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Having understood the relationship between *bingji* (pathogenesis) and *qi yi* (climatic characteristics), Huangdi next asked, "I wish to hear about pathogenesis." Qibo replied, "All wind syndromes characterized by tremors and dizziness belong to the Liver. All cold syndromes characterized by contraction and pulling belong to the Kidney..." Regarding such pathogeneses, Qibo answered a total of nineteen clauses, which are known as the "Nineteen Pathogeneses" (Shijiu Bingji). Although my research on the "Nineteen Pathogeneses" is not profound, I have vaguely felt its importance. However, few people study it now. For instance, in the chapter on pathogenesis in *Basic Theory of Traditional Chinese Medicine* (*Zhongji*), which should take these "Nineteen Pathogeneses" as its core, they are rarely even mentioned. What is the reason for this? Naturally, it is due to insufficient recognition of their importance. People think that diseases in the world are so numerous and complex, how can they be summarized and explained by just these simple nineteen pathogenetic clauses? Can the "Nineteen Pathogeneses" make such summaries and explanations? The answer is affirmative! Here, Qibo used the words "zhu" (all/various) and "jie" (all/belong to), which constitutes an affirmative statement. Whenever there is "wind," or whenever there are "tremors and dizziness" (Diao Xuan), there must be a relationship with the Liver. You should search from the perspective of the Liver; you will definitely find the pathogenesis and the key factor leading to the occurrence of the disease. Qibo has already given you his guarantee on this point. By analogy, "All pain, itching, and sores belong to the Heart." For all syndromes involving pain, itching, and sores, there must be a connection with the Heart. You can look for problems from the Heart. As for how to look, we will discuss this later. After Qibo stated these "Nineteen Pathogeneses," he anticipated that Huangdi might have similar doubts as ours. To further eliminate these confusions, Qibo then quoted a passage from *Da Yao*: "Closely observe the pathogenesis, and investigate each syndrome's corresponding organ. If signs are present, seek them; if signs are absent, seek them. If excess, hold accountable; if deficiency, hold accountable. First determine the five-fold overcoming relationships, unblock the blood and qi, ensure their smooth flow, and achieve harmony." Pathogenesis must be closely observed without doubt; this is certain and leaves no room for ambiguity. Each syndrome must correspond to its respective organ. For wind-induced tremors and dizziness, regardless of the specific type, one must always look to the Liver. How to look? This requires implementing the principles of "If signs are present, seek them; if signs are absent, seek them. If excess, hold accountable; if deficiency, hold accountable. First determine the five-fold overcoming relationships." For example, regarding the aforementioned wind-induced tremors and dizziness, when we see a patient with tremors and dizziness, it undoubtedly belongs to the Liver, which is indisputable. When the patient arrives, if we see a liver-like appearance, such as a bluish complexion and a wiry pulse, indicating obvious liver color and pulse signs, this is called "present" (You). Seeking where signs are present is relatively easy because it is direct. But what if they are absent? If we see a dizzy patient whose complexion is not blue and pulse is not wiry, showing no liver color or pulse signs at all, what should we do? This situation is called "absent" (Wu). We must still seek in the absence of signs, because the premise dictated by pathogenesis is that it relates to the Liver. How to seek? This relies on the principle of "First determine the five-fold overcoming relationships." What does "five-fold overcoming" mean? It means seeking based on the relationships among the Five Elements. Clearly, dizziness belongs to the Liver, so why are no liver color/pulse signs visible? You must consider this question: why does this "absence" occur? The above principle tells us to use a convenient method to find the cause: centering on the Liver and utilizing the generation and restriction principles of the Five Elements. Taking the above example, if you do not see liver color/pulse signs but instead see signs of severe Kidney deficiency, you should understand that this "absence" is caused by deficient Kidney Water failing to generate Wood (Mother not generating Child). Therefore, treatment should involve tonifying the Mother to generate the Child, using methods to tonify the Kidney, and the dizziness will resolve. If the Kidney condition is also normal, continue to check for Lung conditions. If present, examine whether it is excess or deficiency. If the Lung is excessive, with Metal being too strong, Liver Wood will inevitably suffer restriction. At this time, drain the excess to prevent Wood from suffering restriction, and the disease will naturally heal. If the Lung is deficient with insufficient Metal, then use the method of assisting Metal to calm Wood. If that doesn't work, check the Heart. Check the Spleen. If the Heart is deficient, the Child steals from the Mother; if the Heart is excessive, Fire is strong and restricts Metal, causing Metal to fail to control Wood. In this case, draining Heart Fire will cure the disease. Sometimes, the problem may stem from Earth; deficient Earth also fails to nourish Wood. From this process, we can see that the convenience of pathogenesis lies in establishing this central coordinate. You search based on this center point, following the principles of five-fold overcoming and generation/restriction, thus having a clear target. This is much better than searching aimlessly, don't you agree? Thus, these principles are remarkable; they reveal the most crucial aspect of all diseases to us—this is pathogenesis! The most critical factor causing wind, tremors, and dizziness is the Liver, and it tells you this. Think about it, what was this in the past? It was a secret, a trick, a treasure! Yet we treat such treasures lightly, even using golden basins as chamber pots. No wonder the ancients said: "Passing [knowledge] to the wrong person leads to the careless leakage of heavenly treasures." Few people today research or care about this pathogenesis-based differentiation method. I intend to conduct in-depth research in this area and hope others will do the same. Didn't the ancients have thirty methods for treating the Liver? The famous Qing Dynasty physician Wang Xugao specifically had "Thirty-Six Methods for Treating the Liver." Where did these "Thirty-Six Methods" come from? They come from here. There are also methods described as treating the organ separated by one, two, three, or four steps. Clearly, it is a disease of one Zang organ, yet one treats another organ. The medication appears plain, with no single herb obviously targeting the Liver, yet the Liver disease is cured. If you desperately try to pacify the Liver and extinguish wind, using formulas like Lingyang Gouteng Tang (Antelope Horn and Uncaria Decoction) or Longdan Xiegan Tang (Gentian Liver-Draining Decoction), treating repeatedly yields no effect. Why? Because you haven't truly understood. You only know "to cure the disease, add the formula," and you only know "all wind tremors/dizziness belong to the Liver," but you don't know "if signs are present, seek them; if absent, seek them; if excess, hold accountable; if deficiency, hold accountable," nor do you know the principle of "first determine the five-fold overcoming relationships," nor do you know "seeing Liver disease, knowing it transmits to the Spleen, one should first strengthen the Spleen." Consequently, you are merely "waiting by a stump for a rabbit" (acting foolishly/stagnantly) and ending up as an incompetent practitioner. Therefore, although there are many variations within pathogenesis, the essence remains unchanged. Utilizing the principles provided by *Da Yao*, searching around this "essence," you will surely find the crux of the disease. Here I only provide the general line of thought, hoping everyone will research along this path and apply it clinically. Above, I discussed the "Nineteen Pathogeneses" and briefly introduced the basics of Yunqi (Five Movements and Six Qi). I believe this insight is quite deep. Now that Minor Snow has passed, what climatic characteristic do we feel? It is very humid; people feel lethargic, and many catch colds. This cold differs from previous ones. If one does not know the annual influences or understand Yunqi, treating such colds will likely encounter obstacles. Currently, Cold-Dampness is commanding, and Dampness is particularly heavy, resembling spring, which is the only season typically this humid. A few days ago, I treated three patients: one with a malignant tumor of the hard palate, one with sciatica, and one with stomach pain. I prescribed the same formula for all three: Wuji San (Five Accumulations Powder) from *Heji Jufang*. Except for the malignant tumor patient who could not take the medicine due to special circumstances, the other two cases had good results. Three different diseases treated with the same method is called "treating different diseases with the same method" (Yi Bing Tong Zhi). Actually, since the treatment is the same, there must be a common factor, and that factor is climatic characteristic (Qi Yi). Therefore, if climatic characteristics are grasped well, pathogenesis is easier to clarify; once pathogenesis is clear, treatment plans are easily formulated. This is indeed a very convenient method in clinical practice. The aforementioned malignant tumor patient was only 26 years old, looked pale and unhealthy, had few subjective symptoms, mainly head distension and slight cough (with lung metastasis). Palpation revealed a wiry and slippery pulse on the right, a choppy pulse at the Chi position, and a deep, fine pulse on the left that could not withstand pressure. The tongue was pale and dark with a white, slippery coating. How should we think about such a patient? Looking at the medications he previously took, they were large doses of Ban Zhilian (Scutellaria Barbatae Herba) and Bai Hua She She Cao (Hedyotis Diffusae Herba). So, my first suggestion was to stop these medications immediately. Ban Zhilian and Bai Hua She She Cao are heat-clearing herbs. If the tumor were truly caused by heat-toxin accumulation, their use would be unquestionable, producing anti-cancer effects. However, if the tumor is凝结 (coagulated/condensed) due to Cold-Dampness, as in this case, continuing to use heat-clearing herbs is equivalent to aiding the tyrant (doing harm). Upon encountering a cancer patient, if you immediately think of using Ban Zhilian for anti-cancer purposes, you are walking the path of "treating the disease name directly," acting like a Western doctor, not a TCM practitioner. TCM emphasizes pattern differentiation (Bian Zheng); only use the appropriate formula for the identified pattern. *Neijing* states: "Treat cold with heat, treat heat with cold." This is a principle that must be followed. If it is a cold-natured disease, warm-hot herbs should be used, regardless of whether it is a tumor or something else. The aforementioned patient first manifested in 1994. 1994 was the year of Jia Xu. Jia indicates excessive Earth movement; Xu indicates Taiyang Cold Water ruling the Heaven (Si Tian) and Taiyin Damp Earth ruling the Earth (Zai Quan). For such a tumor patient, it is difficult to specify the exact day of onset; the boundary of onset cannot be defined by days as easily as with a cold. Therefore, the framework of the year becomes extremely important. We know that the "annual influence and climatic abundance/deficiency" of 1994 was primarily dominated by Cold-Dampness, especially Dampness. Why did this disease not manifest in 1993? Perhaps the cancer was incubating in 1993. Why did it have to erupt in 1994? It is certain that the annual movement of 1994, with its changes in the Six Qi, greatly facilitated the onset of this tumor, serving as a contributing factor for its eruption. Thus, it triggered in such a special annual movement. Looking at this year, it is the year of Geng Chen. Si Tian and Zai Quan are again Cold Water and Damp Earth. This gives us a hint: this disease is related to Cold-Dampness. This indicates that such Cold-Dampness climate is certainly unfavorable to his internal environment and immune system, while conversely, it is helpful to the tumor. Think about it, is this "annual influence" important? Indeed, it is very important. If combined with tongue and pulse observations, which correspond to this, the pathogenesis is confirmed. Therefore, regardless of what the disease is called, treat it according to Cold and Dampness. Remove factors favorable to the tumor and unfavorable to the body. Even if it doesn't improve, at least it won't aid the pathology. At the beginning of discussing pathogenesis, Huangdi raised this question: "The generation of hundreds of diseases all arises from Wind, Cold, Summer-Heat, Dampness, Dryness, and Fire, through their transformation and variation." Here, "hundreds of diseases" refers to numerous illnesses all affected by these factors; tumors are no exception. Whether tumors or other diseases, all are influenced by this macro-environment and the comprehensive factors of the Six Qi. Once you understand this factor and attempt to block or change it, it will obviously have a beneficial impact on the disease's outcome. From this perspective, why say Wuji San cannot fight cancer? Wuji San can fight cancer! However, do not use it for projects or experiments; the results might be negative. Many people would then lose faith in TCM, saying it is unscientific, not universal, and not reproducible. Actually, it is not that TCM lacks universality or reproducibility, but rather that your approach makes reproduction impossible. Wuji San targets the factor of Cold-Dampness; for Cold-Dampness, Wuji San is universal and reproducible. If you use it against other factors, how can it be universal or reproducible? Just as antibiotics are only universal against bacteria, can you expect them to be universal against viruses? Is that possible? Yet, this is the current situation in TCM research: using antibiotics to treat viruses, failing, and then blaming the antibiotics. Blaming others for one's own mistakes—what logic is there in this? Now, looking at journals, the most common type of article uses a certain formula or method to treat a certain disease in a certain number of cases. The sample size cannot be small, otherwise statistical processing is impossible. Honestly, in clinical practice, how often do we encounter the same disease caused by identical factors? Rarely. What to do then? Force unrelated things together. Such practices and research attitudes are truly worrying. Our research departments and journals' policies have fueled this unhealthy trend. Pathogenesis is a major discipline in TCM. Previously, we only briefly mentioned "all wind tremors/dizziness belong to the Liver." What about "all pain, itching, and sores belong to the Heart," "all dampness, swelling, and fullness belong to the Spleen," and "all sudden stiffness belong to Wind"? These are the same. Everyone can analyze them clause by clause using the same method. Since the premise is fixed, taking this premise as the center and searching around it according to the aforementioned principles will surely yield evidence. Once you memorize the "Nineteen Pathogeneses" and the search methods thoroughly, you will handle treatments effortlessly.

3. Grasping the Main Syndrome, Recognizing Pathogenesis

How to observe pathogenesis in clinical practice? The aspects mentioned above are very important; these are classic teachings. Another aspect is "grasping the main syndrome" (Zhua Zhu Zheng), proposed by Professor Liu Duzhou. Old Liu is an authority in the field of *Shanghan Lun*, known as "North Liu, South Chen." "North Liu" refers to Liu Duzhou, and "South Chen" refers to my supervisor, Professor Chen Yiren. Professor Liu Duzhou wrote a book titled *Fourteen Lectures on Shanghan Lun*. Although the book is not long, it covers Old Liu's experiences. The final lecture addresses the issue of grasping the main syndrome. Old Liu believed that grasping the main syndrome reflects the highest level of pattern differentiation and treatment. Therefore, the ability to grasp the main syndrome becomes a key issue in clinical practice. Why is grasping the main syndrome so important? My understanding has two points. First, the main syndrome best reflects the essential mechanism of disease causation, i.e., it best reflects pathogenesis; only a syndrome that reflects pathogenesis can be called the main syndrome. Second, the main syndrome is most likely to reflect the pathway for eliminating the disease, suggesting whether you should use sweating, purging, vomiting, or other methods. Such main syndromes often play a decisive role; based on this syndrome, you can identify the direction to proceed. The main syndrome should possess these two basic characteristics. Why raise this issue in *Fourteen Lectures on Shanghan Lun*? Obviously, in Zhang Zhongjing's clauses, many of the described syndromes are main syndromes. His clauses are often very simple, such as Clause 155: "Epigastric fullness/stuffiness accompanied by aversion to cold and sweating is treated with Fuzi Xie Xin Tang." Clause 301: "Shaoyin disease, newly acquired, presenting with unusual aversion to heat and a deep pulse is treated with Mahuang Xixin Fuzi Tang." In other words, the clauses of *Shanghan Lun* essentially run through the issue of main syndromes.