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Three Reversals (three critical signs): Coughing accompanied by urinary incontinence indicates that both Qi and Blood are depleted. Emaciation of the body and flesh indicates that Spleen Qi has been severed. A rapid and agitated pulse indicates the appearance of the Zang-organ Pulse (Zhen Zang Mai, a sign of organ failure).

Hematemesis (vomiting blood), chest fullness radiating to the back, with a small and rapid pulse, constitutes the Four Reversals. Hematemesis progressing to chest fullness and a curved back indicates the disease has reached its extreme. A small pulse belongs to Qi failure, and a rapid pulse belongs to Blood failure.

Coughing, vomiting, abdominal distension, and diarrhea with undigested food (Sun Xie), with an imperceptible pulse, constitutes the Five Reversals. The upper manifestation is coughing and vomiting; the middle manifestation is abdominal fullness; the lower manifestation is Sun Xie. When the San Jiao (Triple Burner) is diseased throughout and all six pulses are absent, death occurs within less than one shichen (two-hour period). "Less than one shichen" means unable to last a full day.

The *Biao Ben Bing Zhuan Lun* (Treatise on Root and Branch Disease Transmission) states: In the transmission of disease, Heart disease first presents as heart pain. After one day, it transmits to the Lung, causing coughing (Heart fire overacts on Lung metal). After three days, there is distending pain in the hypochondrium (Lung metal transmits to Liver wood, where metal overacts on wood, causing hypochondriac distending pain). After five days, there is obstruction and inability to pass stool or urine, along with body pain and heaviness (Liver wood transmits to Spleen earth, where wood overacts on earth; Spleen disease causes obstruction. As the Spleen governs muscles, the body feels heavy and painful). If after another three days the disease does not resolve, death ensues (if unresolved after three more days, the Spleen transmits to the Kidney, where earth overacts on water; damage to all five Zang organs leads to death). Death occurs at midnight in winter or midday in summer. Midnight in winter is when Water Qi is at its peak; midday in summer is when Fire Qi is at its peak. Since Fire fears Water, death in winter occurs at midnight. Yang pathogenic factors reaching extreme excess lead to death at midday in summer. Generally, both extreme deficiency and extreme excess lead to death.

Lung disease manifests as wheezing and coughing (the Lung governs respiration, hence wheezing and coughing). After three days, there is distending pain in the hypochondrium (transmission to the Liver after three days, metal overacting on wood). After one day, the body feels heavy and painful (transmission to the Spleen after one day, wood overacting on earth). After five days, abdominal distension occurs (transmission to the Stomach after five days, from Zang to Fu). If unresolved after ten days, death ensues (if unresolved after ten days, the Stomach transmits to the Kidney; the number of the Five Elements reaches its limit, leading to death). Death occurs at sunset in winter or sunrise in summer (these are the Mao and You hours, associated with the transformation of Dry Metal).

Liver disease manifests as dizziness and vertigo, and distending fullness in the hypochondrium (the Liver opens into the eyes, and its meridians distribute through the hypochondrium and ribs). After three days, the body feels heavy and painful (transmission to the Spleen). After five days, abdominal distension occurs (Spleen transmits to Stomach). After three days, there is pain in the lower abdomen, lumbar spine, and calves (transmission to the Kidney). If unresolved after three days, death ensues (if unresolved after three days, the Kidney transmits to the Heart, leading to death). Death occurs at sunset in winter or during breakfast time in summer (also the Mao and You hours, governed by Dry Metal, which is feared by Wood).

Spleen disease manifests as body pain and heaviness (the Spleen governs muscles). After one day, abdominal distension occurs (Spleen transmits to Stomach). After two days, there is pain in the lower abdomen, lumbar spine, and calves (Stomach transmits to Kidney). After three days, there is pain in the back muscles and closed urination (transmission to the Lumbar Bladder after three days). If unresolved after ten days, death ensues (if unresolved after ten days, it transmits to the Heart, leading to death). Death occurs at the Ding Hai hour in winter or at dinner time in summer (these are the Si and Hai hours, governing the transformation of Wind Wood, which the Spleen fears).

Kidney disease manifests as pain in the lower abdomen, lumbar spine, and calves (the Kidney governs the lower part, and its meridians run through the lower abdomen, lumbar spine, and between the tibiae). After three days, there is pain in the back muscles and closed urination (transmission to the Lumbar Bladder). After three days, abdominal distension occurs (transmission to the Small Intestine). After three days, there is distending pain in both hypochondria (transmission upward to the Heart after three days; the regular channel of the Pericardium emerges from the chest, enters the thorax via the Yuan Ye point three cun below the armpit, causing hypochondriac distending pain). If unresolved after three days, death ensues (due to injury by Lung Metal in summer). Death occurs at early morning in winter or late afternoon in summer (these are the Chen and Xu hours. Earth is prosperous in the four seasons and is feared by Water, so Kidney disease perishes here).

Stomach disease manifests as abdominal distension and fullness. After five days, there is pain in the lower abdomen, lumbar spine, and calves (transmission to the Kidney). After three days, there is pain in the back muscles and closed urination (transmission to the Lumbar Bladder). After five days, the body feels heavy and painful (The *Bing Zhuan Lun* states transmission to the Heart after five days; the mention of body heaviness here may be an error). If unresolved after six days, death ensues (the Heart transmits to the Lung). Death occurs after midnight in winter or during the Wei hour in summer (the Chou and Wei hours govern the transformation of Damp Earth; Qi connects to the Stomach, and loss of regulation leads to death).

Bladder disease manifests as closed urination. After five days, there is lower abdominal distension, lumbar spine pain, and calf pain (transmission to the Kidney). After one day, abdominal distension occurs (transmission to the Small Intestine). After one day, body pain occurs (transmission to the Heart, from Fu to Zang. The Heart governs blood vessels, thus causing body pain). If unresolved after two days, death ensues (if Heart disease does not resolve, it must transmit to Metal, leading to death). Death occurs at cockcrow in winter or in the late afternoon in summer (Chou and Wei hours; Earth controls Water, so the Bladder fears this. The timing of death varies depending on the depth of transmission and the critical nature of the organs. Sequential transmission guarantees death; skipping one or two, or three or four organs, allows for treatment).

The *Ling Shu · Jing Mai* chapter states: When the Qi of the Hand-Taiyin (Lung) meridian ceases, the skin and hair become dry and brittle. The Taiyin meridian circulates Qi to nourish the skin and hair; thus, if Qi fails to nourish, the skin and hair become dry. When skin and hair are dry, body fluids leave the joints; when body fluids leave the joints, the nails become withered and fine hairs break. Breaking of fine hairs indicates that hair dies first; the condition worsens on Bing days and death occurs on Ding days, because Fire overacts on Metal (the Lung belongs to Metal, governs Qi, and is the mother of Water; thus, when its Qi ceases, fluids are lost, nails wither, and hairs break). When the Qi of the Hand-Shaoyin (Heart) meridian ceases, the vessels become blocked. When vessels are blocked, blood does not flow. When blood does not flow, the hair loses luster. Thus, when the face becomes black like lacquered charcoal, it indicates that blood dies first; the condition worsens on Ren days and death occurs on Gui days, because Water overacts on Fire (the Heart governs blood vessels; thus, when Heart Qi ceases, blood dies first. Symptoms include lack of luster in hair and a black face, indicating the manifestation of Water transformation). When the Qi of the Foot-Taiyin (Spleen) meridian ceases, the vessels fail to nourish the muscles. The lips and tongue are the root of the muscles; when vessels fail to nourish, the muscles become soft. When muscles are soft, the tongue atrophies and the philtrum becomes full. When the philtrum is full, the lips invert. Lip inversion indicates that flesh dies first; the condition worsens on Jia days and death occurs on Yi days, because Wood overacts on Earth (the Spleen governs muscles; thus, when Spleen Qi ceases, flesh dies first. Symptoms include tongue atrophy, full philtrum, and inverted lips). When the Qi of the Foot-Shaoyin (Kidney) meridian ceases, the bones become withered. The Shaoyin meridian is the Winter pulse, hidden and moistening the bone marrow. Thus, when bones are not moistened, flesh cannot adhere. When flesh and bone do not adhere, the flesh becomes soft and recedes. Consequently, the teeth appear long and dirty, and the hair lacks luster. Lack of luster in hair indicates that bone dies first; the condition worsens on Wu days and death occurs on Ji days, because Earth overacts on Water (the Kidney belongs to Water, hence the Winter pulse. The Kidney governs bones; thus, when Kidney Qi ceases, bone dies first. Symptoms include non-adherence of flesh and bone, long and dirty teeth, withered essence, and lusterless hair). When the Qi of the Foot-Jueyin (Liver) meridian ceases, the sinews cease. The Jueyin meridian is the Liver meridian; the Liver is the convergence of sinews. Sinews gather at the genitalia and connect to the base of the tongue. Thus, when vessels fail to nourish, sinews become tense. Tense sinews pull the tongue and testicles, causing cyanosis of the lips, curling of the tongue, and retraction of the testicles. This indicates that sinews die first; the condition worsens on Geng days and death occurs on Xin days, because Metal overacts on Wood (when the Liver ceases, sinews die first. Symptoms include cyanotic lips, curled tongue, and retracted testicles/scrotum). When the Yin Qi of all five Zang organs ceases, the eye connections rotate, causing dizziness. Dizziness indicates that the Shen (Spirit/Mind) dies first. If the Shen dies first, death occurs in one and a half days (the essence of the five Zang organs ascends to the eyes; thus, when Yin Qi of the five Zang organs ceases, the eyes rotate and dizzy. The Shen resides in the Kidney; when true Yin is exhausted, death occurs within a day and a half). When the Yang Qi of the six Yang meridians ceases, Yin and Yang separate. Separation causes the pores to open and sweat to leak out, resulting in "Jue Han" (desperate sweat). Thus, if observed in the morning, death comes in the evening; if observed in the evening, death comes in the morning (Yang Qi cannot defend the exterior and secure the interior, leading to sweat leakage. Jue Han appears as beads of sweat that coagulate and do not flow, or as continuous panting with sweat pouring like a wash).

The *Yin Yang Lei Lun* states: For diseases occurring in the three winter months, if the disease combines with Yang (manifests as Yang syndrome), by the first month of spring, the pulse will show signs of death, and death will occur after spring passes. During the three winter months, Yin is abundant. If Yang disease appears, when Yang Qi begins to stir in early spring, the pulse will inevitably show death signs. "After spring passes" refers to entering summer; Yang disease should coincide with abundant Yang, leading to extreme hyperactivity and inevitable death. For diseases in the three winter months, if the principles indicate that life is already exhausted (color, pulse, form, and symptoms show no sign of vitality), death will occur when grass turns green and willow leaves appear (signifying the arrival of spring). If both Yin and Yang pulses are absent in spring, death will occur in Meng Chun (early spring). For diseases starting in winter, if both Yin and Yang pulses are absent upon entering spring, death will occur in Meng Chun, without waiting for Zhong or Ji Chun. Absent Yin pulse means the pulse form is not felt; absent Yang pulse means the pulse form is minute, or stops above the Guan position (Yang absence), or stops below the Guan position (Yin absence). For diseases in the three spring months, termed "Yang Sha" (Sha sounds like 'sai', meaning Yang Qi decline), if both Yin and Yang are absent, death will occur when grass dries up. In spring, Wood is prosperous; if both Yin and Yang are absent, death occurs in autumn when grass dries, as Metal overacts on Wood. For diseases in the three summer months, the Zhi Yin (extreme Yin, referring to the Spleen) will not survive more than ten days. The *Jin Gui Zhen Yan Lun* states the Spleen is the Zhi Yin within Yin, the root of the five Zang and six Fu organs. When the Zhi Yin organ faces the time of extreme Yang, if a fatal syndrome occurs, death occurs within ten days. If Yin and Yang intersect (Yin pulse appearing in Yang positions, causing Yang Qi to lose control; Yang pulse appearing in Yin positions, causing Yin Qi to lose control), death will occur during the period of flowing water in mid-autumn. In summer, seeing this reversal means life cannot be preserved during the mid-autumn water phase. For diseases in the three autumn months, if the Qi of the Three Yang meridians arises simultaneously, the disease may heal spontaneously without treatment. In autumn, Yang Qi gradually declines and Yin Qi gradually grows. Although the Three Yang diseases arise, Yang cannot overcome Yin, so it heals itself. If Yin and Yang are mixed (Yin-Yang Jiao He), the patient cannot sit while standing nor stand while sitting (indicating Yin-Yang combined disease and difficulty in flexion/extension). If the Three Yin meridians alone are excessive (text says "Three Yang" but should be "Three Yin"), death will occur during the time of stone water (freezing). If Yin disease coincides with Yin abundance, solitary Yin cannot generate life. Just as ice hardens like stone and cannot revive, this corresponds to the previous statement about Three Yang healing spontaneously. The following text mentions "Two Yin," confirming this refers to Three Yin. If the Two Yin meridians alone are excessive, death will occur during the time of abundant water (spring rain). Two Yin disease is slower than Three Yin disease, so death occurs in Zheng Yue (first lunar month) during the rain.

The *Zhen Yao Jing Zhong Lun* states: When the Taiyang meridian ends, the eyes stare upward without rotation, the body arches backward (opisthotonos), there are spasms, the complexion is white, and desperate sweat appears; once the sweat appears, death follows. "Dai Yan" means the eyeballs look upward and cannot turn. "Fan Zhe" means the waist and spine arch backward. Spasm of tight sinews is called "Yuan"; flaccidity is called "Xian." Desperate sweat resembles oil. The Foot-Taiyang meridian originates at the inner canthus, crosses the forehead, meets at the vertex, enters the brain, descends the neck, runs alongside the spine to the loins, and reaches the little toe. The Hand-Taiyang meridian originates at the tip of the little finger, runs up the arm to the shoulder, and its branch runs up the neck to the cheek, ending at the outer canthus. Hence the symptoms. Taiyang is the exterior of the Three Yang, thus governing white complexion and sweating. When the Shaoyang meridian ends, there is deafness, flaccidity of all joints, and staring eyes with severed connections. Death occurs in one and a half days. The complexion turns blue-white before death. Both Hand and Foot Shaoyang meridians enter the ear and reach the outer canthus, causing deafness and staring. "Shi" means staring straight like fear. Due to the severance of Shaoyang connections, rotation is impossible. The Gallbladder corresponds to sinews, hence joint flaccidity. Wood color is blue, Metal color is white; Metal and Wood attacking each other cause blue-white colors to appear first. When the Yangming meridian ends, there is twitching of the mouth and eyes, frequent fright, delirious speech, yellow complexion, and excessive pulsation in the upper and lower channels. Numbness marks the end. Both Hand and Foot Yangming meridians flank the mouth and enter the eyes, causing twitching. Fright at the sound of wood indicates Yangming's tendency toward fright. Scolding without recognizing relatives indicates delirious speech. Yellow is the external manifestation of Earth color. Excessive pulsation in head, neck, hands, and feet indicates agitation of Yangming meridians and failure of the Stomach. Numbness (lack of pain/itch sensation) indicates muscle failure. When the Shaoyin meridian ends, the face is black, teeth appear long and dirty, abdominal distension and closure occur, and upper/lower blockage leads to death. Shaoyin Qi cessation causes blood failure; Foot-Shaoyin cessation causes coal-black complexion. The Kidney governs bones; teeth are the surplus of bones, hence loose and dirty. Hand-Shaoyin meridians descend through the diaphragm to connect with the Small Intestine; Foot-Shaoyin meridians connect with the Bladder, pierce the Liver and Diaphragm, causing abdominal distension/closure and upper/lower blockage, indicating Heart-Kidney non-interaction. When the Taiyin meridian ends, there is abdominal distension/closure preventing breathing, frequent belching and vomiting. Vomiting causes Qi rebellion, turning the face red. If Qi does not rebel, upper/lower blockage persists, turning the face black and drying the skin/hair, leading to death. Foot-Taiyin meridians enter the abdomen and belong to the Spleen, causing distension. Hand-Taiyin meridians ascend through the diaphragm to belong to the Lung, governing respiration, causing breathlessness. Distension prevents breathing, leading to belching/vomiting. Qi rebelling upward causes red face. If not rebelling, Spleen Earth Qi does not ascend, and Lung Heaven Qi does not descend. Upper/lower blockage signifies non-interaction of Heaven and Earth. Spleen failure fails to control Water, causing black face. Lung failure fails to govern Qi, causing dry skin/hair. When the Jueyin meridian ends, there is internal heat, dry throat, frequent urination, and irritability. Severe cases involve tongue curling and testicular retraction, leading to death. Hand-Jueyin Pericardium meridian originates in the chest, belongs to the Pericardium, descends through the diaphragm, and connects with the San Jiao. Foot-Jueyin Liver meridian follows the throat, enters the nasopharynx, and descends through the groin to the genitalia. Hence the symptoms. The tongue is the organ of the Heart; the Liver is the convergence of sinews; sinews gather at the genitalia and connect to the tongue base. Hence severe cases involve tongue curling and testicular retraction.

My Commentary: Human illness is like a tree infested with borers. The manifestations of disease (Bing Neng) are like the location of the borer. Not knowing where the borer is, one chops the entire tree; the borer may not be removed, but the tree withers first. Not knowing where the disease lies, one treats broadly; the disease may not go away, but life is exhausted first. Therefore, even if the manifestations of disease are profound and complex, they should be as clear as rows of eyebrows. I still fear making mistakes. To attempt medication before the disease manifestations are evident—I cannot bear to speak of such practices. Physicians of the world boast of family secrets; contemporary physicians boast of their experience with many cases. Arrogantly catering to vulgarity, they do not realize their error. When asked about the origins of the Three Causes (Internal, External, Non-internal/External) and their transformations, they dismiss it as superfluous. This is like wanting to know the location of the borer but only thinking of chopping the tree to claim credit. Alas! How tragic.