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[Scriptural Interpretation]
Diseases of the three Yang meridians manifest with aversion to cold and fever; their pathogenic transmission can result in hernia (Shan). ○ The pathological transmission from the Spleen to the Kidney is named Shan-Jia (Hernia Mass). ○ When the Ren Mai (Conception Vessel) is diseased, men develop seven types of internal hernia. ○ When the Du Mai (Governing Vessel) is diseased, Qi rushes upward from the lower abdomen to the heart causing pain, accompanied by inability to pass stool and urine, known as Chong-Shan (Rushing Hernia). ○ When pathogenic factors invade the collaterals of the Foot Jueyin (Liver) meridian, it causes sudden onset of hernia and severe pain. (From *Su Wen*)

Diseases of the Small Intestine manifest as pain in the lower abdomen, pain radiating from the lumbar spine to the testicles, and occasional urgency in defecation. ○ Diseases generated by the Liver include Hu-Shan (Fox Hernia). ○ Diseases of the sinews of the Foot Yangming (Stomach) meridian involve hernia and spasm of the abdominal sinews. ○ Diseases of the sinews of the Foot Taiyin (Spleen) meridian involve twisting pain in the genitalia. ○ Diseases of the Foot Jueyin (Liver) meridian cause hernia in men and swelling of the lower abdomen in women. (From *Ling Shu*)

[Masters' Discourse]
Hernia invariably begins with pain in the testicles, which then extends to the lower abdomen, and subsequently attacks the chest and hypochondrium. "Small Intestine Qi" is characterized by a drawing pain beside the umbilicus extending to the lumbar spine; "Bladder Qi" presents with distension and dysuria, with audible sounds upon palpation; "Kidney Qi Distension" presents with cramping and pulling pain around the yin region below the umbilicus, or extending to the inner thigh. The onset of these three conditions always proceeds from the abdomen downward to the testicles, showing a trend from top to bottom. In contrast, Pian-Zhui (Unilateral Drooping) and Mu-Shen (Wooden Kidney/Hard Hernia) are solely diseases of the testicles without the aforementioned rushing symptoms. ○ Generally, if hernia is caused by external cold pathogens, it is accompanied by headache, aversion to cold, and fever; if caused by internal stagnation of damp-heat, it is accompanied by redness and swelling of the scrotum; if caused by labor injury to the Liver and Spleen, it involves bloody stool, sallow complexion, and emaciation; if caused by labor injury to the Liver and Kidney, it involves soreness of the waist and enuresis. Pain rushing upward indicates rebellious pathogenic Qi; pain dropping downward indicates sinking of Yuan Qi (Primal Qi). ○ If hernia persists for a long time, it forms accumulations; when coiled around the upper and lower left and right of the umbilicus, it is called Jia (Mass); if pain is unceasing, it may transform into Pi (Accumulation) or trigger Ben-Tun (Running Piglet Qi). (From *Zheng Zhi Hui Bu*)

Question: Regarding hernia, ancient formulas attribute it to Small Intestine Qi or Bladder Qi, whereas Zhang Hezi and Zhu Danxi exclusively attribute it to the Liver. Their theories differ; how should they be distinguished?
Answer: Small Intestine Qi is a disease of the Small Intestine; Bladder Qi is a disease of the Bladder; Hernia Qi is a disease of the Liver Meridian. These three are inherently distinct. It was erroneous for past physicians to classify Small Intestine and Bladder Qi as Hernia. One must realize that the Foot Jueyin (Liver) Meridian circles the genitalia and reaches the lower abdomen; therefore, patients with this condition invariably experience distending pain in the testicles extending to the lower abdomen, indicating the close association of Hernia Qi with the Liver Meridian. Small Intestine Qi, commonly called Heng-Xian or Shu-Xian, features wandering stabbing pain around the umbilicus and attacking pain in the lower abdomen. Bladder Qi causes pain above the pubic hair line and in the lower abdomen. This differs from Hernia Qi, which has a tangible shape like a melon, produces sounds like a frog, and may rush upward to the abdomen or downward to the scrotum. However, because the meridians of the Small Intestine and Bladder connect with the Jueyin Meridian, pathology in them can affect the Liver, causing downward traction and testicular pain. Nevertheless, these remain diseases of those two meridians and should not be classified as Hernia. (From *Yi Xue Tong Zhi*)

Commentary: The argument in *Yi Xue Tong Zhi* does not fully elucidate the meaning of the Classics. *Su Wen* states that all six meridians can have hernia; hence, later discussions on hernia name some as Small Intestine Qi, some as Bladder Qi, and some as Cold-Kidney Qi. Zhang Dairen and Zhu Danxi attributed it solely to the Liver Meridian. Essentially, each has its basis, but most involve the Liver and Kidney. Commentary: *Ling Shu Jing* states: "Pathogens in the Small Intestine connect to the spermatic cord, belong to the spine, penetrate the Liver and Lungs, and link to the Heart System; when Qi is excessive, it rebels and rushes upward." Generally, when pathogens invade the meridians, they are named according to the affected meridian. Invasion of the Kidney is Kidney Qi; invasion of the Bladder is Bladder Qi; invasion of the Small Intestine is Small Intestine Qi. The Kidney and Bladder are exterior-interior pairs, their Qi connects to the external kidneys and is tied to the testicles. These three meridians are interconnected with Jueyin and are located in the lower part, converging with the Chong, Ren, and Du vessels. Dairen also stated: "There are ten acupoints of the Kidney, five of which relate to hernia." Danxi claimed it has absolutely nothing to do with the Kidney. The word "absolutely" lacks careful examination. (From *Chi Shui Xuan Zhu*)

The Classics state: "When the Ren Mai is diseased, men develop seven types of internal hernia, and women develop leukorrhea and masses." The seven hernias are: Hu-Shan (Fox), Chong-Shan (Rushing), Bi-Shan (Flaccid), Jue-Shan (Rebellious), Jia-Shan (Mass), Chi-Shan (Spasmodic), and Long-Shan (Obstructive). Any internal or external pathogenic factor can cause Yin-Yang disharmony; excess Yin leads to cold Qi impact, while excess Yang leads to internal heat congestion, resulting in Ren Mai disease. The Liver assists the Ren Mai in generation and transformation; thus, the root of hernia lies in the Ren Mai but necessarily involves the Liver. Focusing solely on the Liver while ignoring the Ren Mai contradicts the scriptural intent; focusing solely on the Ren Mai while ignoring the Liver ignores the source and flow of the disease. Hernia occurs below the Zhongji point, in the lower abdomen, where all Yin meridians converge and ascend to Guanyuan. This is governed by the Ren Mai, which collects all Yin Qi. Symptoms may arise from heat, cold, fatigue, or deficiency, but the invasion of the Yin aspect and damage to the sinews are consistent. Thus, the disease is in the Yin, the injury is to the sinews, movement generates Wind, and accumulation is like a mountain, hence the name "Hernia." (Shen Jin'ao)

*Nei Jing* states that Ren Mai disease causes internal clustering of seven hernias, summarizing the origin of the disease. The mention of Chong, Hu, Bi, Jue, Jia, Chi, and Long describes the manifestations. Chao Yuanfang arbitrarily divided hernia into seven types: Jue, Zheng, Han, Qi, Pan, Bi, and Ye-Lang. Zhang Hezi criticized him, yet his own theory only distinguished that the genitalia belong to the Liver, having no relation to the Small Intestine, Bladder, or Kidney, and he further divided them into seven names: Han, Shui, Jin, Xue, Qi, Hu, and Bi. His error is no different from Chao's. One must understand that *Nei Jing* has its own seven hernias, and the Ren Mai is the origin of the seven hernias. Saying hernia is a sinus disease involving Liver pathogens is acceptable, but saying it is exclusively in the Jueyin Meridian contradicts the Classic text. Generally, cold causes pain, heat causes flaccidity, dampness causes swelling and drooping, and deficiency is similar. Blood-level diseases are fixed; Qi-level diseases move. There are two testicles; the left belongs to Water and governs Blood, controlled by the Liver; the right belongs to Fire and governs Qi, controlled by the Lungs. Thus, cold contraction causes blood stasis to return to the Liver and descend to the left testicle; Qi stagnation causes dampness to gather in the Lungs and descend to the right testicle. Moreover, the sinews connecting the testicles are not solely from Jueyin; Taiyin and Yangming sinews also connect. Danxi argued that hernia starts from long-term damp-heat stagnation, where dampness and turbidity condense, enter the blood channels, flow to Jueyin, and due to the Liver's rapid nature, cause severe pain. This supplements previous deficiencies but should not be held as a rigid rule. (From *Yi Zong Bi Du*)

Hernia Qi disease refers to any case where the lower abdomen and testicles swell or hurt, with irregular onset and cessation. However, hernia syndromes vary: Hu-Shan (Fox Hernia) is so named because it enters and exits irregularly; Bi-Shan is so named because it is hard-swollen and insensible; Chong-Shan is so named because it rushes upward from the lower abdomen with pain; Jue-Shan is so named because Qi knots in the Yin area and rebels; Shi-Han-Jia (Hernia Mass) is so named because of burning pain in the lower abdomen and discharge of white fluid, also called Gu; Liu-Jing Feng-Shan (Six Meridian Wind Hernia) refers to what is described in *Si Shi Ci Ni Cong Lun*; Xiao-Chang-Shan (Small Intestine Hernia) refers to what is described in *Xie Qi Zang Fu Bing Xing*. These seven types collectively define hernia. However, hernia is not exclusive to men; women also suffer from it. The Classics state: "Accumulated Qi in the abdomen with rebellious Qi is named Jue-Shan; women follow the same pattern." Also: "Jueyin Bi-Shan, where women have lower abdominal swelling." Chong-Shan and Hernia-Mass are common to both sexes; only testicular disease is unique to men. Today, people only speak of men's hernia and ignore women's hernia, which is a significant error. (Zhang Jingyue)

Aversion to wind, fever, redness, swelling, and pain behind the ears is named Ma-Sai (Mumps). As the swelling and pain subside, the testicles suddenly swell, appearing as unilateral drooping but actually being something else. The side of the ear is the site of the Shaoyang Gallbladder Meridian; the Liver and Gallbladder are exterior-interior pairs. Shaoyang contracting wind-heat allows pathogens to linger in the Liver Meridian. (From *Feng Shi Jin Nang*)

[Supplement]
Abdominal pain with a string-tight pulse (Xian) and tight pulse (Jin): Xian indicates Wei Qi stagnation, leading to aversion to cold; Jin indicates loss of appetite. Struggle between pathogen and righteous Qi results in Cold Hernia, with periumbilical pain. If attacks cause spontaneous sweating, cold hands and feet, and a deep-tight pulse, Da Wu Tou Jian (Major Aconite Decoction) is indicated. ○ For Cold Hernia with abdominal pain and hypochondriac pain with interior tension, Dang Gui Sheng Yang Rou Tang (Angelica Ginger Mutton Soup) is indicated. ○ For Cold Hernia with abdominal pain, cold limbs, and numbness in hands and feet, where moxibustion, acupuncture, and other drugs fail, Di Dang Wu Tou Gui Zhi Tang (Di Dang Aconite Cinnamon Twig Decoction) is indicated. (From *Jin Gui Yao Lue*)

Commentary: The pulse description repeats here, while the next clause has symptoms but no pulse. The phrase "its pulse is deep and tight" likely belongs after "interior tension" in the next clause. However, a string-tight pulse indicates extreme tension, belonging to severe Cold Hernia. The character "Bai" (white) in "Bai Han" (White Sweat) should be "Zi" (Self/Auto). The "deep and tight pulse" in the next clause indicates interior pain, belonging to mild Cold Hernia; this is likely a transcription error. ○ Commentary: The characters "Di Dang" are superfluous. (From *Yi Zong Jin Jian*)

The method for treating hernia requires investigating the cause. Although often caused by cold and damp, it can result from sexual indulgence, overwork, anger, or improper diet after consuming alcohol and rich foods, leading to cold invasion. Pathogens seek Yin, accumulating in the Chong and Ren seas of Blood and Qi, descending to the Yin aspect, forming various hernias. Thus, onset may be triggered by cold, heat (from long-term stagnation), anger (Qi rebellion), dampness (cold stagnation), fatigue (sinew injury), sexual activity (deficiency pathogens in Shaoyin/Jueyin), or diet (dampness in Yangming/Taiyin). Over time, righteous Qi sinks and fails to lift, while pathogens remain, forming hard masses difficult to cure. One must identify the cause and treat accordingly. ○ Treating hernia requires regulating Qi first, hence the name "Hernia Qi." Cold has Cold Qi; Heat has Heat Qi; Dampness has Damp Qi; Rebellion has Rebellious Qi. Qi in the Yang aspect is Qi within Qi; Qi in the Yin aspect is Qi within Blood. Excess Qi requires breaking Qi; Deficient Qi requires tonifying Qi. Therefore, treating hernia involves using Qi-regulating herbs alongside other treatments. (Zhang Jingyue)

Ancients often treated hernia with Wu Ling San (Five-Ingredient Powder with Poria) plus Qi-moving herbs with good results. Zhu Ling and Ze Xie regulate Yin-Yang and harmonize Heart-Small Intestine Qi; Bai Zhu drains dampness and dead blood from the waist, aiding Middle Qi to transport medicine; Fu Ling leaches out Bladder water; Rou Gui suppresses Liver pathogens and warms/disperses; Xiao Hui Xiang treats Small Intestine Qi; Jin Ling Zi and Ju He remove Bladder stagnation; Bing Lang directs Qi downward; slight Mu Tong guides Small Intestine fire. Hernia arises from internal deficiency and external attack, but one must first vent Qi ("Unblocked means no pain"). Sudden tonification will cause abdominal turmoil. (Feng Chu Zhan)

All hernias belong to the Liver. The Liver desires dispersion; urgently consume pungent herbs to disperse it. Although this disease stems from deficiency, sudden tonification is inadvisable. Where pathogens gather, Qi is deficient; if they remain, the condition becomes excess. Thus, one must first cleanse accumulated pathogens before considering tonification. (From *Ben Shi Fang*)

Commentary: Although hernia starts from deficiency, if there is severe pain from excess pathogens that have not been expelled, purgation should precede tonification. However, if deficiency is severe with pain, vomiting, or seminal emission, this is extreme excess-pathogen and deficiency-righteous-Qi. Is it possible not to tonify? Fearful that tonification is useless and purgation causes further sinking of righteous Qi, few survive. (Liu Zong Nong)

Most hernias result from Liver-Kidney deficiency. The Liver is the Child of the Kidney; the anterior yin is the aperture of the Kidney. To tonify the Liver, one must consider the Mother (Kidney). People clinging to the theory "Liver has no tonification method" often declare Liver Excess in hernia cases, overusing draining methods, leading to many deaths. Danxi said: Hernia can occur with deficiency; use Ren Shen and Bai Zhu as sovereigns with guiding herbs. Where is there no tonification method? Zhongjing treated Cold Hernia with abdominal pain and interior tension using Dang Gui Sheng Yang Rou Tang, which is a form of Liver tonification. I often treat hernia with severe pain and Qi rushing to the heart using Ba Wei Wan (Eight-Ingredient Pill), which instantly works, verifying Kidney tonification. (From *Yi Lun*)

Hernia often uses pungent-dispersing and bitter-descending herbs to resolve mixed cold-heat pathogens. However, the Jueyin Meridian contains Dragon Fire; slightly pungent-warm herbs like Wu Tou, Gui Zhi, Rou Gui, and Hui Xiang often cause damp-heat stagnation, leading to numerous cases of scrotal abscesses and ulceration. (Zhang Lu Yu)

The root of hernia lies in the Liver and is not beyond Cold, as the Liver meridian connects to the genitalia (extreme Yin organ); the Foot Taiyang Bladder Meridian belongs to the Kidney and connects to the Bladder (Cold-Water meridian). Thus, Zhongjing's description: Cold Hernia with abdominal pain, cold limbs, numbness, abdominal fullness, string-tight pulse, aversion to cold, anorexia, periumbilical pain, and hypochondriac interior tension. This indicates internal and external Cold Qi dominance without boundary. The two Wu Tou formulas specifically break pathogens to treat the branch; Dang Gui Mutton Soup specifically tonifies deficiency to secure the root. Zhang Hezi said hernia relates to the Liver because symptoms include scrotal swelling, pain with interior tension/sinew contraction, penile pain radiating to testicles, lower abdominal attacking pain, or pain induced by laughter/anger—all Liver meridian signs. Jin Ling Zi San drains Liver and disperses rebellion (Liver governs free flow); Hu Qian Wan softens and guides (treating Liver while considering Kidney). The Master's approach to hernia emphasizes acute hernia is mostly cold, chronic hernia is mostly heat. Other treatments include: for Qi sinking/knotting, use Lu Rong/Lu Jiao to raise Yang; for tangible distension/pain below, follow Danxi's method of venting Yang and draining turbidity; for Fire-Fu damp-heat stagnation, use bitter-cold to control heat, counter-assisted by pungent-warm to open blood stasis; for cold-damp drooping with Bladder Qi disharmony and urinary/fecal obstruction, modify Wu Ling San to vent Taiyang Bladder; for long-term damp-heat accumulation with Qi sinking to lower abdomen/scrotum, use Kong Yan Dan/Xun Chuan Wan to drain bi and vent bowels; for lower Jiao Yin-Yang dual deficiency, use animal-derived warm-patent herbs to nurture Sheng Qi. (From *Lin Zheng Zhi Nan*)

Mu Shen (Wooden Kidney): If Heart Fire descends, Kidney Water is warmed; if True Yang descends, Kidney Water is harmonized. Where is Mu Shen? Only due to internal damage from lust, Kidney deficiency, Yin-Yang non-interaction, and Water-Fire non-balance, causing deep cold and stubborn stagnation, swelling, pain, and hardness. Do not use purely drying-hot herbs; use warm-dispersing and warm-draining to expel pathogens. Once pathogens dissipate internally, Ying and Wei circulate, like spring returning to a cold valley—subtle effects achieved without haste. (Dai Fu An)

[Pulse Diagnosis]
Pulse arriving with accumulation: Accumulated Qi in abdomen with rebellious Qi is named Jue-Shan. ○ Kidney pulse large, urgent, deep; Liver pulse large, urgent, deep: both indicate Hernia. Heart pulse slippery, urgent: Heart Hernia. Lung pulse deep, firm: Lung Hernia. Three Yang pulses urgent: Jia (Mass). Three Yin pulses urgent: Hernia. (From *Su Wen*)

[Selected Cases]
*Yan Yi* states: Zhongjing treated Cold Hernia with Dang Gui Sheng Yang Rou Tang with universal success. A woman gave birth in winter; cold entered the birth canal, causing fullness below the umbilicus, intolerant to touch. This was Cold Hernia. The physician intended to treat with Di Dang Tang (assuming blood stasis). This was incorrect treatment. Two doses of Mutton Soup cured her. (From *Zheng Zhi Zhun Sheng*)