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Urination is difficult, water-dampness overflows while Spleen Earth is deficient, leading to abdominal distension and undigested food diarrhea. This is because the Kidney is the Zang organ of Cold Water; when Cold Water overwhelms Earth, it is called "Kidney Excess." "Excess" here means surplus, which clarifies the principles alongside the previous section.

Yin-Yang, Qi, and Blood Interacting through Tilting and Merging

The Yellow Emperor said: I have heard of the forms of Deficiency and Excess, but do not know how they arise. Qibo replied: When Qi and Blood merge, and Yin-Yang tilt against each other, Qi becomes chaotic in the Wei (Defensive) level, and Blood rebels in the meridians. Qi and Blood separate from their original residences, resulting in one area being Excess and another Deficient. If Blood merges into Yin and Qi merges into Yang, it leads to fright and mania; if Blood merges into Yang and Qi merges into Yin, it results in internal burning heat; if Blood gathers in the upper part and Qi gathers in the lower part, it causes vexation, sorrow, and irritability; if Blood gathers in the lower part and Qi gathers in the upper part, it leads to confusion and forgetfulness.

This passage discusses the tilting and merging of Yin-Yang, Qi, and Blood. "Tilting" refers to deviation or bias. Due to this biased merging, there is mutual presence of Excess and Deficiency. Generally, Wei Qi governs Qi, and Ying (Nutritive) Blood governs Blood. If Qi is chaotic in the Wei level, Blood will not follow Qi's circulation and will rebel in the Ying level. Consequently, Qi and Blood depart from their natural residences and merge. When Qi merges with Blood, Blood becomes Excess and Qi becomes Deficient; when Blood merges with Qi, Blood becomes Deficient and Qi becomes Excess. If Blood merges into Yin meridians and Qi merges into Yang meridians, the Yin and Yang meridians lose harmony, leading to disorders like fright and mania. If Blood merges into Yang meridians and Qi merges into Yin meridians, Yin and Yang contend, causing "Jiong Zhong" (internal burning heat); "Jiong" means scorching heat. If Blood rushes to the Upper Jiao and Qi rushes to the Lower Jiao, it causes vexation, sorrow, and anger; "Wan" means sorrowful distress. If Blood gathers in the Lower Jiao and Qi gathers in the Upper Jiao, it causes mental confusion and forgetfulness, described as a solitary fire disturbing the Spirit. Fundamentally, Yin and Yang are mutually rooted and used to generate Qi and Blood. Thus, when Qi moves, Blood follows; when Qi is chaotic, Blood rebels; when Qi is obstructed, Blood stasis occurs; when Qi is hot, Blood is consumed; when Qi is cold, Blood coagulates; when Qi declines, Blood diminishes. When Blood is insufficient, Yin cannot overcome Yang, leading to Blood heat; when Qi declines, Yang cannot overcome Yin, leading to Qi cold. When Qi is vigorous, Blood is abundant; when Blood is abundant, Yang cannot overcome Yin, leading to cool Blood; when Qi is vigorous, Yin cannot overcome Yang, leading to hot Qi. These fluctuations in the prosperity, decline, cold, and heat of Qi, Blood, Yin, and Yang give rise to various diseases.

The Yellow Emperor asked: If Blood merges into Yin and Qi merges into Yang, and thus Qi and Blood separate from their residences, which is Excess and which is Deficient? Qibo answered: Qi and Blood prefer warmth and dislike cold. Cold causes them to congeal and fail to flow, while warmth dissipates the congestion. Therefore, where Qi merges, Blood is Deficient; where Blood merges, Qi is Deficient. The Yellow Emperor asked: What humans possess is merely Blood and Qi. Now you say that merging of Blood leads to Deficiency, and merging of Qi leads to Deficiency. Is there no Excess? Qibo replied: That which is present is Excess; that which is absent is Deficient. Thus, where Qi merges, Blood is absent; where Blood merges, Qi is absent. Since Qi and Blood have lost each other, it is considered Deficiency. However, Luo (Collateral) vessels and Sun-Luo (Sun-Collateral) vessels all transport Qi and Blood to the main meridians. If Blood and Qi merge together, it constitutes Excess.

If Blood and Qi both rush upward, it results in Da Jue (Great Revulsion), which can cause sudden death. If Qi returns downward, life is preserved; if it does not return, death ensues.

Cold and Heat are the biased energies of Yin and Yang. When Yin and Yang are balanced, Qi and Blood are mild and circulate without harm. If Cold causes condensation and contraction, Qi and Blood become sluggish and cease to flow. "Qi" (congealing/sluggishness) means friction; warming resolves the cold, allowing Qi and Blood to harmonize. If they do not harmonize, they will tilt and merge. For instance, Qi merging into Yang causes Blood Deficiency, and Blood merging into Yin causes Qi Deficiency, creating one Excess and one Deficiency due to the bias on one side. Qi and Blood circulate in the meridians, exchanging internally and externally in an endless cycle. The finest branches are Sun-Luos. The Qi and Blood in Luo and Sun-Luo vessels are transported to the Twelve Main Meridians to nourish the whole body. Wherever Blood and Qi merge, that location becomes Excess. Thus, if they merge upward, the Upper Jiao becomes Excess and the Lower Jiao becomes Deficient, leading to Great Revulsion and sudden death. If Qi returns, life is saved; otherwise, death occurs. However, such tilting and merging must stem from external invasions or internal injuries, and treatment must address the root cause. This should be studied in conjunction with the principles of alternating Deficiency and Excess discussed in the *Taiyin Yangming Lun* chapter of the Zang-Fu section.

The Yellow Emperor asked: From what path does Excess come? From what path does Deficiency go? I wish to hear the rationale behind the essentials of Deficiency and Excess. Qibo replied: Yin and Yang both have Shu (Transport) and Hui (Meeting) acupoints. Yang Qi flows into Yin, and Yin fills outward. When Yin and Yang are even and balanced, they fill the form, and the pulses at the nine positions are uniform; this is called a Healthy Person. Pathogens arise either from Yin or from Yang. Those arising from Yang result from wind, rain, cold, and summer-heat. Those arising from Yin result from diet, lifestyle, and emotional extremes (joy, anger).

All diseases must be differentiated by Yin-Yang and Deficiency-Excess as the primary guidelines. Yin-Yang meridians have intersecting acupoints where Qi and Blood interpenetrate. Yang meridians inject into Yin, Yin meridians overflow back to Yang. Inside and outside the vessels, Ying and Wei, Zang and Fu, circulate superficially and deeply. When Yin and Yang are balanced and fill the form, the pulses at the three regions and nine positions appear unified without discrepancy, defining a Healthy Person free of disease. Regarding the origin of pathogens: external invasion by wind, rain, cold, and summer-heat first injures the Yang aspect; only after prolonged penetration does it injure Yin. Conversely, improper diet, lifestyle, and emotional disturbances (joy, anger) first injure Qi, Blood, Zang, and Fu, belonging to the Yin aspect. This uses the exterior-interior distinction to define Yin-Yang as the beginning of disease.

External Invasions and Internal Injuries Differentiated by Yin-Yang

The Yellow Emperor asked: How do wind and rain injure the human body? Qibo replied: Wind and rain first lodge in the skin, then transmit to the Sun-Luo vessels. When Sun-Luos are full, they transmit to Luo vessels. When Luo vessels are full, they transport to the large meridians. Qi, Blood, and pathogens gather between the muscle intervals (Feng Cou). The pulse becomes firm and large, hence termed Excess. Excess means the exterior is firm and full; pressing causes pain. The Yellow Emperor asked: How do cold and dampness injure the body? Qibo replied: Cold and dampness cause the skin to relax and fail to contract, muscles to become tight, Ying Blood to congeal, and Wei Qi to depart. Hence, it is termed Deficiency. Deficiency means a state of weakness and Qi insufficiency; pressing provides Qi to warm the area, bringing comfort and relieving pain.

This differentiates Excess and Deficiency based on the Yin-Yang nature of external pathogens. Wind is a Yang pathogen, so it first lodges in the skin and Wei level (Yang). It enters Sun-Luos, transmits to Luo vessels, and then to the large meridians' Ying level and blood vessels. There, Qi and Blood merge with pathogens in the Feng Cou, making the pulse firm and large, hence Excess. Because pathogens knot in the vessels, the exterior feels firm and full, causing pain upon pressure. If injured by Cold-Damp (Yin pathogens), the skin relaxes due to insecure Wei Yang. Yin pathogens injure muscles where Ying Blood resides, causing tight muscles and sluggish Ying Blood, hence Deficiency due to Yang Qi deficiency. "Nie Pi" describes a state of depletion, as stated in the *Lingshu: Genjie Chapter*: "When Qi and Blood are exhausted, the intestines and stomach are depleted." Here, Yin pathogens injure Yang; pressing stimulates Yang movement to provide warmth, resulting in comfort without pain.

The Yellow Emperor asked: How does Yin generate Excess? Qibo replied: Unregulated joy and anger cause Yin Qi to reverse upward. Upward reversal leads to Lower Deficiency. When the Lower is Deficient, Yang Qi rushes to fill the void, resulting in Excess. The Yellow Emperor asked: How does Yin generate Deficiency? Qibo replied: Joy causes Qi to sink; grief causes Qi to dissipate. Dissipation leaves the vessels empty. If combined with cold food and drink, cold qi fills the interior, causing Blood to congeal and Qi to depart, resulting in Deficiency.

This explains internal injury-induced Deficiency and Excess. Unregulated emotions disturb the Heart Mind, causing Yin Qi to reverse upward and the Lower Jiao to become Deficient. As Yang Qi rushes to fill this void (also moving upward), it mirrors the earlier concept of Qi and Blood merging, hence termed Excess. Joy causes Qi to descend, grief causes Qi to consume, leaving vessels empty. Cold from diet fills the interior vacuity, causing Blood to congeal and Qi to depart, hence Deficiency. Generally, Anger causes Qi reversal (Excess), while Joy and Grief cause Qi sinking/dissipation (Deficiency). All result from emotional excess disrupting Yin-Yang balance, leading to Deficiency and Excess, as detailed later. One view states Joy scatters Qi, Fear sinks Qi; scattering also involves downward leakage.

Yang Deficiency Causes Exterior Cold; Yin Deficiency Causes Interior Heat; Yang Excess Causes Exterior Heat; Yin Excess Causes Interior Cold

The Yellow Emperor asked: The classics state that Yang Deficiency causes exterior cold, Yin Deficiency causes interior heat, Yang Excess causes exterior heat, and Yin Excess causes interior cold. I do not understand the mechanism. Qibo replied: Yang receives Qi from the Upper Jiao to warm the skin and muscle intervals. Now, if cold pathogenic factors remain outside, the Upper Jiao becomes blocked. Blockage prevents Yang Qi from circulating, leaving cold to linger exclusively on the exterior, causing chills. This is why Yang Deficiency leads to exterior cold. The Yellow Emperor asked: How does Yin Deficiency generate interior heat? Qibo replied: Fatigue deforms Qi and reduces vitality. Grain Qi becomes insufficient. The Upper Jiao fails to function, and the Lower Wan (stomach outlet) becomes obstructed. Stomach Qi generates heat, which steams the chest, causing interior heat. The Yellow Emperor asked: How does Yang Excess generate exterior heat? Qibo replied: If the Upper Jiao is not smooth, the skin becomes dense, pores close, and the Xuan Fu (pores) block. Wei Qi cannot vent, causing exterior heat. The Yellow Emperor asked: How does Yin Excess generate interior cold? Qibo replied: Rebellious Qi rises, and cold accumulates in the chest without dispersing. Without dispersion, warming Qi departs, leaving cold alone. Cold causes Blood to congeal and stagnate, blocking the vessels. The pulse becomes large and choppy, indicating interior cold.

This clarifies diseases of Yin-Yang, exterior-interior, Deficiency-Excess, and cold-heat, covering both external invasions and internal injuries. "Yang receives Qi from the Upper Jiao" refers to Wei Yang emerging from Zong Qi in the chest to circulate outside the vessels and warm the skin and muscles. External cold blocks Upper Jiao Yang Qi, leaving cold on the exterior; this is Wei Yang Deficiency causing chills, hence "Yang Deficiency causes exterior cold." "Yin Deficiency generates interior heat" results from fatigue depleting form and Qi, reducing Grain Qi. Clear Yang fails to distribute to the Upper Jiao, causing turbid stagnation and obstruction of the Lower Wan. Stomach Qi stagnates and generates heat, steaming the chest due to fluid consumption from labor, hence "Yin Deficiency generates interior heat." "Yang Excess generates exterior heat" occurs because Upper Jiao Qi is obstructed, making skin dense and pores closed. External pathogens trap Wei Yang, preventing venting, hence "Yang Excess causes exterior heat." "Yin Excess generates interior cold" stems from emotional disturbance causing Qi rebellion and damaging Yang harmony. Yin-cold accumulates in the chest and does not disperse, driving away warming Qi and leaving cold alone. Blood congeals due to cold; since vessels are the residence of Blood, congestion makes the pulse large and choppy. This is Yang damage leading to Yin-turbidity excess, forming interior cold, hence "Yin Excess causes interior cold." Exterior cold/heat are external invasions with varying Yin-Yang/Deficiency-Excess patterns as discussed by Zhang Zhongjing. Interior heat/cold are internal injuries differing in whether they injure fluids or Yang harmony. The *Neijing* provides the outline, while Zhang Zhongjing details syndrome differentiation and treatment, serving as a bridge for students. Zhang stated he used the *Suwen*; his theories are based on *Neijing* principles. Students who grasp *Neijing* theory but ignore Zhang’s works cannot apply them effectively, making Zhang the Sage of Medicine of the Middle Antiquity. Few today understand Zhang’s Way, causing medical standards to decline.

Five Zang Organs as the Root

The Yellow Emperor asked: You mentioned ten types of Deficiency and Excess originating from the Five Zang organs and their five pulses. Yet all twelve meridians produce diseases. Why do you speak only of the Five Zang? The twelve meridians connect to 365 joints. Joint diseases affect meridians, which have Deficiency and Excess. How do these align? Qibo replied: The Five Zang are inherently linked to the Six Fu organs as interior-exterior pairs. Meridians, collaterals, and joints each develop Deficiency and Excess. Treatment follows the location of the disease. Disease in the vessels: regulate Blood. Disease in Blood: regulate Collaterals. Disease in Qi: regulate Wei. Disease in flesh: regulate muscle spaces. Disease in sinews: regulate sinews. Disease in bones: regulate bones.

Each Zang has Deficiency and Excess, totaling ten cases. The Emperor referred to the earlier "five Excesses and five Deficiencies," questioning how the five Yin meridians of the Zang relate to the twelve Yin-Yang meridians, their collaterals, and 365 joints, all subject to Deficiency-Excess differentiation. Qibo explained that Zang-Fu and meridians share a common source. Zang and Fu are interior-exterior; Zang is the root, Fu is the trunk, and meridians/blood vessels are branches. Thus, Deficiency-Excess in meridians and joints ultimately reflects Zang Deficiency-Excess. Treatment targets the specific location. For vessel disease, regulating Blood works because vessels are the residence of Blood, associated with Ying, governed by the Heart. For Blood disease, regulating Collaterals works because Blood resides in collaterals; collateral injury causes bleeding. "Vessels" here refers to main meridians; meridians and blood vessels are one entity, named differently based on pathway vs. flow. For Qi disease, regulating Wei works because Wei Qi circulates outside vessels to secure the exterior, governed by the Lung. It travels 25 cycles in Yang during the day and 25 in Yin at night; deviation indicates disharmony. For flesh disease, regulating muscle spaces works because muscles are governed by the Spleen, encompassing Ying and Wei; strengthening the Spleen harmonizes Ying and Wei, soothing muscle spaces. For sinew disease, regulating sinews works because sinews are governed by the Liver; harmonizing Liver Qi and Blood heals sinew disorders. For bone disease, regulating bones works because bones are governed by the Kidney; sufficient Kidney Yin-Yang and circulating Essence heal bone disorders. Thus, disorders of Ying-Wei-Qi, meridians-joints, and muscles-sinews-bones all stem from the Five Zang. Examining Zang Deficiency-Excess reveals the Deficiency-Excess of all diseases.

Full Collaterals, Empty Meridians; Empty Collaterals, Full Meridians

The *Suwen: Tongping Xu Shi Lun* states: "Chong Shi" (Double Excess) refers to severe heat diseases where Qi is hot and pulses are full. If both meridians and collaterals are Excess, the Cun pulse is rapid/tight while the Chi pulse is slow/relaxed. Smoothness indicates favorable prognosis; choppy indicates unfavorable. Deficiency and Excess originate from their respective categories. If the Five Zang and bones/flesh are smooth and agile, longevity is possible. If Collateral Qi is Deficient and Meridian Qi is Excess, the Mai Kou (pulse at wrist) is hot while Chi skin is cold. This is unfavorable in Autumn/Winter but favorable in Spring/Summer. If Meridians are Deficient and Collaterals are Full, Chi is hot/full while Mai Kou is cold/choppy. This is fatal in Spring/Summer but survivable in Autumn/Winter. For Full Collaterals/Empty Meridians: moisturize Yin, puncture Yang. For Empty Collaterals/Full Meridians: puncture Yin, moisturize Yang.

This continues the discussion on pathogen excess causing Excess, using pulse signs to differentiate favorable/unfavorable outcomes. In severe heat, Qi is hot and pulses full, meaning pathogens merge with Qi and Blood, termed Double Excess. Meridians belong to Ying/Blood; Collaterals belong to Wei/Qi. If both are Excess, both Qi and Blood are affected. Rapid Cun and relaxed Chi indicate rebellious Ying-Wei Qi. Smoothness implies fluid Qi and Blood, allowing easy pathogen resolution (favorable). Choppyness implies pathogens stuck with Qi and Blood, hard to resolve (unfavorable). Deficiency/Excess arise from Yin-Yang/Qi-Blood bias following their categories. Yin pathogens cause Yin Excess/Yang Deficiency; Yang pathogens cause Yang Excess/Yin Deficiency. Yang is Wei/Qi; Yin is Ying/Blood. Without pathogens, balanced Yin-Yang/Qi-Blood circulates smoothly in Zang and bones/flesh, ensuring longevity. If pathogens invade Meridians, Meridian Qi is Excess, Collateral Qi is Deficient. Meridians are Ying, flowing inside vessels, causing hot/rapid Mai Kou pulses. Collaterals are Wei, flowing outside vessels; Collateral Deficiency causes cold Chi skin. This follows Yin-Yang categorization. "Mai Kou" generally refers to Cun-Chi pulses at the wrist, also called Cun Kou or Qi Kou. Rapid pulse indicates heat and Meridian Excess. Cold Chi skin indicates cold and Collateral Deficiency. If "Chi" referred only to pulse, it would be illogical to have one pulse showing both hot and cold. "Collateral Deficiency" clearly points to Wei Qi outside vessels, i.e., Chi skin. "Smooth/Choppy" applies to both pulse and Chi skin, explaining why smooth Zang/bones ensure longevity. For Collateral Deficiency/Meridian Excess, Yin is already dominant; encountering Autumn/Winter (Yin prosperous) leads to Yang extremity (unfavorable). Spring/Summer (Yang prosperous) aids recovery (favorable). Meridian Deficiency/Collateral Fullness can be inferred similarly. Thus, for Full Collaterals/Empty Meridians, moisten Yin to tonify Meridians, puncture Yang to drain Collaterals. For Empty Collaterals/Full Meridians, puncture Yin to drain Meridians, moisten Yang to tonify Collaterals. Medicinal methods follow the same logic.

Deficiency of Meridians, Collaterals, Ying, and Wei

The Yellow Emperor asked: What is Chong Xu (Double Deficiency)? Qibo replied: When both the upper pulse and Chi region show Deficiency, it is Double Deficiency. "Qi Deficiency" means variability in presentation. "Chi Deficiency" manifests as unsteady gait. "Pulse Deficiency" lacks the characteristics of Yin. In such cases, smoothness indicates survival; choppyness indicates death.

This follows the statement that "exhaustion of Essence-Qi is Deficiency," differentiating pulse and symptoms. Deficiency of both meridians and collaterals is Double Deficiency. Earlier "Qi Deficiency" referred to Lung Deficiency, as the Lung governs all Qi, so deficiency may appear anywhere in meridians or Zang-Fu. Clarifying Double Deficiency: if meridians and collaterals are both Deficient, then Yin and Yang are both Deficient, encompassing Ying, Wei, Zang, and Fu. Soft Chi skin indicates Wei and Collateral Deficiency; unsteady gait shows weakness. Pulse Deficiency indicates Meridian Deficiency, leading to Ying-Blood Deficiency. Ying-Blood is Yin; normally pulses are calm, soft, and full. In Deficiency, pulses may be hollow/large or rigid/tense, lacking the soft Yin character. In Double Deficiency, if pulse and Chi skin are smooth, Qi and Blood are still fluid, allowing recovery through nourishment. If choppy, Qi and Blood are exhausted with pathogenic stagnation, leading to death. "Smooth/Choppy" here shares the meaning of the previous section: favorable/unfavorable signs indicate life/death.

Differentiating Life and Death

The Yellow Emperor asked: If cold pathogenic factors suddenly rise, and pulses are full and Excess, what happens? Qibo replied: If Excess and smooth, survival; if Excess and rebellious (reverse), death. The Yellow Emperor asked: If pulses are full and Excess, hands and feet are cold, and head is hot, what happens? Qibo replied: Survival in Spring/Autumn; death in Winter/Summer. If pulses are floating and choppy, and choppy with body heat, death ensues.

This addresses exhaustion of Essence-Qi, where Central Yang lacks power, allowing Yin-cold pathogens to violently reverse upward. Pulses are full and Excess (large and forceful, lacking gentleness). If smooth, Qi and Blood are still active, indicating survival. If Excess and rebellious, it shows true Zang pulses of elemental overcoming, indicating death. In cases of full/excess pulses, cold extremities, and hot head, Central Yang fails to distribute warmth to limbs, causing Qi rebellion upward. This creates Yin-Yang separation and lack of communication, leading to extreme imbalance. In Spring/Autumn, when Yang initially rises or falls, regulation can restore harmony and save life. In Winter/Summer, when Yin-Yang are naturally extreme, combining bodily imbalance with climatic extremity leads to fatal separation. Floating pulses expose Yang on the exterior; Yang should be fluid, but choppyness indicates Yang collapse. Body heat with collapsed Yang signifies severe Essence-Qi exhaustion, like a dying lamp's final flame, with both Yin and Yang exhausted, leading to death.

If the form is completely full, pulses are rapid, large, and firm, while Chi is choppy and unresponsive, survival depends on compliance with trends, death on rebellion. The Yellow Emperor asked: What defines compliant vs. rebellious? Qibo replied: Compliant means warm hands and feet; rebellious means cold hands and feet.