Library

The *Classic of Difficult Issues* (Jing Yue) states: The stomach, large intestine, small intestine, sanjiao (Triple Burner), and bladder are five organs generated by heavenly qi (yang qi). Their nature resembles heaven; therefore, their function is "to drain and not to store" (transmitting and excreting food residues without storing essence). The nine orifices are governed by the five zang organs, but they must rely on stomach qi to function smoothly. If stomach qi is deficient, the mouth, eyes, ears, and nose will all suffer diseases. Fever, headache, tinnitus, dizziness, and heaviness of the body occur because heat pathogen damages the primordial qi.

Yang qi most detests excessive labor; complying with it consolidates the righteous qi. Only when the spleen and stomach are harmonious can grain qi ascend, mimicking the spring and summer growing mandate, leading to longevity. If the spleen and stomach are disharmonious, grain qi flows downward, mimicking the autumn and winter storage mandate, leading to premature death. The functions of all eleven organs depend on the ascending of gallbladder qi. When gallbladder qi ascends, the other organs follow; if it does not ascend, it leads to undigested diarrhea and borborygmus. Heaven provides humans with the five qi (wind, summer heat, fire, dampness, dryness), and earth provides the five flavors (sour, bitter, sweet, pungent, salty). The flavors are stored in the stomach to nourish the qi of the five zang organs. If the qi mechanism is disordered, how can the form exist? Thus, it is evident that various diseases arise from the spleen and stomach.

Let us discuss the scenario of excess and deficiency: If the yuan qi (original qi) in the stomach is vigorous, one can eat without injury and feel no hunger past meal times. If both spleen and stomach are vigorous, one eats well and becomes plump. If both are deficient, one cannot eat well and becomes thin. Or, one may eat little yet be obese, though unable to lift the limbs due to spleen excess and pathogenic abundance. Some who eat well yet become thin have latent fire pathogen in the qi level of the stomach, allowing them to eat, but spleen deficiency causes muscle wasting. Therefore, facial heat indicates stomach disease; stomach disease means the spleen cannot receive nutrients, so the spleen also becomes diseased.

Spleen disease causes qi to flow downward and overcome the kidney (Earth overcomes Water), resulting in empty marrow, weakness, and inability to stand. This is an accumulation of yin, yin excess, and yang deficiency. Such conditions should be treated with sweating methods to heal, while purgative methods would be fatal. However, this is not true sweating, but rather using acrid-sweet medicines to moisten stomach qi, causing it to ascend and float, thereby strengthening the growing qi to assist yang.

Stomach disease presents with a slow pulse; spleen disease presents with a delayed pulse. If fire pathogen attacks the Earth position, the pulse is surging and slow. There are also symptoms of body heat and mental discomfort, indicating weak yang qi. Medication should be administered according to the principles of ascending, descending, floating, and sinking for tonification and sedation (see later sections on medicinal properties). Generally, failing to understand the principles of ascending, descending, floating, and sinking means any recovery is merely fortuitous.

In the past, a patient with long-standing spleen and stomach decline lost half of their vision and hearing. During prolonged rainy and cold weather, they suffered from diarrhea, heavy body weight, joint pain, loose stools, and urinary retention. Using diaphoretic agents might temporarily stop the illness, but further descending actions would increase yin and doubly exhaust yang, shortening the spirit. Therefore, ascending-yang herbs must be used: Qiang Huo (Notopterygii Rhizoma et Radix), Du Huo (Angelicae Pubescentis Radix), Chai Hu (Bupleuri Radix), and Sheng Ma (Cimicifugae Rhizoma), each 1 qian; Fang Feng (Saposhnikoviae Radix) and Gan Cao (Glycyrrhizae Radix), each 0.5 qian. Decocted and taken warm, the ascending yang qi dispels the disease.

Another case involves spleen and stomach deficiency with recurrent eye disorders, jaundice of the whole body, face, and eyes, yellow or white urine, irregular bowel movements, poor appetite, shortness of breath, and lethargy. A physician administered Xie Gan San (Drain Liver Powder) several times, worsening the condition. Coinciding with summer rains and pre-existing jaundice, the condition aggravated. Thus, Qing Shen Yi Qi Tang (Clear Spirit and Boost Qi Decoction) was prescribed. Fu Ling (Poria), Sheng Ma (Cimicifugae Rhizoma), each 2 fen; Ze Xie (Alismatis Rhizoma), Cang Zhu (Atractylodis Rhizoma), Fang Feng (Saposhnikoviae Radix), each 3 fen; Sheng Jiang (Zingiberis Rhizoma Recens), 4 fen. These herbs move through meridians to remove damp-heat without staying central, thus not draining the righteous qi of the lungs, stomach, and spleen. Qing Pi (Citri Reticulatae Pericarpium Viride), 1 fen; Sheng Gan Cao (Raw Glycyrrhizae Radix), Bai Shao (Paeoniae Radix Alba), Bai Zhu (Atractylodis Macrocephalae Rhizoma), each 2 fen; Ren Shen (Ginseng Radix et Rhizoma), 5 fen. These herbs stay central without moving through meridians, avoiding nourishing pathogens in the meridians, while tonifying the yuan qi of the zang organs. Huang Bo (Phellodendri Cortex), 1 fen; Mai Men Dong (Ophiopogonis Radix), Ren Shen (Ginseng Radix et Rhizoma), each 2 fen; Wu Wei Zi (Schisandrae Fructus), 3 fen. These remove seasonal floating heat and damp-heat. Decocted and taken warm on an empty stomach, the patient recovered. These two cases serve as evidence.

If the pulse is slow, with symptoms of lethargy, desire to lie down, flaccidity of limbs, or diarrhea, this is dampness excess; use Ping Wei San (Calm the Stomach Powder). If the pulse is wiry, with weak qi, spontaneous sweating, heat in the four limbs, diarrhea, and brittle hair loss, treat with Huang Qi Jian Zhong Tang (Astragalus Decoction for Building the Middle).

Using Jian Zhong Tang for a slow pulse or Ping Wei San for a wiry pulse would be erroneous.

For deficient pulse and weak blood, select one or two herbs from Si Wu Tang (Four Substances Decoction). For weak pulse and shortness of breath, select one or two herbs from Si Jun Zi Tang (Four Gentlemen Decoction). For red-yellow urine, modify Wu Ling San (Five-Ingredient Powder with Poria) by removing Gui Zhi (Cinnamomi Ramulus), selecting one or two herbs, and adding them to the primary formula. If feeling stifled (not abdominal distension, but scattered qi failing to gather), add Bai Shao (Paeoniae Radix Alba) to astringe. Using Bai Shao in the middle jiao raises spleen yang, preventing liver-gallbladder pathogens from invading. If there is abdominal tightness or cramping, remove Bai Shao and other astringent-sour herbs. For abdominal pain, add Gan Cao (Glycyrrhizae Radix) and Bai Shao (Paeoniae Radix Alba). Sweetness corresponds to Ji Earth; sourness corresponds to Jia Wood; Jia-Ji transform into Earth, which is Zhang Zhongjing's profound method.

Wu Ling San (Five-Ingredient Powder with Poria) treats thirst with difficult urination; do not use Gui Zhi (Cinnamomi Ramulus) if there is no aversion to cold. If there is no thirst but normal urination, accompanied by hallucinations, it is a blood stasis pattern; use Chao Huang Bo (Processed Phellodendri Cortex) and Zhi Mu (Anemarrhenae Rhizoma). For heart heat causing orifice obstruction, use Dao Chi San (Directing Red Powder). For tenesmus with inability to pass stool, it is blood deficiency; blood deficiency causes interior urgency. For eye pain due to weak blood and qi, add Dang Gui Shen (Angelicae Sinensis Radix Radix), regulating the spleen and stomach. Adjustments among these five formulas are effective, though complete restoration may not always be achieved.

Internal injury is most severe when spleen and stomach collapse, followed by alcohol and sexual excess. In deficiency patterns, those with strong spleen and stomach recover easily; those with weak spleen and stomach only partially recover. Farmers and woodcutters work hard all year without internal injury because their spleen and stomach are strong, capable of ingestion and transformation.

Subsequent recurrences are often due to pathogens in the Du, Ren, and Chong vessels (yin fire) caused by weak stomach qi. Treatment must be adjusted according to the syndrome. Adhering rigidly to one prescription contradicts the *Su Wen*. The Classics state: "Arrival without arrival" is insufficiency; the overcoming element acts recklessly, the generated element suffers disease, and the overcoming-by element attacks. "Arrival without arrival" refers to deficiency evil coming from behind; Heart and Small Intestine attack Spleen and Stomach. The pulse is floating, large, and wiry. Symptoms include irritability of the four limbs, bitter taste, dry tongue and throat. Since Heart governs Fire and Small Intestine governs Heat, fire-heat attacking Earth combines with damp-heat, causing irritability. The four limbs are the extremities of Spleen and Stomach; fire attack causes heat. Damage from diet and labor weakens Spleen and Stomach, affecting blood generation and fluid transport, causing dry mouth and throat.

The Spirit of the Heart is another name for True Qi. Now, the Seven Spirits have left the form, leaving only Fire in the pulse. To treat this well, one must ensure the Heart has no stagnation. Joyful events, warm weather, tasty food, or pleasant sights can resolve the illness because the Yuan Qi in the Stomach is able to expand.

Avoid Wu Ling San (which depletes fluids). Instead, tonify the Mother organ in the Heart and Small Intestern to strengthen the root of Spleen and Stomach. Use Acrid-Sweet-Warm (Bai Zhu/Atractylodis Macrocephalae Rhizoma) as Sovereign, Bitter-Cold (Huang Lian/Coptidis Rhizoma) as Envoy, and Sour (Bai Shao/Paeoniae Radix Alba) as Minister/Assistant. Because the Heart dislikes laxity, urgently use sour to astringe (treating Heart Fire's failure to generate Earth, termed insufficiency). When Fire is strong, Lung Metal suffers; if Metal is weak, use sour to tonify. Use Acrid-Sweet-Warm and Acrid-Sweet-Cold (Huang Qin/Scutellariae Radix, Huang Lian/Coptidis Rhizoma, Zhi Mu/Anemarrhenae Rhizoma, Huang Bo/Phellodendri Cortex, Sheng Di Rehmanniae Radix) to drain excessive Heart Fire in the Spleen-Stomach, treating the root.

Fire excess attacking Spleen is also insufficiency. Heart Fire is Yin Fire, originating in the Lower Jiao, connected to the Heart. The Heart does not issue commands; Ministerial Fire replaces it. Ministerial Fire is the fire of the Pericardium in the Lower Jiao, a thief of Yuan Qi. Fire and Yuan Qi cannot coexist; one wins, the other loses. A surging pulse with irritability, thirst, and asthma indicates strong fire and weak qi. Li Dongyuan's theory of Yin Fire elaborates on the *Su Wen*.

"Overcoming element acting recklessly" means strong Heart Fire makes the Mother (Liver Wood) full. Wood excess carries fire recklessly, first affecting Spleen and Stomach, causing heavy body and wandering hypochondriac pain. Damp-heat struggles, wind-heat stagnates, attaching to form. Anger indicates wind-heat sinking. Eye cataracts relate to Liver Blood and opening to the eyes. Hallucinations and dreams of the dead indicate wild mind. Alternating chills and fever, limb fullness, difficult urination, and spasms are all Liver Wood-Fire excess pathogens. Atrophy, bi-syndrome, jue-syndrome, stroke, malignant sores, kidney atrophy, upper heat/lower cold—all result from wind-heat failing to ascend and water-fire being trapped in form.

Use Chai Hu (Bupleuri Radix) as Sovereign; Fang Feng (Saposhnikoviae Radix), Chi Shao (Paeoniae Radix Rubra), Gan Cao (Glycyrrhizae Radix), Gui Zhi (Cinnamomi Ramulus) as Ministers; Zhu Ling (Polyporus), Ze Xie (Alismatis Rhizoma), Fu Ling (Poria), Cang Zhu (Atractylodis Rhizoma), Zhi Mu (Anemarrhenae Rhizoma), Huang Bo (Phellodendri Cortex), Hua Shi (Talcum), Shi Gao (Gypsum Fibrosum), Qiang Huo (Notopterygii Rhizoma et Radix), Du Huo (Angelicae Pubescentis Radix), Chuan Xiong (Ligustici Chuanxiong Rhizoma), Xi Xin (Asari Radix et Rhizoma), Man Jing Zi (Vittariae Fructus) as Envoys; Sheng Ma (Cimicifugae Rhizoma) as Envoy. The Classics state: Only Yangming and Jueyin do not follow the root/surface but follow the middle. "Middle" implies indeterminacy, not location. Jueyin is the leader of the twelve meridians, governing yin-yang generation; Foot-Yangming is the sea of the twelve meridians, managing qi-blood. All meridians rely on them. When Yangming/Jueyin combine with other meridions, adjust based on the middle qi. This emphasizes that spleen-stomach diseases cannot be generalized; all diseases arise from spleen-stomach. A slight error brings disaster.

In late summer, when the dominant qi is weak and guest qi is strong, prescribe accordingly. Add seasonal herbs. For late summer, tonify spleen-stomach and drain yin fire; Sheng Yang Tang (Raise Yang Decoction) is appropriate. This method aims to raise and float yang qi. Strictly avoid diuretic and yin-nourishing substances. Occasionally, Huang Bo and Zhi Mu are used opportunistically due to盛 (excess) in Du, Ren, and Chong vessels.

"Generated element suffering disease" occurs when weak Earth fails to generate Metal, instead suffering from Fire/Water pathogens, damaging clear-pure qi. Chest fullness, shortness of breath, low spirit, lethargy, and sadness indicate insufficient yang and excess yin. Cough and chills/fever indicate damp-heat invading internally.

Spleen failing to transform leads to phlegm, causing cough, asthma, and vertigo. Treat with Ren Shen (Ginseng Radix et Rhizoma) as Sovereign; Bai Zhu (Atractylodis Macrocephalae Rhizoma), Bai Shao (Paeoniae Radix Alba) as Assistants; Chen Pi (Citri Reticulatae Pericarpium), Qing Pi (Citri Reticulatae Pericarpium Viride) to break stagnation; Sang Bai Pi (Mori Cortex), Gan Cao (Glycyrrhizae Radix), Mu Xiang (Aucklandiae Radix), Bing Lang (Arecae Semen), Wu Wei Zi (Schisandrae Fructus) as Assistants; Gui Zhi (Cinnamomi Ramulus), Jie Geng (Platycodonis Radix) as Guides.

"Overcoming-by element attacking" refers to Water attacking Wood recklessly, then insulting Earth. Kidney entering Heart causes sweat; entering Liver causes tears; entering Spleen causes saliva; entering Lung causes phlegm, cough, mucus, sneezing, nasal discharge; self-entry causes polyuria and aversion to cold.

Treat with Gan Jiang (Zingiberis Radix) as Sovereign; Bai Zhu (Atractylodis Macrocephalae Rhizoma), Fu Zi (Aconiti Lateralis Radix Preparata), Rou Gui (Cinnamomi Cortex) as Ministers; Fu Ling (Poria), Zhu Ling (Polyporus), Ze Xie (Alismatis Rhizoma) as Assistants/Envoys.

Another view: Excess lower-earth overcomes Water, causing盛 in Du, Ren, Chong vessels. Fire boils water, which attacks Spleen-Lung, causing sputum. Downward flow causes genital sweat, cold external kidneys, inability to bear weight, back pain. Water following Wood rises causing dry eyes, discharge, cold tears. This is Lung Metal deficiency and lack of restraint. Spleen-Stomach insufficiency leads to blood disease, blocking the nine orifices. All yang qi roots in yin blood. Yin receiving fire becomes excess, attacking yang, blocking yang pathways, preventing rising qi. Yang qi moves through hollow orifices; yin qi attaches to solid forms. Like yin attaching to earth and yang rising to heaven, each stays in its place. Current prescriptions use Acrid-Sweet-Warm and Bitter-Cold together. Wine serves as envoy to guide bitter-cold herbs to the top and then to Kidney/Liver. This is the way of ascending/descending/floating/sinking, moving from even to odd, odd to even.

Yang is odd, Yin is even. Drain yin fire with wind herbs; raise yang to nourish Liver/Gallbladder use, allowing yang to rise from yin. Finally, use Acrid-Sweet-Warm to anchor the rising herbs, preventing dispersion in yang, directing them to the nine orifices.

Ascending/Descending/Floating/Sinking theory: Heaven generates yin with yang; Earth kills/stores yin with yang. Heaven qi peaks at Yin hour (leading). Spring begins with Shaoyang qi rising from springs, leading yin up, cracking seeds. Summer heat peaks, plants flourish—Heaven generates yin with yang. First half of year, Heaven qi dominates, focusing on ascending/floating. Earth qi peaks at Shen hour. Autumn Taiyin qi expands from heaven to earth, things perish. Winter Shaoyin qi hides in springs, ice cracks—Earth kills/stores yin with yang. Second half of year, Earth qi dominates, focusing on descending/sinking.

Spring warmth, Summer heat, Autumn coolness, Winter cold are the sequence of righteous qi. Ascend then descend, descend then ascend, like a circle, transforming all things. Hence, "starting correctly ensures no error." Human breathing and qi movement mirror heaven and earth. Food enters stomach, qi goes to Spleen-Lung, ascends via Spring-Summer mandate to nourish the body (clear yang as heaven); descends to Bladder via Autumn-Winter mandate to transmit waste (turbid yin as earth).

Damaging spleen-stomach causes true qi to sink or leak, unable to rise, creating autumn/winter without spring/summer, giving rise to all diseases. Long ascent without descent also causes disease. Seeking here clarifies the meaning of "starting correctly."

The Classics state: Food enters stomach, disperses essence to Liver, floods sinews. Food enters stomach, turbid qi returns to Heart, floods vessels. Vessel qi flows through meridians, meridian qi returns to Lung. Lung faces all vessels, transmits essence to skin/hair. Hair-vessel essence combines, moves qi to fu organs. Diet enters stomach, first follows yang dao, raising and floating. Floating scatters yang in skin/hair; Rising reaches head, opening nine orifices. Irregular diet damages stomach qi, failing to transform, disperse to Liver, return to Heart, overflow Lung. Eating causes drowsiness; lying down allows food to settle, qi temporarily relaxes. This shows failure of ascending qi.

The Classics state: Drink enters stomach, overflows essence, transports up to Spleen. Spleen disperses essence, returns up to Lung. Patient drinks, feels urge to urinate below navel. Essence fails to transport to Spleen, return to Lung. Heart fire attacks upward, causing dry mouth/throat. This is yin excess, easily understood. Moreover, spleen-stomach disease presents with pulsation at the navel, firm and painful upon pressure. Presence indicates spleen-stomach deficiency; absence indicates otherwise. This aids differentiation.