect for his expertise. Qin classified boils as the yang type
(carbuncle) and the yin type (furuncle) at the same time advocating the treat-
ment of boils with decoctions.
The translation of ju as “furuncle”, a deep-seated carbuncle, is not entirely
satisfactory. It is generally accepted that a ju has a hard tip and develops a

58
Liu Juanzi 劉涓子, Guiyi fang 鬼遺方, annotated by Yu Wen-zhong 于文忠 (Beijing:
Renmin weisheng chubanshe 人民衛生出版社, 1986).

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 Morbid Manifestations 433

fistula that drains inside into the body, whereas a yong is a large boil, a
carbuncle, on the surface of the body, with a large, thin, hot area at its tip; the
pus can easily be drained from it. The last sentence of this long and compli-
cated paragraph tries to differentiate ju 疽 from yong 癰. But the argument,
relying on their surface characteristics, is rather thin. Zhuangzi mentions
“draining the carbuncle” (kui yong 潰 癰) (《莊 子．大 宗 師》), and at least
one annotator understood that it was the possibility of drainage that differen-
tiated the two. It says: “Hot at the surface is ju, being unable to drain the pus is
yong.” (fou re wei ju, bu tong wei yong 浮 熱 為 疽，不 通 為 癰). That leaves us
none the wiser, however, as in both cases, it might simply be referring to two
different stages of purulence. In another essay, Zhuangzi talks about a kind of
purulent (biao ju 瘭 疽)” (《莊 子．則 陽》), implying that a deep-seated
carbuncle (ju) could nevertheless drain outwards on the body’s surface.
Zhuangzi seems to know a considerable amount about yong, and in Zhuangzi:
Lie yu gou 莊 子．列 禦 寇, he writes about calling for the services of a doctor
who could break open (i.e., drain) carbuncle and acne (po yong kui cuo 破 癰
潰痤). (For acne, see ibid. 8-2-15, ibid. 8-2-18.)

Footnotes

[1] principal waterways: The term used is actually jingshu 經 數, meaning the
number of principal waterways. This term resonates with a quotation from
Suwen Chapter 27: On Replenishing and Purging in Acupuncture. There it
says: “When the sages started to measure [different parts of the body], they
observed the events in heaven and earth. Therefore, there are [28] constella-
tions in heaven and [12] principal waterways (jingshui 經 水) on earth, just
like the [12] regular conduits (jingmai 經 脉) in man.” The principal Chinese
rivers run from west to east; they define the topography of the Chinese land-
mass and Chinese culture evolved along their banks. Hence, the flow of water
down the rivers inspired the concept of the flux of qi flowing in the conduits.
Disturbance in the flow of the waterways would cause natural disaster, just as
the uneven flow of qi would give rise to disease.
[2] boils ensue: The term yongzhong 癰 腫 means “purulent swelling”; it also
appears in Suwen Chapter 3: On Harmony between Yinqi and Yanqi, where it
is ascribed to the failure of nutritive qi flow, i.e when it is not following the
direction of the musculature. (See Sections 8.2 and 8.3 above) In this
section, it appears twice as yongnong 癰 膿 (abscess). The meaning of the
word yong 癰 is derived from yong 壅 (congestion, piling up). When yong 癰

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 434 Neijing Zhiyao Yigu 內經知要譯詁

is used in a generic context to mean carbuncle or furuncle and the like, it is

translated loosely as “boil”. When a carbuncle or furuncle carries a specific
name, it needs to be clarified whether this concerns a carbuncle (yong, “a
topical abscess including a cluster of furuncles”), a deep-seated carbuncle (ju,
here translated as “furuncle”), or a simple furuncle (which is an individual
hair follicle infection with a hard core called jie 癤). The common terms for
ulcerative sore (chuang 瘡) and its deep-seated variation (ding 疔) are not
used in this section. Cases of cellulitis or phlegmon (fa 發) and gangrene
(huaiju 壞疽) are also mentioned in this section, but without specific names;
the latter are lumped under the category of yong (liyong, tuoyong). Further
differentiation of carbuncle and furuncle will be described below.
[3] pharynx: The character 嗌 ai (ancient pronunciation), or yi (current
pronunciation), means the throat (fauces), literally “narrow passage”. The
character 咽 yan refers to the pharynx, the common passage for air and food,
comprising the nasopharynx (biyan 鼻 咽), throat (kouyan 口 咽) and larynx
(yanhou 咽 喉). Yan can also be read ye 咽 (suppressed sobbing) or yan 嚥
(swallow).
[4] malignant furuncle: Mengju and mengyong 猛 疽/癰, are interchangeable
when “carbuncle” is used in a generic sense. (See the differentiation between
yong and ju later in this section). Such an acute and malignant laryngeal
furuncle (jiehouju 結 喉 疽) may refer to pharyngeal or laryngeal diphtheria,
(baihou 白 喉), with inflammation of the pharynx and tonsils blocking the
air passage. It could be complicated by myocarditis, causing acute circulatory
failure. Diphtheria, caused by Corynebacterium, is characterised by rapid
onset, and its telltale sign is a whitish membrane at the back of the throat,
which is not mentioned here. Later literature on diphtheria did not identify
it with mengyong. It has to be a space-occupying lesion at the throat to be
quickly lethal. It may simply mean acute peritonsillar abscess (quinsy); its
rapid onset and inflammatory oedema may cause considerable narrowing of
the airway, and hence can be life-threatening.
[5] pus is not drained: Draining the pus would require laceration and suction.
For laceration, use was made of chanzhen 鑱 針, an instrument like a scalpel,
the metal form of the stone needle. The pizhen 鈹針, that looks like the blade
of a dagger, was used to drain pus. They are counted among the nine tradi-
tional forms of needles (jiuzhen 九 針). Suwen Chapter 14: “Chan needle,
stone needle, needle and [cauterisation with downy] mugwort are used to
treat topical ailments”. To apply suction, medical practitioners used cupping,

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 Morbid Manifestations 435

or simply sucking by mouth. Shiji describes how a general personally sucked

the deep-seated carbuncle of a foot-soldier (to win his loyalty) (《史 記．孫
子 吳 起 列 傳》︰「將 軍 自 吮 其 疽。」). But shun ju 吮疽, or shi yong 舐癰
was considered a demeaning act of sycophancy. Zhuangzi describes how the
Duke of Qin gave out greater rewards for those who would agree to perform
an even more demeaning act, in this instance, licking clean haemorrhoids (shi
zhi 舐 痔). (《莊 子．列 禦 寇》︰「所 治 愈 下，得 車 愈 多。」). The pizhen
鈹針, is still used today to drain pus.
[6] [processed] pork fat: Shigao 豕 膏 is prepared by heating lard to clarify the
fat. When cooled, it is mixed with white honey, reheated, filtered, then
allowed to settle.
[7] avoid cold food: According to Taisu, the wording reads thus: “after draining
the pus, hold pork fat in mouth, do not eat cold food.” It is amended here
accordingly.
[8] lethal: Lethal furuncle: Yaoju 夭 疽; yao, “death at a tender age”. Yao can also
mean a dark colour, as described in the text. It may mean discoloration, but
not gangrene. Li Zhong-zi assigned this deep-seated carbuncle to both sides
of the cervical vertebrae just under the hairline (tianzhu 天 柱, “celestial
column”, acupoint BL-10), as suggested by the vernacular name duikou 對 口
(a pair of opposing mouths). A few decades before NJZY, Chen Shi-gong (see
[46] below) in his Waike zhengzong 外科正宗 (Orthodox Topical Medicine),
published in 1617, already declared that lethal deep-seated carbuncles occur
as a pair on the protuberances behind the ears (er hou gao gu 耳 後 高 骨,
“mastoid process”). This is most likely referring to mastoiditis, where infec-
tion of the middle ear spreads to the mastoid antrum. In some severe cases,
the pus escapes along the sternocleidomastoid muscle to reach the chest.
This fits very well with the description that follows. However, it must be
noted that bilateral mastoditis is rare today and the telltale symptom of pain
in the ear is not mentioned at all. Furthermore, if pus could drain as far as
the chest, perhaps through necrotising fasciitis, it would fill up all the area
surrounding the ear, and the brain would suppurate before the liver and
lungs are affected. These collateral symptoms of mastoiditis are not
mentioned.
[9] yuanye acupoint: Acupoint GB-22 on the podotelic gall-bladder conduit at
the level of the fifth rib, deep in the armpit, hence its name. Yuan 淵, “deep
gorge”; ye 液, “liquid”, or ye 腋, “armpit”. This corresponds to inflammation
of the axillary lymph nodes.

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 436 Neijing Zhiyao Yigu 內經知要譯詁

[10] wears out the brain: The podotelic tai-yang urinary bladder conduit starts
from the inner canthus and soon reaches the vertex. From the top of the
head, it goes down the back of the neck. This itinerary serves to explain the
connection between the neck and the brain. This is however the intrepreta-
tion of latter-day annotators like Zhang Yin-an. But in this chapter, there is
no recourse to conduit theory to explain the pathogenesis of the boils.
[11] “brain-wasting”: the original meaning of shuo 爍/鑠 was “smelt at a high
temperature” as in the popular maxim:「眾 口 鑠 金」(zhong kou shuojin).
But shuo 爍 can also mean “sparkling, scintillating”, whereas shuo 鑠 means
“burnt out”. The description “brain-wasting” is used in this context.
However, “brain” (nao 腦) may refer only to the back of the head (occipital
or occipitocervical) but not the brain in the strict sense of the word. Hence
“brain-wasting” may mean an open sore at the back of the head as a result of
an infected lymph node at the nape.
[12] nevo-carbuncle: Ci 疵 “black spot”, or “mole” (zhi 痣), nevus. Ciyong 疵 癰 is
a boil which has developed from a mole, a melanocytic nevus. It has the
potential to turn malignant. The character ci has several meanings : in
Zhuangzi, cili 疵 癘 means “pestilence” or “destructive” (Zhuangzi: Xiao Yao
You 莊 子．逍 遙 遊). Only the Huainanzi 淮 南 子 uses it to mean “a mole, a
black spot”.
[13] cauterisation: Ruo , see ibid. 8-27-1.
[14] grainy furuncle: Miju 米 疽; mi 米, “rice grain”, or any cereal grain, size-wise.
The small size refers only to the tip of the furuncle, a blind boil (wutouju 無
頭 疽). It is actually deep-seated, as suggested by the use of a long thin stone
needle. In this context, it is more likely a purulent myelitis of the shoulder
joint rather than axillary lymphadenopathy. The treatment described
promotes draining of the pus.
[15] stone needle: Bianshi 砭 石, a pointed stone for topical stimulation or lacera-
tion rather than transdermal penetration.
[16] applied repeatedly: According to Taisu, shu , “sparingly”, should read shuo
數, “frequently, repeatedly”.
[17] “sabre tassel”: Madao jiaying 馬 刀 挾 纓 means a chain of swollen lymph
nodes, particularly on the neck, i.e. the lateral cervical lymph nodes. Also
called scrofula (luoli 瘰癘, or luo 瘰), it can be purulent, or not, and is due to
infection by tuberculosis mycobacterium. This is the only boil that is
ascribed to the malfunction of a regular conduit, the podotelic shao-yang
gall-bladder conduit. However, this conduit is indicated for diseases of the

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 Morbid Manifestations 437

bone, whereas scrofula is tuberculosis of the lymph nodes.

[18] deep-seated furuncle: Jingju 井 疽; jing 井, “a well”, describing a deep-seated
boil with a small surface. According to the Encyclopedia of Chinese Medicine
(2005), this is cellulitis on the chest. The well metaphor suggests it is collar-
stud abscess that is of tubercular origin. Since this would not kill in seven
days, the pocket of pus may be ascribable to empyema necissitatis, secondary
to pneumonia. The perforation, draining the pus outside or inside the body
to the pleural cavity, plus pneumonia, could be lethal.
[19] This may refer to cellulitis, acute inflammation of the loose subcutaneous
tissue caused by Streptococcus. It has a small surface area, but spreads broadly
and deeply under the skin. In Chinese medicine, it is called fa 發 (spreading,
sprouting, rapidly developing), in this case xiongfa 胸 發, “thoracic cellulitis”,
appearing under the xiphoid sternum or above. It is hot and tender to the
touch; it easily forms a fistula, draining towards the thoracic cavity.
[20] sweet-tasting furuncle: Ganju 甘 疽 refers to its association with the stoma-
chic conduit which governs the spleen, the representative taste of which is
sweet.
[21] greater pectoral muscle: Acupoint yingchuang 膺 窗 (ST-16) sits on the
greater pectoral muscle where the stomachic conduit runs through it. Ying 膺,
or as yi 臆 (the chest), refers to this muscle and its location, hence the term
xiongyi 胸臆 (aspiration, deep thought).
[22] paper-bark tree: Brussonetia papyrifera, chu 楮, also known as gu 穀, or gou 構,
of the mulberry family, is a useful plant of which the tender bark is used in
medicine, but the old bark is an important source material for making paper.
The “xuan paper” (xuan zhi 宣 紙) produced from it is best for brush
painting and calligraphy, Hence chu is a synonym for paper and chumo 楮 墨
(literally “paper-bark and ink”) means literary articles. The seeds are oval or
elliptical grains of 2–4 mm.
[23] gualou: 瓜 蔞 or 栝 樓 (Trichosantes kirilowii) was known from the dawn of
Chinese history. Although not mentioned specifically in the text, the seeds
are ellipsoid in shape and 2–3 cm in length. These two seeds are chosen to
describe the size of the furuncle, or it may refer to clusters of these seeds in
the fruit, like nodules in an abscess. As the term yongnong 癰 膿 suggests,
there are buddings of regenerating tissue amid the pus. It looks similar to
fruit of the chu trees or gualou, pulled apart to show the cluster of seeds.
Such seed-like structures may refer to granulation in these lesions.
[24] This paragraph is not found in Taisu, Volume 26, the section on Carbuncles

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 438 Neijing Zhiyao Yigu 內經知要譯詁

and Furuncles. Otherwise all the other boils are identical in the two refer-
ences. Since this paragraph is found in different versions of Lingshu, as well
as in Jiayi jing, it was presumbably omitted by Yang Shang-shan, the editor of
Taisu (ref. 16). One odd thing about the “sweet-tasting” furuncle is the refer-
ence to its taste affiliation. This is unique among the 19 kinds of boils that
carry a specific name (all other boils being named after their size/shape, loca-
tion or malignancy) but no doubts about its authenticity have ever been
raised. Zhang Jie-bin called this ruyong 乳癰 (carbuncle of the breast). Zhang
Yin-an boldly identified it as breast cancer (ruyan 乳 岩, or shi-yong 石 癰,
“hard carbuncle”). He was no doubt inspired by its location over the pectoral
muscle, and in this case, the cancer must have spread to the axillary lymph
nodes, which would explain why it becomes purulent over a long time. But it
is strange that the text does not mention the sex of the patient, as in the next
case; or it is assumed that it could only occur in women. The granulation,
long prognosis and recurrent fever suggest that it could be a cold abscess of
tubercular origin, but this assumption is not compatible with the blue-green
colour for any inflamed lesion.
[25] rotting mole: Baici 敗疵: bai means “rotting”, as in baixue 敗血 (septicaemia),
literally “rotten blood”, while ci is “mole”. (See [12] above.) While this sounds
like a malignant melanoma, it is unlikely to be cured by sweating and herbal
decoction, as described in such detail in the text. With the bold assumption
that the woman mentioned in the text was pregnant or lactating, the swollen
breast could be more susceptible to suppuration after infection. The appro-
priate treatment would then involve incision (cauterisation, laceration with
stone needles) and drainage, with fomentation to hasten the resolution of
inflammation. Hence the appearance of granulation. But this is “upgrading”
Neijing.
[26] small red beans: This is Delanda umbellata (chixiaodou 赤 小 豆, “small red
bean”), not to be confused with the red bean, Phaseolus angularis (hongdou
紅豆, “adzuki bean”). Tissue buds are granulation (see [23] above).
[27] sheng: One sheng 升 is about 500 ml. See ibid. 8-25-8.
[28] Forsythia root: Many annotators treat this as two plants, viz. Trapa ( ling)
and Forsythia (lianqiao 連 翹), because of the word ge 各 (each). They seem
not to have noticed that Trapa is a water plant, which bears the water caltrop,
(lingjiao 菱 角, Trapa bispinosa) the shape and colour of a pair of buffalo
horns. It has not much root, and certainly none hard enough to require
chopping into small pieces. In Jiayi jing, there are an additional five

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 Morbid Manifestations 439

characters “and red pine root” (ji chi song zi gen 及 赤 松 子 根) following the
“Forsythia root”. This makes sense, because there are now two plants, viz.
forsythia and red pine, “each” (ge 各) with hard roots that require chopping.
Then lingqiao  翹 becomes lianqiao 連 翹 (Forsythia suspensa). Having said
that, it is noted that there is no medicinal material known as “red pine root”,
and in that case, the character zi 子 (seed) is irrelevant. Chisongzi is Daoist
deity.
[29] 16 sheng: The text actually reads: “one dou and six ‘sheng’”. One dou 斗 is ten
sheng. According to the standard Qin dynasty measurements, it was 2000 ml,
with one sheng therefore equal to 200 ml.
[30] A rotting mole can be easily identified with malignant melanoma, or basal
cell papilloma; the difficulty here is that these are most likely to appear on
exposed parts of the body, and not on the costal region below the armpit. It
is hard to envisage any specifically female part of the anatomy on the sides of
the rib cage that could give rise to a boil. In the human embryo, there is a
cord of mammogenic tissue running down the front of the chest, so that in
rare cases, an extra pair of mammary glands develops below the normal pair.
The way it is described in Lingshu, this kind of femal costal boil with
pigmentation was not an isolated case. In Waike lili 外 科 理 例 (Medical
Records of Cases in Topical Disease), written by Wang Ji 汪 機 (1463–1539)
in 1519, mention is made of a costal furuncle (xieju  疽). Wang clearly
knew a great deal about topical diseases. He mentions syphilis but did not
realise that it was a sexually-transmitted disease.
[31] does not show changes [on the surface]: This is a tipless or blind boil (wutouju
無頭疽).
[32] pus reaches the bone: It is described as a deep-seated furuncle that is attached
to the bone (fuguju 附 骨 疽), but is more likely a purulent myelitis, with the
pus seeping out of the bone.
[33] This may refer to myelitis or tuberculosis in the bone although these do not
kill in one month. Since it is a blind boil, prognosis starts counting when
suppuration becomes obvious. It is also called fuguyong 附 骨 癰, an acute
purulent osteomyelitis (yongnong bo gu 癰 膿 搏 骨, “pus attacking bone”)
that occurs at the upper end of the femur. Myelitis, in the strict sense, occurs
in the spinal cord, hence the term “poliomyelitis”.
[34] sharp furnucle: Ruiju 銳疽, a kind of blind boil with a sharp tip.
[35] sacral region: The sacrum, kao 尻. Waike zhengzong called this a “stork bill
furuncle” (guankouju 鸛 口 疽), a reference to the protruding coccyx when

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 440 Neijing Zhiyao Yigu 內經知要譯詁

the boil erupts. This may occur as a result of traumatic injury, like falling off
a horse and landing on the buttocks.
[36] groin: This boil is not identified as a carbuncle or furuncle. The vernacular
term describes only the red-spreading appearance. Chi 赤 (red with a
burgundy hue) describes the appearance of an inflamed area, like cellulitis;
shi 施 (give, deliver, apply) may also mean “being applied”, as with cosmetics,
or “spreading”; in the latter case, it is synonymous with yi 移 (displace). This
may refer to a chancroid caused by Haemophilus ducreyi that begins with an
erythromatous lesion that spreads serpiginously under the skin to form a
large ulcerative lesion. Alternatively, inguinal lymphadenopathy also ends up
with large purulent buboes. But a chancroid will not kill in 60 days. To kill
the patient in 10 days, it would have to involve some kind of festering lymph
nodes pyogenic suppuration at the groin, complicated by cellulitis, hence the
vernacular name “red spreading”.
[37] nevo-carbuncle: see [12] above. In this case, it is not blackish (the normal
appearance). This may refer to patellar bursitis (which is why it is hard) that
can turn septic (which is why it becomes soft).
[38] corresponding joints: This is a rather ambiguous statement concerning the
exact meaning of “joint” (jie 節) and what structure it is “corresponding to”
(xiang ying 相應). Zhang Deng-ben, quoting Zhang Jie-bin, simply noted the
corresponding joints on both sides of the body (such as the left and right
elbows), or those in the upper part of the body with those in the lower part
(like the elbow and the knee). Other annotators have preferred to interpret
jie as meaning the vertebrae, especially the 12 thoracic vertebrae. A “joint”
would be guan jie 關節. For example, in Lingshu Chapter 7: the phrase “cannot
move the joints” (bu neng tong guan jie 不 能 通 關 節) and in Suwen Chapter
71, the phrase “locked joints” (jin gu guan jie 禁 固 關 節), both imply move-
ment (diarthrosis). If “jie” is interpreted as vertebra instead of joint, it leaves
vague which body part the vertebrae are corresponding to. In either meaning,
it may involve a pre-patellar bursitis, or a tuberculous node in a vertebral
body; both conditions can kill. This still does not answer the requirement of
parity.
[39] yang conduits: The three cheirogenic yang conduits govern the large intestine
(yang-ming), the three burners (shao-yang) and the small intestine (tai-yang)
Respectively. These are fu-organs; they are deemed to lie “near the surface”
(biao 表) and are thus more amenable to treatment. Hence the patient can
survive longer. Since there is no reference in this entire section to the

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 Morbid Manifestations 441

conduits in order to qualify the nature and location of the boils, the simple
sentence “develop in the yang [domain] ” (sheng yu yang 生於陽) may simply
mean that the boil occurs on the sunny side, e.g. at the back of the elbow (i.e.
olecranal).
[40] yin conduits: The three podogenic yin conduits govern the spleen (tai-yin),
the liver (jue-yin) and the kidney (shao-yin) respectively. These are zang-
organs, deemed to lie deep “inside the body” (li 裡), and are thus less
amenable to treatment. Hence the patient can only survive for a brief time.
But using the same argument as [34] above, “develop in the yin domain”
(sheng yu yin 生 於 陰) may simply mean “develop on the shady side”, e.g. at
the front of the elbow (i.e. antecubital).
[41] rabbit-gnawed [boil]: Tunie 兔齧 means a boil with a raw wound surface that
goes deep to reach the bone, a kind of osteomyelitis. The description fits with
a gumma, or syphiloma, a festering wound occurring on the shin below the
knee. The ulcer has a sharply rising punched-out edge while the base is
covered with wet, wash-leather slough. However, gumma and chancre from
syphilis did not appear in China until late in the Ming dynasty. (See [36]
above.)
[42] “slow-walking” boil: Zouhuan 走 緩, “walk slowly”. This is called “inner ankle
furuncle” (neihuaiju 內 踝 疽) today. It may refer to osteomyelitis or tubercu-
losis at the medial malleolus. It is hard to see why repeated laceration at this
spot could help; it would only lead to sinus formation with an opening,
inviting infection.
[43] sore spot: When a spot feels sore or tender upon compression, it is consid-
ered a temporary acupoint (yi tong wei shu 以 痛 為 腧). Sun Si-miao calls
this a “sycophantic acupoint” (E-shi xue 阿 是 穴). (E 阿, as in E-yu 阿 諛,
“sycophantic”.) It is a figurative way of describing an indeterminate site
that hurts upon compression, much as a sycophant, a yes-man, will yield to
the least pressure. The famous historian Chen Yin-ke 陳 寅 恪 (1890–1969)
vowed never to debase his scholarship to “suit the whims of a political
master” (qu xue a shi 曲 學 阿 世) (《史 記．儒 林 列 傳》); it costed him his
life.
[44] “four excesses”: Siyin 四 淫; yin, literally “lewd, licentious”, here means a
proliferation of boils on the four (si 四) extremities of the limbs. The text
specifies carbuncles on the sole and instep. That may imply diabetic foot
ulcer due to neuropathy.
[45] ferocious carbuncle: Liyong 厲 癰 (li 厲, “perilous, ferocious” as in liyi 癘 疫,

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 442 Neijing Zhiyao Yigu 內經知要譯詁

“pestilence”). Compare this with [4], the malignant carbuncle mengyong

(meng 猛, “malignant, develop quickly”). Li is also used instead of lai 癩 to
mean “leprosy”. This sounds like the development of a gangrenous foot in an
advanced stage of diabetic ulcer. Unlike gas gangrene, which is described in
the next paragraph, gangrenous foot usually starts with the toes, due to
ischaemia further up the leg, which deprives the extremity of its blood
supply. Zhang Yin-an interpreted this as the acupoint lidui 厲 兌 (ST-45), on
the second toe. This may help us to recognise this boil, but the chapter does
not seek the help of the conduit theory at all.
[46] detaching carbuncle: Tuoyong 脫 癰, where tuo, “detach, fall off ”, refers to the
severance of the afflicted parts, usually the toes, in a dry gangrene due to lack
of blood supply to the afflicted area. (Gas gangrene, due to the infection by
Clostridium perfringens of the ulcerative tissue, is blackish and gives off an
odour, which is not mentioned in the text.) Also called tuoju 脫疽 (detaching
furuncle) as early as the fifth century, it was described by Liu Juanzi 劉 涓 子
(ca. 370–450), in his Yongju fang 癰 疽 方 (Prescriptions for Carbuncles and
Furuncles). Liu was the first topical surgeon to specialise in boils. He served
in the army during the internecine wars of the period, and hence had much
experience of dealing with weapon wounds. He elaborated these efficacious
prescriptions into a 10-volume work named Prescriptions Bestowed upon Liu
Juanzi by the Spirits. [See Explanatory Notes above] Later, in the Ming
dynasty, Chen Shi-gong 陳 實 功 (1555–1636), a specialist in topical medi-
cine, wrote in his Waike zhengzong 外 科 正 宗 (Orthodox Topical Medicine):
“The detaching furuncle often occurs on the hands and feet. It begins the
size of a millet grain, with a head of yellow vescicle, and the surface dark red
like a cooked jujube. Discoloration spreads until all the five toes are affected,
then it spreads further to the instep; it hurts with a burning sensation. It
looks as if the bone is dry and the sinews are lax. The ulcer emits a strange
odour that lingers.”
[47] yong (carbuncle): Carbuncles start with the infection of a group of hair folli-
cles by Staphylococcus, causing inflammation, then suppuration of the
surrounding tissues. The term yong is here interchangeable with ju, which is
deep-seated with induration and suppuration but less swelling. Usually, a
carbuncle is larger than a furuncle, with a thin surface, and visible suppura-
tion. Yong 癰 may derive from yong 壅, as in yongsai 壅 塞, “congestive
blocking”, and yongji 壅積, “congestive accumulation”.
[48] ju: Ju 疽, a large, chronic and deep-seated carbuncle. Ju 疽 may derive from

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 Morbid Manifestations 443

cu 徂/殂 (depart, die). The text suggests the presence of a fistula.

[49] nape of the cow: The most resilient but thinnest part of the cow’s hide is
from the nape, because here it bears the yoke.

NB: Dr. Pau contributed much to the medical insight of these footnotes.

[Section 8.29] Lingshu Chapter 60: (Instructions Engraved

on) Jade Tablets

《靈樞．玉版》曰：白眼青，黑眼小，是一逆也；內藥而吐者，是二逆也；
腹痛、渴甚，是三逆也；肩項中不便，是四逆也；音嘶聲（色）脫，是五逆
也。

When the white of the eye turns blue-green [vertical gaze] and the black of the
eye is much reduced [1], this is the first kind of unfavourable prognosis [2].
When one ingests a decoction and vomits it up immediately, this is the second
kind [3] of unfavourable prognosis. Abdominal pain and intense thirst are
signs of the third kind [4] of unfavourable prognosis. Being unable to move
the neck and shoulders is the fourth kind [5] of unfavourable prognosis.
Hoarseness and pallor are signs of the fifth kind [6] of unfavourable
prognosis.

Explanatory Notes
Li Zhong-zi puts this short paragraph as end to the long chapter on carbun-
cles and furuncles without any annotation. In fact this is an excerpt from
Lingshu Chapter 60: [Instructions Engraved on] Jade Tablets (Yuban 玉 版),
from which another excerpt will be presented in Section 8.31. Li Zhong-zi
appended this short paragraph here with good reason because it deals with
unfavourable prognosis. It serves to qualify what are considered incurable
cases like mastoiditis (yaoju 夭 疽) and gangrene (tuoyong 脫 廱) in the
previous section. Taisu places this section under the heading “Acupunture for
Favourable and Unfavourable Situations with Carbuncles and Furuncles”.
When read independently, this short paragraph is not directly related to
carbuncles and furuncles, and none of these morbid signs is ever mentioned

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 444 Neijing Zhiyao Yigu 內經知要譯詁

in association with the 19 kinds of boils. However, Lingshu Chapter 60

expounds the application and limitation of the “fine needles” (xiaozhen 小 針)
and illustrates this by the treatment of boils. So it may be safely assumed that
when carbuncles and furuncles become malignant and one of these five kinds
of morbid signs co-present themselves, the case is terminal. That serves to
substantiate the declaration that “death is inevitable” (sibuzhi 死 不 治), which
was left unqualified in the previous section. Of these two sections, Section 8.30
(taken from Lingshu Chapter 21) is a straightforward declaration of incurable
cases of carbuncle and furuncle if they should occur on one of the five sites
indicated. These final sections in NJZY discuss prognosis and projection of the
terminal date in different time scales. It is a fitting end to a long and clinically-
oriented chapter, admitting de facto the unavoidable conclusion of life, in spite
of all the medical expertise available at the time. It presents a realistic attitude
to life which recognises the law of “birth-ageing-sickness-death” (sheng lao
bing si 生老病死).
Lingshu Chapter 60 embodies this realism with regard to life and death. It
begins with Huangdi asking Qibo: “I thought the fine needle is such a tiny
object, how come it fits with the universal laws of the heaven, earth and men?
I think this is an exaggeration.” Qibo answers: “No. Between heaven and earth,
men are ruled with weapons and needles. Weapons are large but are used to
kill, while needles are small and can heal.” Huangdi, not happy to have made a
slip of the tongue, asks: “When disease occurs as a result of emotional upset,
inordinate diet, imbalance of yin and yang and stagnation of the defensive qi,
boils appear. Complicated by the lack of interaction between yin and yang,
with yangqi combating the hot evil qi bringing forth suppuration, can the fine
needle redress this situation?” Qibo patiently explains that suppuration would
not appear out of nowhere, and was “born out of insignificant lesions” (ji wei
zhi suo sheng 積 微 之 所 生). This is almost pointing without knowing to the
bacterial origin (weijun 微 菌) of boils. On a macroscopic scale, boils often
develop out of the infection of individual hair follicles; they may become
deep-seated (furuncle) or recruit neighbouring follicles (carbuncle) before
becoming visible. By that time, suppuration is already progressing steadfastly.
Huangdi pursues obstinately: “If suppuration occurs and no good doctor is
available, what should one do?” Qibo replies: “By the time suppuration occurs,
the chance of survival is one in ten. That is why the sages would not allow the
boil to develop to a visible form. They listed clear instructions on bamboo
tablets and silk fabric for posterity so that no one should suffer from boils and

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 Morbid Manifestations 445

not finding a good doctor.” In one last effort to clear his doubts, Huangdi asks:
“When suppuration occurs and a good doctor is found, can he still use fine
needles to treat the patient?” Qibo replies solemnly: “If treating minor
ailments with insignificant means, the effectiveness is minimal. If treating
serious ailments with drastic means, the damage could be substantial. There-
fore, when suppuration is well established, only the use of stone needles and
dagger needles (for lancing) could be considered.” Now that Huangdi is totally
convinced of the limitations of the fine needle, he asks humbly: “As to patients
who are seriously damaged, could they still survive?” The answer lies in this
section. This long excerpt is translated almost word for word in order to illus-
trate one salient point: Chinese medicine is born out of clinical practice. All
the theoretical tools such as yin and yang and the five elements were extrapo-
lated later from the fields of philosophy and ethics to provide a module of
reasoning in Chinese medicine.

Footnotes

[1] black of the eye: The white of the eye is the sclera, the black of the eye is the
iris and the pupil. When one is gazing with the white of the eye, one looks
away from the object in front. Gazing with the black of the eye, one stares
right into the object in front. Metaphorically, to look with a white eye indi-
cates disdain; with a black eye, respect and attention. In the present context,
“white eye turns blue-green” may mean a vertical gaze, showing more of the
choroid in a squinting eyeball. A much reduced black eye (miosis) means
intense parasympathetic activity. The morbid signs of the eye indicate
profound disturbance in autonomic control.
[2] unfavourable prognosis: This paragraph is about ni shun 逆 順, literally “con
and pro”, regarding antidromic and orthodromic progression of disease.
Thus antidromic (ni) is aggravating, orthodromic (shun) is remitting. This
paragraph is not explicitly linked to boils; it only follows naturally the discus-
sion on the limitation of fine needles to treat boils. The following two para-
graphs, which are the subject of the next section, discuss unfavourable
prognosis in a general sense for all kinds of disease.
[3] second kind: This is called rejection (ge 格, or geju 格 拒). What is rejected
can be food, or herbal decoctions (geshi 格 食) due to lack of peristalsis (geqi
格 氣). Shanghanlun stipulated that “repulsion leads to emesis” (ge ze tu ni 格
則 吐 逆). It is due to failing middle burner function. Suwen Chapter 74 says:
“Rejection at the middle [burner] leads to vomiting (ge zhong er ou 格 中 而

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 446 Neijing Zhiyao Yigu 內經知要譯詁

嘔)”. From the same chapter, there is a discussion on ni cong (逆 從, which is

more or less the same as nishun 逆 順), or converse and reverse modes of
treatment. See ref. 53, Section 8.1.1.1 for further discussion.
[4] third kind: This sounds like internal bleeding.
[5] fourth kind: This sounds like an imminent cardiac attack.
[6] fifth kind: This sounds like failing adrenal function.

[Section 8.30] Lingshu Chapter 21: On Chills and Fever

《靈樞．寒熱病篇》曰：身有五部：伏兔一，腓二，背三，五藏之腧四，項
五。此五部有癰疽者死。

There are five (critical) locations on the body. These are first, the thigh [1];
second, the calf [2]; third, the back [3]; fourth, the five potency level acupoints
[4] and fifth, the neck [5]. If boils develop here, death is inevitable.

Explanatory Notes
This short passage taken from Lingshu Chapter 21 serves to amplify the
previous section on cases of boils with unfavourable prognosis. This Lingshu
chapter deals with a number of miscellaneous diseases and their treament by
acupuncture. It starts with diseases showing signs of chill and/or fever, hence
the chapter title, but in fact it covers a broad range of diseases. Towards the
end of the chapter, these five critical locations are mentioned and specifically
assigned to boils, a point that was left rather vague in the previous section.
The chapter concludes with a statement cautioning against damage due to
mismanagement in acupuncture. It says: “When the needle strikes the point
but is not withdrawn, the essence will escape. When the needle is withdrawn
before hitting the point, the evil qi will linger on site. With the essence
escaping, the disease aggravates and the patient becomes apprehensive. With
the evil qi lingering on site, carbuncles and furuncles ensue.” Li Zhong-zi must
have read Neijing carefully, picking up the few references to boils to assemble
them here.

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 Morbid Manifestations 447

Footnotes

[1] thigh: At acupoint futu 伏 兔 (ST-32), where the rectus femoris joins the
tendon of the quadriceps; it is 6 inches above the knee-cap. It is also referring
to the quadriceps in general, shaped like the back of a crouching rabbit.
[2] calf: At acupoint zhubin 築 賓 (K-19), this generally refers to the calf, the
gastrocnemius.
[3] back: At the level of the thoracic and lumbar vertebrae. It is believed to be
particularly important because the visceral organs are close to the back at
this point.
[4] the five potency level acupoints: These lie on the limbs distal to the elbow
and knee. These special shu acupoints control the volume of flux in their
respective conduits.
[5] neck: It is because the yang conduits run through the neck and up to the
head.

[Section 8.31] Lingshu Chapter 60: (Instructions Engraved

on) Jade Tablets

《靈樞．玉版篇》曰：腹脹、身熱、脈大，是一逆也；腹鳴而滿、四肢清、
泄、其脈大，是二逆也；衄而不止、脈大，是三逆也；咳且溲血、脫形、
其 脈 小 勁，是 四 逆 也；咳、脫 形、身 熱、脈 小 以 疾，是 謂 五 逆 也。如 是
者，不過十五日而死矣。

其腹大脹、四末滿（清）、脫形、泄甚，是一逆也；腹脹、便血、脈大
絕時，是二逆也；咳溲血、形肉脫、脈搏，是三逆也；嘔血、胸滿引背、
脈小而疾，是四逆也；咳、嘔、腹脹且飧泄、其血脈絕，是五逆也。如是
者，不及一時而死。

[The first group of cases with unfavourable prognosis consist of the

following.] With bloating belly, feverish body and strong pulse, this is the first
kind [1]. With borborygmus and abdominal congestion, cold limbs, diarrhoea
and a strong pulse, this is the second kind [2]. Incessant nose bleeds [epistaxis]
and a strong pulse, this is the third kind [3]. Coughing, with blood in the
urine [haematuria], [cachexia] extreme debility with weak but bouncing

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 448 Neijing Zhiyao Yigu 內經知要譯詁

pulse, this is the fourth kind [4]. Coughing, cachexia, feverish body, with weak
but racing pulse, this is the fifth kind [5]. Under these circumstances, death
will occur within a fortnight.
[The second group of cases with unfavourable prognosis consist of the
following.] With belly bloating maximally and oedematous limbs [6],
cachexia, and frequent diarrhoea, this is the first kind [7]. With bloating belly,
haematochezia, and a strong pulse with missed beats, this is the second kind
[8]. Coughing, passing blood in the urine [haematuria], cachexia and a
bouncing pulse, this is the third kind [9]. Regurgitating blood [haematemesis],
[painful] chest congestion radiated to the back, and a weak but racing pulse,
this is the fourth kind [10]. With coughing, emesis, bloating belly, passing
undigested food and a barely detectable pulse, this is the fifth kind [11]. Under
these circumstances, death will occur within a day.

Explanatory Notes
This section is a continuation of Section 8.29, which described five situations
in which advanced cases of boils would become terminal. Other than in these
five situations, boils are seen as curable. Following the same line of thinking,
Huangdi asks if all kinds of diseases could be regarded as favourable or unfa-
vourable. Qibo answers by naming two groups, one with an unfavourable
prognosis of medium term (15 days) and one of impending immediacy (one
day). These examples served to caution against the application of acupuncture
at this late stage, as diseases were likely to develop insidiously. This echoes the
previous statement that boils develop from an accumulation of microscopic
lesions. Lingshu Chapter 55 spells out this notion unambiguously: “Good
doctors apply the needle before the disease begins to evolve. Lesser doctors
apply the needle before the disease is full blown. Still lesser doctors apply the
needle when the disease is regressing.” On the other hand, “bad doctors apply
the needle when the disease is flaring, while the pulse pattern contraindicates
such treatment.” It became a central tenet of clinical Chines medicine that
“good doctors treat diseases before they show up; they will not wait to treat
the diseases when they are obvious.” (shang gong zhi wei bing, bu zhi yi bing 上
工 治 未 病、不 治 已 病). Li Zhong-zi provides a detailed annotation for each
of these ten cases of unfavourable prognosis; they are translated verbatim in
the footnotes below. Archaic as they seem to be, these descriptions agree with
modern physiology.

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 Morbid Manifestations 449

Footnotes

[1] the first kind: Feverish body and strong pulse indicate evil qi remaining on
the surface of the body. Bloating belly indicates evil qi residing in the interior
of the body. In this case, evil qi is rampant both on the surface and internally.
[2] the second kind: The symptoms indicated a yin state (regressing, subdued)
of the disease, but a strong pulse indicates a yang state (progressing,
arousing) of the disease. In this case, the pulse pattern contradicts the
symptoms.
[3] the third kind: Bleeding from the nose (epistaxis) is a yin state, whereas a
strong pulse is a yang state. Now that yang is excessive while yin is deficient,
death is inevitable (si bu zhi 死不治).
[4] the fourth kind: With coughing, haematuria, cachexia, the righteous qi
(zhengqi 正 氣, physiological compensation) is much compromised. A weak
but bouncing pulse indicates entrenched evil qi.
[5] the fifth kind: Cachexia (extreme debility) and depletion of genuine qi (zhenqi
真 氣, “normal organ function”) but with a feverish body both indicate an
active evil qi remaining inside the body. A small but racing pulse indicates
depletion of blood (hypovolaemia). This is a disease state of the collapse of
both qi and blood.
[6] oedematous limbs: Different editions of Lingshu put this as “cold extremi-
ties” (si mo qing 四 末 清). This corresponds to “cold limbs” (si zhi qing 四 肢
清) in the previous paragraph. Li Zhong-zi has this sentence as “oedematous
limbs” (si mo man 四 末 滿), because the bloating is more serious in this case,
but in his annotation, he reverts to “cold limbs” (si zhi leng 四肢冷).
[7] the first kind: Bloating maximally indicates a flaring evil qi. Cold limbs,
cachexia and diarrhoea indicate exhaustion of spleenic function.
[8] the second kind: Bloating and haematochezia indicate evacuation of yin
reserves. A strong but intermittent pulse (arrhythmia) indicates evacuation
of yang reserves.
[9] the third kind: Coughing and haematuria would damage both qi and blood.
Cachexia indicates depletion of spleenic function. A bouncing pulse reveals
the genuine pulse pattern of the zang-organs (zhenzangmai 真 臟 脉, or simai
死脉, see Sections 4.8 and 4.12) in the absence of spleenic function.
[10] the fourth kind: With haematemesis, chest congestion and hunching of the
back (due to radiated pain), the disease reaches its ultimate phase. A small
pulse indicates collapse of qi (weak heart). A racing pulse indicates depletion
of blood (hypovolaemia).

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 450 Neijing Zhiyao Yigu 內經知要譯詁

[11] the fifth kind: Coughing is due to a diseased upper burner. Bloating is due to
a diseased middle burner. Passing undigested blood is due to a diseased lower
burner. With all three burners in a diseased state, the six conduits (governing
the fu-organs) are exhausted.

[Section 8.32] Suwen Chapter 65: On the Rules of Disease

Transmutation

《素問．標本論》曰：夫病傳者，心病，先心痛；一日而咳，三日脅支痛，
五日閉塞不通、身痛體重；三日不已，死：冬夜半，夏日中。
肺 病，喘 咳，三 日 而 脅 支 滿 痛；一 日 身 體 重 痛，五 日 而 脹；十 日 不
已，死：冬日入，夏日出。
肝 病，頭 目 眩、脅 支 滿；三 日 體 重 身 痛，五 日 而 脹，三 日 腰 脊 少 腹
痛、脛痠；三日不已，死：冬日入，夏早食。
脾病，身痛體重；一日而脹，二日少腹腰脊痛、脛痠，三日背膂筋痛，
小便閉，十日不已，死︰冬人定，夏晏食。
腎病，少腹腰脊痛，胻痠；三日背膂筋痛，小便閉，三日腹脹，三日
兩脅支痛；三日不已，死：冬大晨，夏晏晡。
胃病，脹滿；五日少腹腰脊痛、胻痠，三日背膂筋痛，小便閉，五日
身體重；六日不已，死：冬夜半後，夏日昳。
膀胱病，小便閉；五日少腹脹、腰脊痛、胻痠，一日腹脹，一日身體
痛；二日不已，死：冬雞鳴，夏下晡。

Regarding the transmutation of diseases [1], it begins with pain in the heart in
heart disease. In one day, there is coughing (lung). In three more days, pain in
the hypochondrium (liver). In five more days, there is constipation, feeling
painful and heavy all over the body (spleen). If there were no remission in
another three days, death would occur at mid-night in winter, or at noon in
summer [2].
In lung disease, it begins with the lung, [the hallmark is] wheezing and
coughing. In three days, there is congestion and pain in the hypochondrium
(liver). In one more day, the body becomes heavy and painful (spleen); in five
more days, bloating (stomach). If there were no remission in another ten days,
death would occur at sunset in winter, or at sunrise in summer [2].

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 Morbid Manifestations 451

If the disease begins with liver, [the hallmark is] vertigo and fullness in
the hypochondrium [liver]. In three days, there is heavy and painful body
(spleen); in five more days, bloating (stomach), in three more days, pain in the
waist and underbelly (kidney), sore legs. If there were no remission in another
three days, death would occur at sunset in winter, or at breakfast-time in
summer [2].
If the disease begins in the spleen, [the hallmark is] heavy and painful
body. In one day, there is bloating (stomach); in two more days, pain in the
waist and underbelly (kidney), and sore leg; in three more days, pain in the
back muscles (spinal erector) and anuria (urinary bladder). If there were no
remission in another ten days, death would occur in the evening in winter or
at supper-time in summer [2].
If the disease begins with the kidney, [the hallmark is] pain in the waist
and underbelly, and the upper end of the shin [3] feels tender. In three days,
there is low back pain and anuria, and the back muscle hurts (urinary
bladder). In three more days, there is bloating (stomach, Lingshu indicated
heart). In yet another three days, there is pain in the hypochondrium (liver,
Lingshu indicated small intestine). If there were no remission in another three
days, death would occur at late morning [4] in winter, or after supper in
summer [2].
If the disease begins with the stomach, [the hallmark] is bloating. In five
days, there is pain in the waist and underbelly and the upper end of the shin
feels tender (kidney). In three more days, there is low back pain and anuria,
and the back muscles hurt (urinary ladder). In five more days, the body feels
heavy (spleen, Lingshu indicated heart). If there were no remission in another
six days [Lingshu indicated two more days], death would occur after mid-
night in winter, or after lunch in summer [2].
If the disease begins with the urinary bladder, [the hallmark is] anuria. In
five days, the underbelly is bloating, the waist hurts and the shin is sore. In
another day, there is bloating. Yet another day, there is pain all over the body.
If there is no remission in yet another two days, death would occur at cock-
crow in winter, and at supper-time in summer.

Explanatory Notes
This section is taken from the latter half of Suwen Chapter 65. The complete
chapter title is On the Rules of Disease Transmutation (Biaoben bingchuan lun

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 452 Neijing Zhiyao Yigu 內經知要譯詁

標 本 病 傳 論) of which Li Zhong-zi abbreviated it to Biaoben lun 標 本 論,

missing out exactly the part on transmutation (bingchuan 病 傳). This is not a
serious issue; Li Zhong-zi may consider the transition between biao 標 (the
shoots, surface symptoms) and ben 本 (the roots, the underlying cause) is also
a form of transmutation. The central dogma in clinical Chinese medicine is to
treat the ultimate cause of a disease (zhi bing bi qiu zhu ben 治 病 必 求 諸 本.
See Section 2.1). But there is also an exemption clause: “when urgent, treat the
symptoms first.”59 The crux of the matter is to appraise what is symptom and
what is cause, thus deciding the priority of treatment. This dilemma is further
complicated by the fact that this concept of biao-ben relationship is extrapo-
lated to other domains like pulse pattern and causative/climatic factors, body
surface signs and visceral organ dysfunction; new complaints and previous
sufferings; or disease presentation and disease management. Two possible
management plans are derived from these interwoven relationships. The
orthodox mode of treatment (congzhi 從 治) is to treat the symptom OR the
cause, according to where the main complaint lies. The unorthodox mode of
treatment (nizhi 逆 治) is to treat the symptom of urgence first, even though
the cause has been identified, OR to treat the cause first, expecting the symp-
toms to disappear with treatment. This concept is encapsulated at the first
sentence of this chapter (Suwen Chapter 65): “Disease always carries
symptom(s) and ultimate cause(s), therefore the mode of treatment (by
acupuncture) can be orthodox or unorthodox.” (bing you biao ben, ci you ni
cong 病有標本，刺有逆從).
Having discussed so much about symptom and cause, there is no
apparent connection between this first part of Chapter 65 and the latter half
on disease transmuation, except for the fact that the transition between
symptom and cause and vice versa can be considered a form of transmutation.
But it is entirely appropriate to talk about disease transmutation in terminal
cases towards the end of NJZY. At this stage of the book, that aims at
providing a concise conception of disease and treatment, it is apparent that
there are terminal cases. If the clinician cannot do anything about this, at least
he should be able to predict the time of the final outcome. This is the
substance of (terminal) disease transmutation.

59
Gong Xin (ca. 16th century) 龔 信：《病 機 賦》
：「急 則 治 其 標」(ji ze zhi qi biao),
「緩則治其本」(huan ze zhi qi ben).

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 Morbid Manifestations 453

The words cited in this section are not clearly spelled out in the text.
However in Lingshu, Chapter 42: Disease Transmutation (Bingchuan 病 傳), a
similar paragraph appears almost verbatim in no unclear terms. The present
translation observes all the information listed Lingshu; any difference is indi-
cated within brackets. There are three issues:
Firstly, the order of transmutation is from one significant symptom (i.e.
organ dysfunction, with the organ indicated in brackets in the translation) to
another. If the progression of the disease follows the direction of the inhibi-
tory mode (e.g. from heart-fire to lung-metal), thus by-passing on organ in
the generative mode, the disease cannot be treated by acupuncture: it is unfa-
vourable prognosis. This instruction can be found towards the end of the
chapter, which Li Zhong-zi had not cited. However, if the progression to
another organ has a lapse of more than one organ in the generative mode, be
it two or three (i.e. the third or fourth organ down the series), there is a
chance of mitigation because by then acupuncture can be administered. In
Lingshu, acupuncture is only prohibited if the progression is to the next organ,
i.e. in the generative mode of the “five elements”. Otherwise, acupuncture can
apply.
Secondly, the text pronounces definitively the number of days taken to
pass from one organ to another, until, without remission, the limit of the time
schedule. How the number of days is counted appears rather confusing due to
ambiguous wording. It is not sure whether the days are counted in a sequen-
tial or cumulative manner. However, in Lingshu Chapter 42, the number of
days lapsed while moving from one organ to another terminal time segment
in stomach disease (2 days instead of 6 days). The present translation follows
the text in Lingshu where the number of days is concerned.
Thirdly, in Lingshu, the progression of the disease is described as passing
from one organ to another, whereas in Suwen, only the symptoms pertinent to
that organ are mentioned. Thus in the present translation, the organ respon-
sible for such symptoms are indicated between brackets.
An interesting aspect of timing the moment of death concerns the precise
hour when it happens; it varies according to season and the number of
afflicted organs involved. Annotators could provide no better answer than
citing the “five elements”. Nowadays, it is commonly observed that terminal
patients usually die in early morning (when yangqi is at its nadir). Clinicians
at Neijing times pinned down this terminal moment to a two-hour window.
This information is rearranged in tabular form below.

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 454 Neijing Zhiyao Yigu 內經知要譯詁

In the Spring and Autumn period, one day was divided into ten periods.
Later, in Han dynasty with an improved calendar, one day became 12 periods
and coded under the terrestrial branches (dizhi 地 支). It began with the “hour
of zi” (zishi 子 時), from 2300–0100 hours, i.e. mid-night (yeban 夜 半). The
complete sequence is yeban (子 時), jiming 雞 鳴 (choushi 丑 時, 0100–0300
hours and so forth), pingdan 平 旦, richu 日 出, shishi 食 時, yuzhong 隅 中,
rizhong 日中, ridie 日昳, bushi 晡時, riru 日入, huanghun 黃昏, rending 人定.
Since there were only seven period codes cited in the text, this left five periods
unaccounted for. Furthermore, there were period codes cited in the text that
agreed with contemporary literature like Huainanzi of early Han dynasty. For
example, in the Han system, the sequence: [食時─隅中─日中] fits well with
the sequence of [晏食─隅中─正中] in Huainanzi. Other terms were similar
to literature of the time but they did not agree with the annotation by Zhang
Deng-ben. To facilitate the comparison, the information is tabulated below.

Hours Dizhi Period Quoted Remarks

code code in NJZY
2300–0100 zishi yeban Yes Midnight is called ziye 子夜
子時 夜半
0100–0300 choushi jiming Yes 《詩》 〈鄭風〉︰「女曰鳴。」 ；〈齊
丑時 雞鳴 風〉︰「既鳴矣 。」
From Shijing (Book of Odes)
0300–0500 yinshi pingdan Early morning, may mean dachen 大
寅時 平旦 晨 in NJZY. Crack of dawn.
0500–0700 maoshi richu Yes Literally, “sunrise”.
卯時 日出
0700–0900 chenshi shishi Breakfast, may be the same as zaoshi
辰時 食時 早食 in NJZY.《淮南子．天文》︰
「晏食。」
0900–1100 sishi yuzhong 《淮南子．天文》︰「隅中。」
巳時 隅中 Before noon.
1100–1300 wushi rizhong Yes 《淮南子．天文》︰「正中。」
午時 日中 Today, zhongwu 中午 = noon.
1300–1500 weishi ridie Yes Same as rize (Rize 日昃) , “the sun
未時 日昳 declines.”
1500–1700 shenshi bushi 《漢書．天文志》︰「（跌）昳 … 晡
申時 晡時 … 下晡 … 日入。」

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 Morbid Manifestations 455

1700–1900 youshi riru Yes Literally, “sunset”.

酉時 日入
1900–2100 xushi huanghun Dusk. May be the same as yanbu 晏
戌時 黃昏 晡 in NJZY. Today, it means “evening”.
2100–2300 亥時 人定 Yes 古詩．焦仲卿︰「黃昏 … 人定。」
haishi rending

A modern scientific mind would ask immediately what is the statistical

significance of all these quantitative parameters, especially the last group, the
hour of death. At the time of Neijing, these observations were not necessarily
based on “five elements” reasoning, as later date annotators would prefer; it
was simply recording some typical clinical experiences. Today, when we read
about multiple organ dysfunction syndrome (MODS), we need not seek help
from “five elements”. The following is a transcript taken from Kumar and
Clark: Clinical Medicine (4th ed. Saunders, 1998):
“In this condition (of shock), impaired tissue perfusion, microcirculatory
abnormalities, and defective oxygen utilization precipitated by dissemination of
the inflammatory response with the systemic release of ‘mediators’ can damage
vital organs. The most severely ill patient may develop MODS which is almost
invariably associated with persistent or recurrent sepsis and a fever. This is partly
due to damage to the mucosa of the gastrointestinal tract following shock and
reperfusion, which allows bacteria or endotoxin within the gut lumen to gain
access to the circulation, thereby perpetuating the inflammatory response.
Sequential failure of the organs occurs progressively over weeks, although the
pattern of organ dysfunction is variable. In most cases, the lungs are the first
organs to be affected, with development of the acute respiratory distress syndrome
(ARDS) in association with cardiovascular instability and deteriorating renal
function. Secondary pulmonary infection, complicating ARDS, frequently acts as
a further stimulus to the inflammatory response. Later renal failure and liver
dysfunction develop. Gastrointestinal failure, with an inability to tolerate enteral
feeding and paralytic ileus, is common. Ischaemic colitis, acalculous cholecystitis,
pancreatitis and gastrointestinal haemorrhage may also occur. Features of central
nervous dysfunction include impaired consciousness and disorientation,
progressing to coma. The metabolic derangement is associated with elevated
blood sugar levels, catabolism and wasting. Characteristically, these patients
initially have a hyperdynamic circulation and vasodilation and a high cardiac

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 456 Neijing Zhiyao Yigu 內經知要譯詁

output, associated with an increased metabolic rate. Eventualy, however, cardio-

vascular collapse supervenes and is the usual terminal event.
The mortality of MODS is extremely high. Factors affecting outcome include
the number of organs involved, the duration of organ dysfunction and persistent
infection.”
The striking similarity between the modern and the ancient text is truly
impressive. While Clinical Medicine by Kumar and Clark is the desktop refer-
ence for every medical student today, Neijing was written by anonymous
author(s) two millennia ago with neither author’s right nor royalty.

Footnotes

[1] transmution of disease: Transmutation occurs when disease changes from

one organ (system) to another, becoming another kind of disease. This is
called chuanbian 傳 變, chuanhua 傳 化 or chuanjing 傳 經. Transmission
occurs when disease changes from one part of the body to another,
remaining the same kind of disease. Today, this is called zhuanyi 轉移.
[2] See table in Explanatory Notes.
[3] upper end of the shin: Heng 胻 refers to the upper end of the shin, just below
the kneecap.
[4] late morning: Zhang Deng-ben assigned dachen 大 晨 (late morning) to the
“hour of shen” (shenshi 辰 時), which is breakfast (shishi 食 時). There is no
period code as dashen. While pingdan 平 旦 is left unaccounted for, it
describes crepuscular early morning and can hardly be called late morning.

[Section 8.33] Lingshu Chapter 10: The Conduits

《靈樞．經脈篇》曰：手太陰氣絕，則皮毛焦。太陰者，行氣溫於皮毛者
也。故氣不榮，則皮毛焦；皮毛焦，則津液去皮節；津液去皮節者，則爪
枯毛折。毛折者，則毛先死。丙篤丁死，火勝金也。
手少陰氣絕，則脈不通；脈不通，則血不流；血不流，則髦色不澤，
故其面黑如漆柴者，血先死，壬篤癸死，水勝火也。
足太陰氣絕，則脈不榮肌肉。脣舌者，肌肉之本也。脈不榮，則肌肉
軟；肌肉軟，則舌萎、人中滿，則脣反。脣反者，肉先死。甲篤乙死，木
勝土也。
足少陰氣絕，則骨枯，少陰者，冬脈也，伏行而濡骨髓者也。故骨不

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 Morbid Manifestations 457

濡，則肉不能著也；骨肉不相親，則肉軟卻；肉軟卻，故齒長而垢、髮無
澤。髮無澤者，骨先死。戊篤己死，土勝水也。
足厥陰氣絕，則筋絕。厥陰者，肝脈也；肝者，筋之合也；筋者，聚
於陰氣（器）而脈絡於舌本也。故脈弗榮，則筋急；筋急，則弔舌與卵。故
脣青、舌卷、卵縮，則筋先死。庚篤辛死，金勝木也。
五陰氣俱絕，則目系轉，轉則目運（暈）。目運（暈）者，為志先死。志
先死，則遠一日半死矣。
六陽氣絕，則陰與陽相離，離則腠理發泄、絕汗乃出。故旦占夕死，
夕占旦死。

When qi expires [1] in the cheiro(-telic) tai-yin [pulmonic] conduit, the skin
and body hair take on a withered look. The tai-yin [pulmonic] conduit serves
to warm [nourish] the skin and body hair. If the [pulmonic] qi is not flowing
freely, the skin and body hair become withered. In this case, body fluid would
leave the skin and joints, which in turn renders the nails shrivelled and hairs
brittle [2]. Hairs become brittle when they do not grow any more. Under these
circumstances, the morbid state would become terminal on the third day and
terminate on the fourth day [of the 10-day cycle], [3] since fire overrides
metal.
When qi expires in the cheiro(-telic) shao-yin [cardiac] conduit, the
vessels are no longer patent and blood does not flow through. With no blood
flowing in the vessels, hairs lose their sheen, such that the countenance is
sombre and [the body is cachetic like] a bunch of faggots. That is because the
blood is already exhausted. Under these circumstances, the morbid state
would become terminal on the ninth day and terminate on the tenth day [of
the 10-day cycle] since water overrides fire.
When qi expires in the podo(-genic) tai-yin [spleenic] conduit, the vessels
no longer bring nourishment to the muscles. The lips and tongue are repre-
senting the state of the muscles. When the vessels are not full, the muscles are
flaccid. Therefore, the tongue shrinks and the philtrum swells. With a swollen
philtrum, the lips are pursed; that is because the muscles are worn out. Under
these circumstances, the morbid state will become terminal on the first day
and terminate on the second day [of the 10-day cycle], since wood overrides
earth.
When qi expires in the podo(-genic) shao-yin [renal] conduit, the bones
are withered. The shao-yin [renal] conduit is akin to winter [particularly

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 458 Neijing Zhiyao Yigu 內經知要譯詁

sensitive to winter], it lies deep [among the muscles] and nourishes the bone
marrow. Therefore, when the bone marrow does not take up sufficient nour-
ishment, the muscles can no longer attach [firmly] to the bones. When bones
and muscles are not [tightly] connected, the latter become atrophic. With
atrophied muscles, the teeth become longer [4] and caries accumulate. Hair
loses its sheen because the bones are worn out. Under these circumstances, the
morbid state will become terminal on the fifth day and terminate on the sixth
day [of the 10-day cycle], since earth overrides water.
When qi expires in the podo(-genic) jue-yin [hepatic] conduit, the sinews
are failing. The jue-yin conduit governs the liver, which is akin to the sinews.
The sinews [eventually] converge towards the genitalia, with a branch linking
the root of the tongue. So when qi in this conduit is not full, the sinews will
contract. Contracting sinews will then draw in the tongue and testicles. There-
fore the lips turn blue, the tongue curls backward and the testicles retract into
the body because the sinews have failed. Under these circumstances, the
morbid state will become terminal on the seventh day and terminate on the
eighth day [of the 10-day cycle], since metal overrides wood.
When qi expires in the five yin [zang-organ governing] conduits, the eyes
and mental faculties work poorly and syncope ensues. If consciousness is lost,
one will die in one and a half days.
When qi expires in the six [fu-organ governing] conduits, there is no
interaction between the yin and yang forces. In a state of detaching yin from
yang, the subcutaneous striae become porous [leaving the yangqi to seep out
of the body], and terminal sweating [5] occurs. When these signs appear in
the morning, one will die by the evening; likewise, with signs in evening, death
is expected by the next morning.

Explanatory Notes
This is the third excerpt from Lingshu Chapter 10: The Conduits. The first two
excerpts appeared in Sections 6.1 and 8.4, describing respectively the itinerary
and clinical features of the 12 regular conduits. With this third excerpt, albeit a
short passage but important, it completes the function of a regular conduit, its
termination. When qi expires (qi jue 氣 絕) in a certain conduit, which is
detectable through the absence of the genuine pulse-pattern particular to a
certain zang-organ (zhenzangmai 真 臟 脉, see Sections 4.8 and 4.12), it indi-
cates total collapse of this organ. Zhang Deng-ben correctly identified this as

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 Morbid Manifestations 459

xutuo 虛 脫 (collapse) in modern medical terms. Collapse is a broader concept

than syncope or blackout and the primary reason is extreme prostration due
to the failure of a certain vital function, like the liver or the kidney, in which
circulation failure is a precipitating cause. The functional exhaustion of a
certain vital visceral organ was described as qi expiry in the five yang- and six
yin-conduits. The critical signs associated with each failing organ are helpful
in providing a realistic appraisal of the terminal situation. It has a shorter
time-schedule than the organ dysfunction described in the previous section,
where there was still time for disease transmutation. In this section, the
precipitation of the final moment according to the “five elements” connota-
tions of the days in a 10-day cycle may seem unacceptable today. But at the
time when Neijing was produced, it provided a manageable time-frame, albeit
an arbitrary one. It is no more artificial than a computer model constructed
for the sole purpose of predicting the outcome of events in a state of flux, e.g.
climate change. In this context, the paradigm of modelling could be found in
Yi jing 易 經 (Book of Changes) that predates Neijing. The salient point lies in
the fact that the clinician could expect the immediate consequence at a critical
moment.

Footnotes

[1] qi expires: Organ failure. By the same token, when qi is not flowing freely, it
is organ hypofunction.
[2] hair brittle: The hair follicle stops growing and the hair falls out.
[3] 10-day cycle: A month is divided into three 10-day cycles and each is coded
sequentially by the 10 “celestial” (tiangan 天 干); the first day is “day-jia”,
second day is “day-yi” and so forth. The complicated part is that, beginning
with the first two days (i.e. “day-jia” and “day-yi”), each pair of days is
assigned to one of the five elements, starting with wood. Therefore, days jia
and yi are assigned to wood; days bing and ding to fire; days wu and ji to
earth; days geng and xin to metal and days ren and gui to water. The develop-
ment of the morbid state obeys the basic rules of the “five elements”; it will
remit or aggravate accordingly. Compare this cycle with the coding of the
twelve 2-hour periods of the day according to the celestial branches in the
previous section.
[4] teeth become longer: The human teeth cannot grow any longer once fully
established. However, when the gums retract in old age, the teeth appear to
grow longer. This idea is borrowed from the famous quotation the “horse

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 460 Neijing Zhiyao Yigu 內經知要譯詁

teeth getting longer” (ma ci jia chang 馬齒加長, or ma ci tu zheng 馬齒徒增),

which is true, lamenting the futile passage of time without achieving much.
[5] terminal sweating: Juehan 絕汗 is a thick viscous secretion from the apocrine
sweat glands released in moments of intense emotional stress. It is a cold
sweat (leng han 冷汗).

[Section 8.34] Suwen Chapter 79: Additional

Explanation of the Phenomena of Yin-Yang (Disease Patterns
according to Yin-Yang Categorisation)

《素問．陰陽類論》曰：冬三月之病，病合於陽者，至春正月，脈有死徵，
皆歸出春。冬三月之病，在理已盡，草與柳葉皆殺；春，陰陽皆絕，期在
孟春。
春三月之病，曰陽殺。陰陽皆絕，期在草乾。
夏三月之病，至陰不過十日；陰陽交，期在濂（溓）水。
秋三月之病，三陽俱起，不治自已；陰陽交合者，立不能坐，坐不能
起；三陽獨至，期在石水；二陰獨至，期在盛水。

For diseases occurring in the three months of winter with signs of yang
preponderance, when spring comes they show a moribund pulse-pattern, and
death is expected by the end of spring. For diseases occurring in the three
months of winter, the vigour of life inside the body is exhausted, grass and
willow leaves are wilted [1]. Come the spring, both yin and yang pulse-
patterns are absent, and death is expected in early spring.
For diseases occurring in the three months of spring with signs of yang
depletion and both yin and yang pulse-patterns absent, death is expected [in
late autumn] when the grass is parched.
For diseases ocurring in the three months of summer, if it stems from the
ultimate yin (i.e. the spleen) [2], death is expected within ten days. When the
yin or yang pulse-pattern contradicts its corresponding symptoms (yin yang
jiao, “intercross”) [3], death is expected when water is limpid [in mid-
autumn] [4].
For diseases occurring in the three months of autumn, even though the
triple yang conduit is diseased, recovery is expected to be spontaneous.

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 Morbid Manifestations 461

However, those suffering from a confused and contradictory yin and yang find
it hard to sit down when standing, or get up when sitting. Under these circum-
stances, if only the triple yang [urinary bladder] pulse-pattern shows up, death
is expected when water freezes [in winter] [5]. By the same token, when only
the double yin [i.e. the cardiac shao-yin conduit] pulse-pattern shows up,
death is expected when water comes aplenty [snow thaws].

Explanatory Notes
This is the first of the three chapters in the last volume (Volume 24) of Suwen.
The last two volumes of Suwen, 23 and 24, record the dialogue between
Leigong and Huangdi, with Leigong playing the part of a humble student and
Huangdi the part of an authoritative mentor. These chapters are probably a
compilation of the teachings of the Leigong school, which was based primarily
on yin-yang categorisation. Huang-Fu Mi 皇 甫 謐 (214–282), author of Jiayi
jing 甲乙經 (The Classic of the Major Conduits) wrote in his preface: “Huangdi
consulted Qibo, Bogao, Shaoyu and their peers to investigate the five zang-
organs and six fu-organs…. These ideas were excellent; Leigong was taught and
passed on [the knowledge] to posterity (Leigong shou ye, chuan zhi yu hou 雷
公 授 業，傳 之 於 後).” Therefore, it is not surprising to find many passages
treating subjects similar to those covered by Qibo (the erudite counsellor) and
Huangdi (the inquisitive master) in previous chapters. Indeed, Suwen Chapter
79 Yin yang lei lun 陰 陽 類 論 (literally, “On Categorisation of Yin and Yang”)
is very similar to Suwen Chapter 7 Yin yang bie lun 陰陽別論 (literally, “Further
Discussion of Yin and Yang Types of Disease”), which was excerpted in
Sections 4.12 and 8.3. They all deal with pulse-patterns that are in discord
with the season, and from this the clinician could evaluate the severity of the
morbid state. The methodology in both Section 8.3 and the present section is
the same, that is, yin-yang categorisation as multiples of yin or yang and their
combination. But in Section 8.3, only the morbid state is described. In the
present section, the discordance is revealed as bringing dire consequences, and
in the worst-case scenario, imminent death. Since Huangdi reasons that such
evaluation of the morbid state could determine the time of death (zhen jue si
sheng zhi qi 診 決 死 生 之 期), Leigong asks persistently how brief the time
before imminent death might be (duan qi 短 期, literally “short period”).
Huangdi, reluctant to commit himself to a definite span of time, first ignores
the question, then says it has already been mentioned in the classics (like the

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 462 Neijing Zhiyao Yigu 內經知要譯詁

Shangjing and Xiajing). Only upon being asked the third time does Huangdi
break his silence and elaborate on the discordance between pulse-pattern and
prevalent seasonal climate conditions, from which a prognosis could be made.
This “short period” is however measured in terms of the seasons, because the
disease pattern was likewise ascertained within one season. The term duan qi
is also mentioned in Lingshu Chapter 9 Zhong shi 終 始 (Beginnng and End of
Qi Flux). It derives in turn from the term guan ge 關 格 (literally, “closure and
rejection”). The idea hangs on an excessively strong pulse (four times the
normal rate) at the neck (人 迎 ren ying, “carotid artery”), a situation called
“efflux of yang” (yi yang 溢 陽). Yi yang is tantamount to rejection of the exte-
rior (wai ge 外 格). When the pulse is four times stronger than normal at the
wrist (cun kou 寸口, “radial artery”), it is called “efflux of yin” (yi yin 溢陰). Yi
yin is closure to the interior (nei guan 內 關). Now that pulses at neck and
wrist are both four times stronger than normal, this is a state of mutual
closure and rejection (guan ge 關 格); guan ge entails imminent death within a
short time (yu zhi duan qi 與之短期). Instead of elaborating on what involves
yin or yang, or what is the target of closure or repulsion, suffice it to say that
guan ge is a state of dissociation of yin from yang. In this context, yin may be
construed to mean the profile (shape) of the pulse and yang, the magnitude.
Thus when the magnitude of the pusle is no longer in agreement with the
nuance of the pulse profile, death is inevitable. Later annotators introduced a
hint of the “five elements”, saying that disease occurring in winter is actually
referring to disease of the kidney. So a patient with kidney problems who is
showing a strong pulse (bing he yu yang 病 合 於 陽) in winter, will not survive
the next spring. This interpretation is of course a comfortable one for the
adepts of “five elements” theory, but it could be resolved within the concept of
harmony between yin and yang, which is the principal argument of the school
of Leigong.

Footnotes

[1] grass and willow leaves are wilted: The interpretation of this sentence varies,
most commentators adopting the view that there is an unspoken phrase:
“when grass and willow leaves are burgeoning”. The last two words “all killed”
(jie sha 皆殺) refer to the patient, not the leaves.
[2] ultimate-yin: Zhiyin 至陰, i.e. tai-yin, the spleen.
[3] yin yang jiao: The term yin yang jiao 陰 陽 交, means literally “intercross of
yin and yang [pulse-patterns]” with their corresponding symptoms, i.e. a yin

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 Morbid Manifestations 463

pulse pattern appearing with a yang symptom, or vice versa. It was first
mentioned in Suwen Chapter 33: “A febrile patient is still feverish after
sweating, with rapid pulse undiminished by the sweating, raving and loss of
appetite; it is called yin yang intercross.”
[4] mid-autumn: It should be lian shui 溓 水 (limpid water), not lian shui 濂 水
—a typographic error by Li Zhong-zi.
[5] water freezes: Literally “stone water” (shi shui 石 水), here it means water
freezing. The same term appears in Section 8.3, where it means an oedema/
ascite hard to the touch.

[Section 8.35] Suwen Chapter 16: Essentials of Diagnosis by

Pulse-taking and Expiry of Qi

《素 問．診 要 經 終 論》曰：太 陽 之 脈，其 終 也，戴 眼、反 折、瘛 瘲、其 色

白、絕汗乃出，出則死矣。
少陽終者，耳聾、百節皆縱、目睘、絕系，絕系一日半死。其死也，
色先青，白乃死矣。
陽明終者，口目動作、善驚、妄言、色黃，其上下經盛、不仁，則終
矣。
少陰終者，面黑、齒長而垢、腹脹閉，上下不通而終矣。
太陰終者，腹脹閉、不得息、善噫、善嘔；嘔則逆，逆則面赤；不逆
則上下不通，不通則面黑、皮毛焦而終矣。
厥陰終者，中熱、嗌乾、善溺、心煩，甚者舌卷、卵上縮而終矣。

When qi expires [1] in the tai-yang [small intestine and urinary bladder]
conduits, there are [moribund signs like] vertical gaze, opisthotonos, spasm
and pallor; by the time terminal sweating [2] occurs, the moment of death
arrives.
When qi expires in the shao-yang [three burners and gall bladder]
conduits, there are [moribund signs like] loss of hearing, flaccid joints, fixed
stare, or loss of eyesight. With these signs, death will occur in a day and a half.
At the last moment, the face turns blue first, then ashen; it is the moment of
death.
When qi expires in the yang-ming [large intestine and stomach] conduits,

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 464 Neijing Zhiyao Yigu 內經知要譯詁

there are [moribund signs like] twitching of the mouth and eyes, trepidation,
raving and jaundice; by the time the [yang-ming] pulses detected in the wrist
and foot are strong but the limbs are numb, death occurs.
When qi expires in the shao-yin [heart and kidney] conduits, the face
looks dark, gums are regressing and caries accumulating [3], together with a
bloating abdomen but dysuria, the interaction between the heart and kidney
fails [4]; that is the end of life.
When qi expires in the tai-yin [lung and spleen] conduits, there are
[moribund signs like] bloating and dysuria, dyspnea, burping and vomiting.
When vomiting, qi reflux [5] renders the face red. Otherwise, without qi reflux
[6], the face turns dark, the skin and body hair look parched and death ensues.
When qi expires in the jue-yin [liver and pericardium] conduits, there are
[moribund signs like] fever deep inside the body, dry throat, polyuria,
dysphoria, and in extreme cases, retraction of the tongue and testicles, and
death ensues.

Explanatory Notes
Suwen Chapter 16 answers two questions: what are the essentials of pulse
diagnosis (zhen yao 診 要)? And what is the termination of the qi (qi expiry)
in the conduits (jing mai zhi zhong 經 脉 之 終)? To the first question, Qibo
replies that there are different disease patterns in different seasons. It was
important for the clinician to take these “essential” seasonal changes into
consideration while applying acupuncture, otherwise the disease would
change for the worse, with some characteristic symptoms. This answer is
followed by a short paragraph stressing the importance of “steering the needle
away from the zang-organs” (Ci xiong fu bi bi wu zang 刺胸腹必避五臟), plus
some fine points in needle manipulation. If the zang-organ is hit, death ensues
within a few days. (Suwen Chapter 64: “If the five zang-organs are hurt by the
needle, death is inevitable.”60) This leads to the second question, about the
termination of (i.e., qi expiry in) the twelve regular conduits. This presup-
poses that the three-sites and nine-modes pulse diagnosis are current practice
and it is possible to identity the organ affinity of each of the cun, guan and chi
sites on the left and right wrists. If pulse is not detectable in one of these

60
《素問．四時刺逆從論篇》︰「刺傷人五臟必死。」

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 Morbid Manifestations 465

organ-specific sites, the revelant organ is deemed to have expired functionally,

i.e. there is total organ failure.
It is entirely appropriate to talk about termination of organ functions in
these last sections of the last chapter of NJZY. Although the subject of death (si
bu zhi 死 不 治, “incurable disease”) has been mentioned many times in
previous sections, it has appeared repeatedly since Section 8.28. The reader
can readily appreciate that Li Zhong-zi kept doggedly returning to this subject,
carefully building up a crescendo towards the final moment, i.e. when a pulse
is no longer detectable (經終 jing zhong). To recapitulate:

Sect. 8.28—certain boils (mastoiditis, gangrene) are incurable.

Sect. 8.29—boils presenting five kinds of unfavourable prognosis (wu ni
五逆).
Sect. 8.30—boils developing over five critical locations inevitably lead to
death.
Sect. 8.31—generally speaking, there are two groups of unfavourable
prognoses, each containing five kinds, presenting critical symptoms.
Sect. 8.32—transmutation of disease following the inhibitory mode of
“five elements” interaction can be interpreted as multiple organ dysfunction
syndrome, and the moment of death during the day is predictable.
Sect. 8.33—when qi expires in the five yin (zang-organ) and six yang
(fu-organ) conduits, it can be interpreted as organ failure that entails death
within days.
Sect. 8.34—when pulse shape does not agree with magnitude, imminent
death occurs within a limited time span, measured in seasons.
Sect. 8.35—presentation of critical moribund signs when organs have
failed and pulses pertinent to these organs are no longer detectable.

Qin Bo-wei rightly pointed out that many of these critical situations are
not so fatal now as at the time of Neijing. Today, if medical support is available
at these moments that Neijing presumes are the last, death may not be
inevitable.

Footnotes

[1] qi expires: Literally, “end of the conduit function”, meaning total failure of a
certain organ.
[2] terminal sweating: See above 8-33-5.
[3] gums regressing etc.: See above 8-33-4.

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 466 Neijing Zhiyao Yigu 內經知要譯詁

[4] interaction between heart and kidney fails: Literally, “the upper part of the
body is not communicating with the lower”. Li Zhong-zi interpreted this as
the loss of interaction between the heart and the kidney (xin shen bu jiao 心
腎 不 交), a relationship which is of paramount importance in Chinese
medicine.
[5] qi reflux: This is actually referring to reverse peristalsis, where flow of qi
indicates gut movement.
[6] qi reflux: Again, upper not communicating with lower, but here this refers to
the smooth flux of qi in the direction of the conduit sequence.

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