之相配不因清浊。故复言小肠者心之腑云云。以明其一定不可移也。
四十一难（误列四十六难）曰。老人卧而不寐。少壮寐而不寤者。何也。然。经言少壮者。血
气盛。肌肉滑。气道通。荣卫之行。不失于常。故昼日精。夜不寤也。老人血气衰。肌肉不滑。
荣卫之道涩。故昼日不精。夜不寐也。故知老人不得寐也。
荣卫者。即气血也。日行阳二十五度。夜行阴二十五度。少壮气血盛。故不失其常度。而夜
得寐也。老人气血衰。失其常度。故夜不寐也
四十二难（误列四十七难）曰。人面独能耐寒者。何也。然。人头者。诸阳之会也。诸阴脉
。皆至颈胸中而还。独诸阳脉。皆上至头耳。故令面耐寒也。
诸阴脉者。手三阴足三阴也。诸阳脉者。手三阳足三阳也。余义本文自明。以上二章。遥
结此卷首篇之手三阳。从手至头。足三阳。从足至头及颈。行血气。通阴阳。以荣于身之义也。可见古本之
分卷。前后俱有呼应之妙。
四十三难（误列四十一难）曰。肝独有两叶。以应何也。然。肝者。东方木也。木者。春也。万物之
始生。其尚幼小。意无所亲。去太阴尚近。离太阳不远。犹有两心。故令有两叶。亦应木叶也。
此发明五脏合五行之情。而举肝木为言也。肝位在太阴脾土之左。故曰尚近。在太阳膀胱水
之上。故曰不远。木非土不值。非水不生。其与水土。天然有根据此恋彼之情。故云犹有两心。两
叶者。肝本两大叶也。
四十四难曰。七冲门何在。然。唇为飞门。齿为户门。会厌为吸门。胃为贲门。太仓下口
为幽门。大肠小肠会为阑门。下极为魄门。故曰七冲门也。（贲门即胃之上口幽门即胃之下口魄门即肛门）
此章言人一身之内。凡出凡入共七处。皆为要冲。故曰冲门。
四十五难曰。经言八会者何也。然。腑会太仓。脏会季胁。筋会阳陵泉。髓会绝骨。血会膈
俞。骨会大椎。脉会太渊。气会三焦。外一筋直两乳内也。热病在内者。取其会之气穴也。
此章言人身脏腑筋骨血气脉髓。八者俱有交会之穴。故曰八会。太仓。任脉穴。中脘也。六
腑取禀于胃。故曰腑会。季胁。足厥阴章门穴。脾募也。五脏取禀于脾。故曰脏会。阳陵泉。足
少阳穴。筋结于此。肝主筋。胆为之合。故曰筋会。绝骨。足少阳悬钟穴。诸髓皆属于骨。故曰
髓会。膈俞。足太阳穴。谷气由膈达于上焦。化精
微为血之处。故曰血会。大椎。督脉穴。肩脊之骨会于此。故曰骨会。太渊。手太阴穴。平旦脉
会于此。故曰寸口脉之大会也。而三焦者。任脉膻中穴。此三焦宗气所居。为上气海。故曰气会
。其外有一筋直两乳内者。是另一筋直入两乳也。热病在内者。取其会之气血针治之。此即期门穴也。仲景治少阳热入
血室。刺期门。本于此。
四十六难（误列五十九难）曰。狂癫之病。何以别之。然。狂之始发。少卧而不饥。自高贤也。
自辨智也。自贵倨也。妄笑好歌乐。妄行不休是也。癫病始发。意不乐。直视僵仆。其脉三部阴阳
俱盛是也。
此与二十难同义。然二十难但言脉。此则并言病状。欲人知所治也。谓狂之始发。少卧而不
饥者。是六腑阳邪实于胃。胃实而不和。则少卧而不饥矣。阳性动而扬。故自居高贤辨智贵倨也。阳火炽甚而冲于心。
故妄笑歌妄行不休也。治当泻阳明之火而调其气。癫病始发。意不乐者。是七情之阴邪结于心
。阴性静而郁。故意不乐矣。郁火内燔而不得泄。故直视而僵仆也。治当泻少阴之火而调其血。其
脉三部阴阳俱盛者。谓狂则两手寸关尺阳脉俱盛。病属腑也。癫则两手寸关尺阴脉俱盛。病属脏
也。阳脉者。浮滑长也。阴脉者。沉涩短也。盛者。俱带数实之意也。
四十七难（误列六十难）曰。头心之病。有厥痛。有真痛。何谓也。然。手三阳之脉。受风
寒。伏留而不去者。
则名厥头痛。入连在脑者。名真头痛。其五脏气相干。名厥心痛。其痛甚。但在心。手足青者。即名
真心痛。其真心痛者。旦发夕死。夕发旦死。
此章之义。明明说脏病重于腑病。脏气相干重于风寒伏留。故心痛言立死。头痛不言立死也
。如风寒伏留六腑。则三阳之真气逆。故邪得直上而头痛。脑为髓海。诸邪难犯。必大损精髓者
。邪能犯之。犯之难治。如五脏气相干于心。则阴气逆上而痛甚。然心为君主。诸邪难犯。必七
情大伤其真气者。邪能犯之。犯之但在心痛而立死。手足青者。肝之色也。是心之母气绝。而现
真脏色也。五邪之病发。惟狂癫头心痛特异。
故先揭而出之。以起下章诸邪之发病也。（后人言头痛不言死总结在后者非也）
四十八难（误列十难）曰。一脉十变者。何谓也。然。五邪刚柔相逢之意也。假令心脉急甚者
肝邪干心也。（脏乘脏）心脉微急者。胆邪干小肠也。（腑乘腑）心脉大甚者。心邪自干心也。（
邪干本脏）心脉微大者。小肠邪自干小肠也。（邪干本腑）心脉缓甚者。脾邪干心也。（脏乘脏
）心脉微缓者。胃邪干小肠也。（腑乘腑）心脉涩甚者。肺邪干心也。（脏乘脏）心脉微涩者。
大肠邪干小肠也。（腑乘腑）心脉沉甚者。肾邪干心也。（脏乘脏）心脉微沉者。膀胱邪干小肠
也。（腑乘腑）五脏各有刚柔邪。故令一脉辄变为十也。
五邪者。五脏自病之邪也。相逢者。互相乘也。脏乘脏。则甚刚也。腑乘腑。则微柔也。一
脉。举一心脉也。十变者。五脏五变。五腑五变。合而为十也。举心脏而推。则五脏五腑共五十变可知矣。下章详言五
邪之病。
四十九难曰。有正经自病。有五邪所伤。何以别之。然。言忧愁思虑。则伤心。形寒饮冷
。则伤肺。恚怒气逆。上而不下。则伤肝。饮食劳倦。则伤脾。久坐湿地。强力入房。则伤肾。是
正经自病也。
此言内伤七情。大异于外感五邪之病。故首揭之。以明治法之不得混也。
何谓五邪。然。有中风。有伤暑。有饮食劳倦。有伤寒。有中湿。此之谓五邪。
此言外感五邪之病也。然五者之病。亦因前节正经自病之伤。故邪得凑之而举发也。五邪者
木火土金水之邪也。肝属木。木生风而中风。心属火。火旺夏而伤暑。脾胃属土。劳倦伤脾。饮
食伤胃。肺属金。肺主皮毛而伤寒。肾属水。水就下而中湿。下文即发明肝中风。心伤暑。脾伤饮
食劳倦。肺伤寒。肾中湿之病。
假令心病。何以知中风得之。然。其色当赤。何以言之。肝主色。自入为青。入心为赤。入脾
为黄。入肺为白。入肾为黑。肝为心邪。故知当赤色也。其病身热。（心）胁下满痛。（肝）其脉浮
大（心）而弦。（肝）
假令心病者。举心脏为例。此言心病因肝邪而入。肝主色。故专以色推。其病与脉皆兼心肝二经而言也。 肝邪入
肝。谓之自入。
何以知伤暑得之。然。当恶臭何以言之。心主臭。自入为焦臭。入脾为香臭。入肝为臊臭。入肾为
腐臭。入肺为腥臭。故知心病伤暑得之。当恶臭也。其病身热而烦心痛。其脉浮大而散。
首句亦当有假令心病四字。去之者。省文也。下仿此。此言暑邪入心。谓之自入。心主臭。故专
以臭推。其病与脉。俱在心经而言也。
何以知饮食劳倦得之。然。当喜苦味也。虚为不欲食。实为欲食。何以言之，脾主味。入肝
为酸。入心为苦。入肺为辛。入肾为咸。自入为甘。故知脾邪入心。当喜苦味也。其病身热（心
）而体重嗜卧。
四肢不收（脾）其脉浮大（心）而缓。（脾）
此言心病因脾邪而入。脾主味。故专以味推。其病与脉。皆兼心脾二经也。脾邪入脾。谓
之自入。此条有劳倦伤脾。故有虚不欲食之分。
何以知伤寒得之。然。当谵言妄语。何以言之。肺主声。入肝为呼。入心为言。入脾为歌。
入肾为呻。自入为哭。故知肺邪入心。为谵言妄语也。其病身热。（心）洒洒恶寒。甚则喘咳。
（肺）其脉浮大（心）而涩。（肺）
此言心病因肺邪而入。肺主声。故专以声推。其病与脉。皆兼肺心二经也。肺邪入肺。谓之自
入。（此伤寒非仲景伤寒此谵妄非阳明谵妄玩读自见）
何以知中湿得之。然。当喜汗出不可止。何以言之。肾主液。入肝为泣。入心为汗。入脾为涎。
入肺为涕。自入为唾。故知肾邪入心。为汗不可止也。其病身热（心）小腹痛。足胫寒而逆。（
肾）。其脉沉濡（肾）而大（心）
此言心病因肾邪而入。肾主液。故专以液推。其病与脉。皆兼心肾二经也。肾邪入肾。谓之自入。
此五邪之法也。
法者。举一为例之法也。五邪者。木火土金水之邪。欲审五邪之证。必合肝色心臭脾味肺声肾
液。以此心脏互推。则五脏各五五二十五证。了然明白。而五腑二十五证。不另载而可知也。至
于虚实表里种种之病。莫不可推。此真一语而能该千百言之文也。
五十难曰。病有虚邪。有实邪。有贼邪。有微邪。有正邪。何以别之。然。从后来者。为虚
邪。从前来者。为实邪。从所不胜来者。为贼邪。从所胜来者。为微邪。自病为正邪。
此章详言五邪生克之义。病有虚邪者。如心脏属火。其病邪从肝木传来。木生火。则木位居
火之后。故曰从后来。病有实邪者。如心脏属火。其病邪从脾土传来。火生土。则土位居火之前
。故曰从前来。病有贼邪者。如心脏属火。其病邪从肾水传来。水克火。心受克而不能胜。故曰
从所不胜来。病有微邪者。如心脏属
火。其病邪从肺金传来。火克金。金受克而火能胜。故曰从所胜来。正邪者。如心脏止有本
经之病也。此以五邪互传之理。起下文举一心病而推也。
何以言之。假令心病。中风得之。为虚邪。（木生火）伤暑得之。为正邪。（火传火）饮食
劳倦得之。为实邪。（火生土）伤寒得之。为微邪。（火克金）中湿得之。为贼邪。（水克火）
此足上文病传五脏之生克。以起下章五脏传变之生克也。
五十一难（误列五十三难）曰。经言七传者死。间脏者生。何谓也。然。七传者。传其所胜也。
间脏者。传其子也。何以言之。假令心病传肺。肺传肝。肝传脾。脾传肾。肾传心。一脏不再伤
。故言七传者死也。间脏者。传其所生也。假令心病传脾。脾传肺。肺传肾。肾传肝。肝传心。是
子母相传。周而复始。如环无端。故言生也。
此言五脏传变生克之义。传其所胜者。谓传于所受克之脏。如心病传肺。是火克金。肺又传
肝。是金克木。 肝又传脾。是木克土。脾又传肾。是土克水。肾复传心。是水克火。心又欲传肺。
是七传矣。然肺脏不能再伤。故曰七传者死也。间脏者。间一脏而传。如心病传脾而间肾。是火
生土。脾病传肺而间肝。是土生金。肺病传肾而间心。是金生水。肾病传肝而间脾。是水生木。
肝病传心而间肺。是木生火。心又复传于脾。而病自
已。此谓子母相传而生也。下文又明六腑同法之义。七传者。心肺肝脾肾也。间脏者。心脾肺
肾肝也。此与伤寒三阳三阴传经不同。当知此义。
五十二难（误列五十四难）曰。脏病难治。腑病易治。何谓也。然。脏病所以难治者。传其所胜
也。腑病易治者。传其子也。与七传间脏同法也。
此复明七传间脏。脏腑同法。谓脏所以难治者。传其所胜也。若传其子。亦易治也。腑所以
易治者。传其子也。若传其所胜。亦难治也。故曰与七传间脏同法也。云难治。非不治也。故有
下章之法。张注云。脏病深难治。腑病浅易治。如此讲。则七传间脏同法。竟成落空语矣。
五十三难（误列七十七难）曰。经言上工治未病。中工治已病。何谓也。然。所谓治未病者。
见肝之病。则肝当传之于脾。故先实其脾气。无令得受肝之邪也。故曰。治未病焉。中工治已病
者。见肝之病。不晓相传。但一心治肝。故曰治已病也。
此总结上章七传间脏之治也。凡一切类伤寒时证。误治而死者。皆因未明七传间脏之义。伤
哉。此从四十八难起。俱发明五邪之精义。如四十八难言五邪刚柔相逢。脏乘脏。腑乘腑。十变
之理者。示人类推五十变之义也。而又于四十九难言五邪之伤者。即五脏之受伤。是本原病之所由
来也。而又因五脏本来
之伤。发明中风伤暑饮食劳倦伤寒中湿五条之病。又以声色臭味液。合其脉证之理。推出脏有二
十五证。虽不言腑。而腑在其中。以足五十变之义。然必因五脏之所伤在前。所以五邪乘虚而集
。此即经所谓邪之所凑。其气必虚者。是也。若人先有忧愁思虑伤于心者。则邪必乘心矣。如中
风。乃肝邪乘心也。以色推之。当赤。以病推之。当身热而胁下满痛。以脉推之。当浮大而弦。
如伤暑。乃心邪自入心也。以臭推之。当焦臭。以病推之。当身热而心烦痛。以脉推之。当浮
大而散。如伤饮食劳倦。乃脾邪乘心也。以味推之。当恶甘喜苦。以病推之。当身热体重而嗜卧
。以脉推之。当浮大而缓。如伤寒。乃肺邪乘心也。以声推之。当谵言妄语。以病推之。当身热而
Their pairing is not altered by differences in clarity or turbidity. Therefore, it is stated again that the Small Intestine is the Fu organ of the Heart, to clarify that this correspondence is fixed and immutable.
Difficulty 41 (listed as Difficulty 46 in erroneous editions) states: "Why do elderly people lie down but cannot sleep, while young and vigorous people sleep but do not wake?" The response is: The Classics state that young and vigorous people have abundant Qi and Blood, smooth muscles, unobstructed Qi pathways, and their Ying (Nutrient) and Wei (Defensive) Qi flow without deviation from normal rhythms. Thus, they are energetic during the day and sleep soundly at night. Elderly people have declining Qi and Blood, non-smooth muscles, and obstructed pathways for Ying and Wei Qi. Thus, they lack energy during the day and suffer from insomnia at night. Hence, we know that elderly people have difficulty sleeping.
Ying and Wei Qi refer to Qi and Blood. During the day, they circulate through the Yang aspects twenty-five times; at night, through the Yin aspects twenty-five times. Because young and vigorous people have abundant Qi and Blood, they maintain these normal rhythms and can sleep at night. Elderly people, with declining Qi and Blood, lose these normal rhythms and thus cannot sleep at night.
Difficulty 42 (listed as Difficulty 47 in erroneous editions) states: "Why is it that only the human face can resist cold?" The response is: The head is the convergence point of all Yang meridians. All Yin meridians reach only to the neck and chest before returning, whereas all Yang meridians ascend to the head and ears. This allows the face to resist cold.
The so-called "all Yin meridians" refer to the three Yin meridians of the hand and the three Yin meridians of the foot. The "all Yang meridians" refer to the three Yang meridians of the hand and the three Yang meridians of the foot. The remaining meanings are self-evident from the text. These two chapters echo the opening chapter of this volume regarding the Hand Three-Yang meridians running from hand to head, and the Foot Three-Yang meridians running from foot to head and neck, circulating Qi and Blood, connecting Yin and Yang, and nourishing the body. This demonstrates the subtle coherence between the beginning and end of the ancient edition's volumes.
Difficulty 43 (listed as Difficulty 41 in erroneous editions) states: "Why does the Liver alone have two lobes, and what does this correspond to?" The response is: The Liver corresponds to Wood in the East. Wood corresponds to Spring, the beginning of the growth of all things. At this stage, things are still young and tender, with no specific attachment, close to Taiyin (Spleen Earth) yet far from Taiyang (Bladder Water). It is like having two hearts, which causes the Liver to have two lobes, also corresponding to the shape of wood leaves.
This elucidates the relationship between the Five Zang organs and the Five Elements, using Liver Wood as an example. The Liver is located to the left of Taiyin Spleen Earth, hence "close"; it is above Taiyang Bladder Water, hence "far." Wood relies on Earth for support and Water for growth; there is a natural bond between them, hence "like having two hearts." The two lobes refer to the liver's main anatomical structure.
Difficulty 44 states: "Where are the Seven Barrier Gates (Qi Chong Men)?" The response is: The lips are the Flying Gate (Fei Men); the teeth are the Door Gate (Hu Men); the epiglottis is the Inhaling Gate (Xi Men); the stomach is the Receiving Gate (Ben Men); the lower opening of the Tai Cang (Stomach) is the Dark Gate (You Men); the junction of the Large and Small Intestines is the Screen Gate (Lan Men); and the lower extremity (anus) is the Corporeal Gate (Po Men). Hence, they are called the Seven Barrier Gates. (Note: Ben Men is the upper opening of the stomach; You Men is the lower opening of the stomach; Po Men is the anus.)
This chapter explains that within the human body, there are seven key passages for entry and exit, hence called Barrier Gates.
Difficulty 45 states: "What are the Eight Hui (Assembling) Points mentioned in the Classics?" The response is: The Hui Point of the Fu organs is Tai Cang (Zhongwan); the Hui Point of the Zang organs is Ji Xie (Zhangmen); the Hui Point of the sinews is Yanglingquan; the Hui Point of the marrow is Juegu (Xuanzhong); the Hui Point of the blood is Ge Shu; the Hui Point of the bones is Dazhui; the Hui Point of the vessels is Taiyuan; and the Hui Point of the Qi is San Jiao (Shanzhong). Additionally, there is a tendon entering straight between the two breasts (Qimen). For internal heat diseases, one should select the Qi points of these Hui points for treatment.
This chapter explains that the eight categories—Zang organs, Fu organs, sinews, bones, blood, Qi, vessels, and marrow—all have converging points, hence called the Eight Hui. Tai Cang is an Ren Mai (Conception Vessel) point, specifically Zhongwan. Since the Six Fu organs derive from the Stomach, it is called the Hui Point of the Fu organs. Ji Xie is Zhangmen, an acupoint of the Foot Jueyin Liver Meridian and the Mu-Point of the Spleen. Since the Five Zang organs derive from the Spleen, it is called the Hui Point of the Zang organs. Yanglingquan is an acupoint of the Foot Shaoyang Gallbladder Meridian, where sinews converge; the Liver governs sinews, and the Gallbladder is its paired organ, hence it is called the Hui Point of the sinews. Juegu is Xuanzhong, an acupoint of the Foot Shaoyang Gallbladder Meridian; all marrow belongs to the bones, hence it is called the Hui Point of the marrow. Ge Shu is an acupoint of the Foot Taiyang Bladder Meridian; grain Qi reaches the Upper Jiao via the diaphragm, transforming into essence and blood, hence it is called the Hui Point of the blood. Dazhui is an acupoint of the Du Mai (Governing Vessel), where shoulder and spine bones converge, hence it is called the Hui Point of the bones. Taiyuan is an acupoint of the Hand Taiyin Lung Meridian; pulse Qi converges here at dawn, hence it is called the Great Convergence of the Cunkou pulse. The Hui Point of Qi is located at Shanzhong, an acupoint of the Ren Mai; this is where the Zong Qi (Gathering Qi) of the San Jiao resides, serving as the Upper Sea of Qi, hence it is called the Hui Point of Qi. The tendon entering straight between the two breasts refers to another tendon entering the space between the breasts, which is the Qimen point. Zhang Zhongjing treated Shaoyang heat entering the Blood Chamber by puncturing Qimen, based on this principle.
Difficulty 46 (listed as Difficulty 59 in erroneous editions) states: "How can one distinguish between Kuang (Mania) and Dian (Epilepsy/Melancholia)?" The response is: In the initial stage of Kuang, the patient sleeps little and feels no hunger, considers themselves superior and virtuous, clever and wise, noble and arrogant, laughs and sings joyfully without cause, and walks about restlessly. This is Kuang. In the initial stage of Dian, the patient feels unhappy, stares fixedly, and suddenly collapses stiffly. The pulse in all three positions (Cun, Guan, Chi) and both Yin and Yang aspects is excessive. This is Dian.
This aligns with the meaning of Difficulty 20. However, Difficulty 20 discusses only the pulse, while this chapter discusses both symptoms and pulse, to guide treatment. The statement that Kuang begins with little sleep and no hunger indicates that Yang pathogenic factors are excess in the Stomach (a Fu organ), causing Stomach excess and disharmony, leading to little sleep and no hunger. Yang nature is active and expansive, hence the arrogance and self-importance. When Yang fire blazes and rushes to the Heart, it causes irrational laughter, singing, and restless movement. Treatment should involve draining Fire from the Yangming channel and regulating Qi. The statement that Dian begins with unhappiness indicates that Yin pathogenic factors from the Seven Emotions are knotted in the Heart. Yin nature is quiet and depressive, hence the unhappiness. Depressive fire burns internally without release, causing fixed staring and stiff collapse. Treatment should involve draining Fire from the Shaoyin channel and regulating Blood. The pulse description "excessive in all three positions and Yin/Yang" means that in Kuang, the Yang pulses (floating, slippery, long) at Cun, Guan, and Chi on both hands are excessive, indicating disease in the Fu organs. In Dian, the Yin pulses (deep, choppy, short) at Cun, Guan, and Chi on both hands are excessive, indicating disease in the Zang organs. "Excessive" implies a rapid and solid quality.
Difficulty 47 (listed as Difficulty 60 in erroneous editions) states: "Diseases of the head and heart include Jue Tong (Rebellious Pain) and Zhen Tong (True Pain). What is the difference?" The response is: When the Hand Three-Yang meridians are affected by Wind and Cold, which linger and do not depart, it is called Jue Headache. If the pain extends into the brain, it is called Zhen Headache. If the Qi of the Five Zang organs interferes with each other, it is called Jue Heartache. If the pain is severe, localized solely in the heart, and accompanied by cyanosis of the hands and feet, it is called Zhen Heartache. Zhen Heartache results in death if it occurs in the morning and dies by evening, or vice versa.
The meaning of this chapter clearly states that Zang diseases are heavier than Fu diseases, and interference among Zang Qi is more severe than lingering Wind-Cold. Hence, heartache mentions immediate death, while headache does not. If Wind-Cold lingers in the Six Fu organs, the True Qi of the Three Yang meridians rebels, allowing pathogens to ascend directly causing headache. The Brain is the Sea of Marrow; pathogens rarely invade it. Only when essence and marrow are severely damaged can pathogens invade, making it difficult to treat. If the Qi of the Five Zang organs interferes with the Heart, Yin Qi rebels upward causing severe pain. The Heart is the Monarch; pathogens rarely invade it. Only when the Seven Emotions severely damage its True Qi can pathogens invade, causing heartache and immediate death. Cyanosis of the hands and feet reflects the color of the Liver, indicating the exhaustion of the Heart's mother Qi (Kidney Water) and the manifestation of the True Zang color. Among diseases caused by the Five Pathogens, only Kuang, Dian, Headache, and Heartache are unique, so they are highlighted first to introduce the subsequent discussion on various pathogenic diseases. (Later commentators who stated that headache does not mention death and summarized it later were incorrect.)
Difficulty 48 (listed as Difficulty 10 in erroneous editions) states: "What is meant by 'one pulse changing into ten variations'?" The response is: This refers to the interaction of the Five Pathogens in terms of Gang (Hard/Excess) and Rou (Soft/Deficient). For example, if the Heart pulse is extremely wiry/tense, it is Liver Pathogen interfering with the Heart (Zang overacting on Zang). If the Heart pulse is slightly wiry/tense, it is Gallbladder Pathogen interfering with the Small Intestine (Fu overacting on Fu). If the Heart pulse is extremely large, it is Heart Pathogen affecting the Heart itself (Pathogen affecting the home Zang). If the Heart pulse is slightly large, it is Small Intestine Pathogen affecting the Small Intestine itself (Pathogen affecting the home Fu). If the Heart pulse is extremely slow/relaxed, it is Spleen Pathogen interfering with the Heart (Zang overacting on Zang). If the Heart pulse is slightly slow/relaxed, it is Stomach Pathogen interfering with the Small Intestine (Fu overacting on Fu). If the Heart pulse is extremely choppy, it is Lung Pathogen interfering with the Heart (Zang overacting on Zang). If the Heart pulse is slightly choppy, it is Large Intestine Pathogen interfering with the Small Intestine (Fu overacting on Fu). If the Heart pulse is extremely deep, it is Kidney Pathogen interfering with the Heart (Zang overacting on Zang). If the Heart pulse is slightly deep, it is Bladder Pathogen interfering with the Small Intestine (Fu overacting on Fu). Each of the Five Zang has Gang and Rou pathogens, causing one pulse to change into ten variations.
The Five Pathogens refer to pathogens arising from the Five Zang organs themselves. "Interaction" refers to mutual overacting. Zang overacting on Zang is Gang (hard/excess); Fu overacting on Fu is Rou (soft/deficient). "One pulse" refers to taking the Heart pulse as an example. "Ten variations" refers to five variations from the Five Zang and five from the Six Fu, totaling ten. By extrapolating from the Heart, the fifty variations of the Five Zang and Five Fu can be understood. The next chapter details the diseases of the Five Pathogens.
Difficulty 49 states: "There are diseases of the regular meridians originating from oneself, and diseases caused by the Five Pathogens. How are they distinguished?" The response is: Worry and overthinking injure the Heart; exposure to cold and consumption of cold drinks injure the Lungs; anger and rebellious Qi rising upward injure the Liver; improper diet and fatigue injure the Spleen; sitting long in damp places and excessive sexual activity injure the Kidneys. These are diseases of the regular meridians originating from oneself.
This discusses internal injury from the Seven Emotions, which differs significantly from external contraction by the Five Pathogens. Hence, it is introduced first to clarify that treatments must not be confused.
What are the Five Pathogens? They are Wind Strike (Zhong Feng), Summerheat Injury (Shang Shu), Diet and Fatigue (Yin Shi Lao Juan), Cold Damage (Shang Han), and Dampness Strike (Zhong Shi). These are the Five Pathogens.
These refer to diseases caused by external contraction of the Five Pathogens. However, these five diseases also arise because of prior injury to the regular meridians, allowing pathogens to gather and manifest. The Five Pathogens correspond to Wood, Fire, Earth, Metal, and Water. The Liver belongs to Wood; Wood generates Wind, leading to Wind Strike. The Heart belongs to Fire; Fire peaks in Summer, leading to Summerheat Injury. The Spleen and Stomach belong to Earth; fatigue injures the Spleen, and improper diet injures the Stomach. The Lungs belong to Metal; the Lungs govern skin and hair, leading to Cold Damage. The Kidneys belong to Water; water flows downward, leading to Dampness Strike. The following text elaborates on Liver Wind Strike, Heart Summerheat Injury, Spleen Diet/Fatigue Injury, Lung Cold Damage, and Kidney Dampness Strike.
For example, in Heart disease, how do we know it is caused by Wind Strike? The response is: The complexion should be red. Why? The Liver governs colors; Green enters the Liver, Red enters the Heart, Yellow enters the Spleen, White enters the Lungs, Black enters the Kidneys. Since Liver is the pathogen for the Heart, the complexion should be red. Symptoms include body heat (Heart), fullness and pain in the hypochondrium (Liver), and a pulse that is floating and large (Heart) and wiry (Liver).
Taking Heart disease as an example, this describes Heart disease caused by Liver Pathogen. The Liver governs color, so diagnosis relies on complexion. Symptoms and pulse involve both Heart and Liver meridians. Liver Pathogen entering the Liver is called "self-entry."
How do we know it is caused by Summerheat Injury? The response is: There should be aversion to odors. Why? The Heart governs odors; Scorched odor enters the Heart, Fragrant odor enters the Spleen, Fishy odor enters the Liver, Rotten odor enters the Kidneys, Pungent odor enters the Lungs. Thus, Heart disease caused by Summerheat should present with aversion to odors. Symptoms include body heat, vexation, and heart pain. Pulse is floating, large, and scattered.
The phrase "Assuming Heart Disease" was omitted for brevity; the same applies below. This describes Summerheat Pathogen entering the Heart, called "self-entry." The Heart governs odors, so diagnosis relies on smell. Symptoms and pulse are described in terms of the Heart meridian.
How do we know it is caused by Diet and Fatigue? The response is: There should be a preference for bitter taste. Deficiency presents as loss of appetite; Excess presents as desire to eat. Why? The Spleen governs tastes; Sour enters the Liver, Bitter enters the Heart, Pungent enters the Lungs, Salty enters the Kidneys, Sweet enters the Spleen. Thus, Spleen Pathogen entering the Heart should present with a preference for bitter taste. Symptoms include body heat (Heart), heavy body, drowsiness, and inability to control the four limbs (Spleen). Pulse is floating and large (Heart) and slow (Spleen).
This describes Heart disease caused by Spleen Pathogen. The Spleen governs taste, so diagnosis relies on taste. Symptoms and pulse involve both Heart and Spleen meridians. Spleen Pathogen entering the Spleen is called "self-entry." This item mentions fatigue injuring the Spleen, distinguishing between deficiency (no appetite) and excess.
How do we know it is caused by Cold Damage? The response is: There should be delirious speech. Why? The Lungs govern sounds; Calling out enters the Liver, Speaking enters the Heart, Singing enters the Spleen, Moaning enters the Kidneys, Crying enters the Lungs. Thus, Lung Pathogen entering the Heart manifests as delirious speech. Symptoms include body heat (Heart), chills, and potentially wheezing/coughing (Lungs). Pulse is floating and large (Heart) and choppy (Lungs).
This describes Heart disease caused by Lung Pathogen. The Lungs govern sound, so diagnosis relies on voice. Symptoms and pulse involve both Lung and Heart meridians. Lung Pathogen entering the Lungs is called "self-entry." (Note: This "Cold Damage" is not the Shanghan from Zhang Zhongjing, and this delirium is not the Yangming delirium; careful reading will reveal this.)
How do we know it is caused by Dampness Strike? The response is: There should be profuse, uncontrollable sweating. Why? The Kidneys govern fluids; Tears enter the Liver, Sweat enters the Heart, Saliva enters the Spleen, Mucus enters the Lungs, Spittle enters the Kidneys. Thus, Kidney Pathogen entering the Heart manifests as uncontrollable sweating. Symptoms include body heat (Heart), lower abdominal pain, and cold/reversal in the calves and feet (Kidneys). Pulse is deep and soggy (Kidney) and large (Heart).
This describes Heart disease caused by Kidney Pathogen. The Kidneys govern fluids, so diagnosis relies on fluids. Symptoms and pulse involve both Heart and Kidney meridians. Kidney Pathogen entering the Kidneys is called "self-entry."
This is the method of the Five Pathogens.
"Method" refers to using one example to illustrate the rule. The Five Pathogens are Wood, Fire, Earth, Metal, and Water pathogens. To examine the syndromes of the Five Pathogens, one must combine Liver color, Heart odor, Spleen taste, Lung sound, and Kidney fluid, deducing them mutually with the Heart. This yields twenty-five syndromes for the Five Zang, clear and distinct. The twenty-five syndromes for the Five Fu can be known without separate listing. Various conditions of Excess/Deficiency and Interior/Exterior can all be deduced. This is truly a concise text capable of summarizing thousands of words.
Difficulty 50 states: "Diseases include Xu (Deficient) Pathogen, Shi (Excess) Pathogen, Zei (Thief) Pathogen, Wei (Minor) Pathogen, and Zheng (Regular) Pathogen. How are they distinguished?" The response is: Coming from behind is Xu Pathogen; coming from ahead is Shi Pathogen; coming from the organ it cannot overcome is Zei Pathogen; coming from the organ it overcomes is Wei Pathogen; originating from oneself is Zheng Pathogen.
This chapter details the generation and restriction cycles of the Five Pathogens. For Xu Pathogen: If the Heart (Fire) is diseased due to transmission from the Liver (Wood), Wood generates Fire, so Wood is behind Fire. Hence, "coming from behind." For Shi Pathogen: If the Heart (Fire) is diseased due to transmission from the Spleen (Earth), Fire generates Earth, so Earth is ahead of Fire. Hence, "coming from ahead." For Zei Pathogen: If the Heart (Fire) is diseased due to transmission from the Kidney (Water), Water restricts Fire, and the Heart cannot overcome it. Hence, "coming from the one it cannot overcome." For Wei Pathogen: If the Heart (Fire) is diseased due to transmission from the Lung (Metal), Fire restricts Metal, and the Heart overcomes it. Hence, "coming from the one it overcomes." Zheng Pathogen refers to disease confined to the meridian itself. This uses the theory of mutual transmission of the Five Pathogens to introduce the subsequent deduction starting with Heart disease.
Why? Assuming Heart disease: Caused by Wind Strike is Xu Pathogen (Wood generates Fire); caused by Summerheat Injury is Zheng Pathogen (Fire transmits to Fire); caused by Diet/Fatigue is Shi Pathogen (Fire generates Earth); caused by Cold Damage is Wei Pathogen (Fire restricts Metal); caused by Dampness Strike is Zei Pathogen (Water restricts Fire).
This matches the generation and restriction of pathogen transmission among the Five Zang mentioned earlier, introducing the subsequent discussion on the generation and restriction of Zang transmission.
Difficulty 51 (listed as Difficulty 53 in erroneous editions) states: "The Classics say 'Seven Transmissions result in death; Interspersed Zang transmissions result in survival.' What does this mean?" The response is: Seven Transmissions refers to transmission to the organ it overcomes (restricts). Interspersed Zang Transmission refers to transmission to its child organ. Why? Assuming Heart disease transmits to Lung, Lung to Liver, Liver to Spleen, Spleen to Kidney, Kidney to Heart. No Zang is injured twice. Hence, "Seven Transmissions result in death." Interspersed Zang Transmission refers to transmission to the organ it generates. Assuming Heart disease transmits to Spleen, Spleen to Lung, Lung to Kidney, Kidney to Liver, Liver to Heart. This is mother-child transmission, cycling endlessly like a ring. Hence, "survival."
This explains the generation and restriction in Zang transmission. "Transmission to the organ it overcomes" means transmitting to the organ it restricts. Heart (Fire) transmits to Lung (Metal, Fire restricts Metal); Lung (Metal) transmits to Liver (Wood, Metal restricts Wood); Liver (Wood) transmits to Spleen (Earth, Wood restricts Earth); Spleen (Earth) transmits to Kidney (Water, Earth restricts Water); Kidney (Water) transmits to Heart (Fire, Water restricts Fire); Heart attempts to transmit to Lung again, completing seven steps. However, the Lung cannot be injured again, hence "Seven Transmissions result in death." Interspersed Zang Transmission skips one organ. Heart (Fire) transmits to Spleen (Earth, skipping Kidney, Fire generates Earth); Spleen (Earth) transmits to Lung (Metal, skipping Liver, Earth generates Metal); Lung (Metal) transmits to Kidney (Water, skipping Heart, Metal generates Water); Kidney (Water) transmits to Liver (Wood, skipping Spleen, Water generates Wood); Liver (Wood) transmits to Heart (Fire, skipping Lung, Wood generates Fire); Heart transmits to Spleen again, and the disease resolves. This is called mother-child transmission resulting in survival. The following text clarifies that the Six Fu organs follow the same method. Seven Transmissions involves Heart, Lung, Liver, Spleen, Kidney. Interspersed Zang Transmission involves Heart, Spleen, Lung, Kidney, Liver. This differs from the transmission of the Three Yang and Three Yin in Shanghan; this distinction must be understood.
Difficulty 52 (listed as Difficulty 54 in erroneous editions) states: "Zang diseases are difficult to treat; Fu diseases are easy to treat. Why?" The response is: Zang diseases are difficult because they transmit to the organ they overcome (restrict). Fu diseases are easy because they transmit to their child organ. This follows the same logic as Seven Transmissions and Interspersed Zang Transmission.
This reiterates that Seven Transmissions and Interspersed Zang Transmission apply equally to Zang and Fu. Zang diseases are difficult because they transmit to the organ they overcome; if they transmit to their child, they are easy to treat. Fu diseases are easy because they transmit to their child; if they transmit to the organ they overcome, they are difficult. Hence, "same logic as Seven Transmissions and Interspersed Zang Transmission." Saying "difficult to treat" does not mean "untreatable," hence the methods in the next chapter. Commentary by Zhang states: "Zang diseases are deep and difficult; Fu diseases are superficial and easy." If interpreted this way, the logic of Seven Transmissions and Interspersed Zang Transmission becomes void.
Difficulty 53 (listed as Difficulty 77 in erroneous editions) states: "The Classics say 'Superior physicians treat disease before it arises; average physicians treat disease after it arises.' What does this mean?" The response is: Treating disease before it arises means: Seeing Liver disease, one knows the Liver will transmit to the Spleen, so one first strengthens the Spleen Qi to prevent it from receiving the Liver pathogen. Hence, "treating disease before it arises." Average physicians treating disease after it arises see Liver disease, do not understand the transmission, and focus solely on treating the Liver. Hence, "treating disease after it arises."
This summarizes the treatment of the previous chapter on Seven Transmissions and Interspersed Zang Transmission. Tragically, many deaths from misdiagnosis in seasonal febrile diseases similar to Shanghan occur because practitioners fail to understand the principles of Seven Transmissions and Interspersed Zang Transmission. Starting from Difficulty 48, the text elucidates the essence of the Five Pathogens. Difficulty 48 discusses the interaction of Gang and Rou among the Five Pathogens, Zang overacting on Zang, and Fu overacting on Fu, illustrating the logic of ten variations and the deduction of fifty variations. Difficulty 49 discusses injuries from the Five Pathogens, which are injuries to the Five Zang, the origin of primary disease. Based on these primary injuries, it elaborates on five disease types: Wind Strike, Summerheat Injury, Diet/Fatigue, Cold Damage, and Dampness Strike. By combining sound, color, odor, taste, and fluids with pulse and syndrome analysis, it deduces twenty-five syndromes for the Zang organs. Although the Fu organs are not explicitly listed, they are included, fulfilling the logic of fifty variations. However, since the injury to the Five Zang precedes, the Five Pathogens exploit the deficiency to gather. This aligns with the Classic saying: "Where pathogenic factors gather, the Qi is necessarily deficient." If a person first injures the Heart with worry and overthinking, pathogens will attack the Heart. For example, Wind Strike is Liver Pathogen attacking the Heart. Deduced by color, the complexion should be red; by symptoms, body heat and hypochondriac pain; by pulse, floating, large, and wiry. Summerheat Injury is Heart Pathogen affecting the Heart itself. Deduced by odor, scorched smell; by symptoms, body heat, vexation, and heart pain; by pulse, floating, large, and scattered. Diet/Fatigue Injury is Spleen Pathogen attacking the Heart. Deduced by taste, aversion to sweet and preference for bitter; by symptoms, body heat, heaviness, and drowsiness; by pulse, floating, large, and slow. Cold Damage is Lung Pathogen attacking the Heart. Deduced by sound, delirious speech; by symptoms, body heat and