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*Suwen: Zhizhen Yao Dalun* (On the Most Essential and Necessary Principles of the Yellow Emperor's Inner Canon) Appendix: Differentiating True and False Manifestations of Disease

The Yellow Emperor asked: How are the functions of the Five Flavors distinguished in terms of Yin and Yang? Qibo replied: Pungent and Sweet flavors have a dispersing function, which belongs to Yang; Sour and Bitter flavors have an emetic and purgative function, which belongs to Yin; Salty flavor has an emetic and purgative function, which belongs to Yin; Bland flavor has a damp-draining and orifice-unblocking function, which belongs to Yang. These six flavors may either astringe or disperse, either moderate or accelerate, either dry or moisten, either soften or harden. One should act according to their beneficial effects to regulate Qi and restore balance. (Emesis refers to vomiting. Purging refers to defecation. Damp-draining refers to promoting urination and unblocking orifices. The characteristics of the six flavors—Pungent, Sweet, Sour, Bitter, Salty, and Bland—are as follows: Pungent governs dispersion and moistening; Sweet governs moderation; Sour governs astringency and acceleration; Bitter governs drying and hardening; Salty governs softening; Bland governs damp-draining. *Zangqi Fashi Lun* states: Pungent disperses, Sour astringes, Sweet moderates, Bitter hardens, Salty softens. Therefore, among the functions of the Five Flavors, those that ascend and are light belong to Yang, while those that descend and are heavy belong to Yin. Acting in accordance with their respective properties allows Qi to be regulated and balanced. "Yong" sounds like yǒng, like water gushing forth. "Ruan" is synonymous with soft.)

The Yellow Emperor asked: For conditions not cured by regulating Qi, how should they be treated? Regarding toxic and non-toxic substances, which should be used first and which later? I wish to hear the principles. (Non-Qi-regulation refers to diseases not caused by Qi dysfunction. Wang Bing noted: There are four categories of disease origin: First, internal formations resulting from Qi movement, such as accumulations, masses, tumors, goiters, tubercles, and epilepsy; Second, external formations resulting from Qi movement, such as carbuncles, sores, ulcers, warts, scabies, gangrene, hemorrhoids, convulsions, edema, red eyes, rashes, swelling, pain, and itching; Third, internal diseases not caused by Qi movement, such as retained fluids, food stagnation, damage from hunger/fullness or overwork, leftover food, cholera, sorrow/fear/anger/happiness, longing/worry/knotting; Fourth, external diseases not caused by Qi movement, such as miasma, malevolent spirits, insect/snake/poisonous worm toxins, flying corpses, ghost strikes, collisions, falls, wind/cold/damp-heat, cuts/stabbing/cutting/blows/compression. Of these four categories, some heal by treating only internally, some by treating both internally and externally, some by treating only externally, some by treating both, some by treating internally then externally, some by treating externally then internally, some require the use of toxic substances for attack, and some require non-toxic substances for regulation. In each case, whether heavy or light, slow or fast, astringent or dispersing, moistening or drying, softening or hardening, the choice of medication must be appropriate.)

Qibo replied: Whether toxic or non-toxic, the treatment should be primarily directed at the disease being treated, and the dosage should be adjusted according to the size/severity of the condition. (In treatment, there are cases suitable for toxic substances and cases unsuitable for them. The primary goal is to treat the disease appropriately. Therefore, the size and weight of prescriptions should be formulated according to the disease.)

The Yellow Emperor said: Please explain the system of prescription formulation.
Qibo said: One Sovereign herb and two Ministers constitute a small formula; one Sovereign, three Ministers, and five Assistants constitute a medium formula; one Sovereign, three Ministers, and nine Aides constitute a large formula. (The meaning of Sovereign, Minister, Assistant, and Courier is discussed in the next chapter.) Cold conditions are treated with Heat methods; Heat conditions are treated with Cold methods. Treating cold with heat and heat with cold is the method of Direct Treatment (Zheng Zhi). (For mild conditions, oppose the nature of the disease; for severe conditions, follow the nature of the disease. (Mild conditions, such as Yang disease presenting with heat or Yin disease presenting with cold, show true manifestations easily, so the disease is mild and can be treated by opposing its nature. Opposing is the Direct Treatment mentioned above. Severe conditions, such as extreme heat presenting with cold signs or extreme cold presenting with heat signs, present false manifestations that are hard to distinguish, so the disease is severe and should be treated by following its nature. Following is the Indirect Treatment (Fan Zhi) mentioned below. Wang Bing noted: Mild diseases are like human fire; encountering grass it burns, encountering wood it flares up. It can be subdued by dampness and extinguished by water. Thus, one opposes its nature to subdue and attack it. Severe diseases are like dragon fire; encountering moisture it flames, encountering water it burns. If one does not understand its nature and tries to extinguish it with water, the flames will only reach the sky until the fuel is exhausted. Those who understand its nature act against common sense, using fire to drive it away, causing the burning to self-extinguish and the flames to be quenched. However, "opposing" means attacking heat with cold and cold with heat. "Following" means attacking with cold or heat, but one must follow its nature in usage, not necessarily being identical. Hence, the text says: Opposing is Direct Treatment, Following is Indirect Treatment. Follow less or follow more, observing the circumstances. This is what is meant.) Hardness is reduced by scraping; invaders are removed by expulsion; exhaustion is warmed by tonification; knotting is scattered by dissipation; retention is attacked by purging; dryness is moistened by lubrication; tension is eased by relaxing; scattering is gathered by astringing; loss is benefited by tonifying; leisure is promoted by moving; fright is calmed by pacifying; conditions above are treated by inducing vomiting; conditions below are treated by purging; massage is applied; bathing is used; pressure is exerted to trap; drastic measures are taken to劫夺 (seize/rob); opening is performed; sweating is induced. All actions should be appropriate to the situation. (Warming refers to nourishing with warmth. Leisure refers to erratic and chaotic movement. Moving refers to circulating stagnant Qi. Pacifying refers to calming. Above refers to vomiting. Massage refers to manual therapy. Pressure refers to pursuing hidden pathogens. Seizing refers to overcoming strong pathogenic factors. Appropriate to the situation means acting suitably to the specific circumstance.)

The Yellow Emperor asked: What do you mean by Opposing and Following?
Qibo said: Opposing is Direct Treatment; Following is Indirect Treatment. Follow less or follow more, depending on the observation of the situation. (Treating heat with cold and cold with heat, opposing the disease's nature, is called Direct Treatment. Treating cold with cold and heat with heat, following the disease's nature, is called Indirect Treatment. "Follow less" means one similarity and two differences; "Follow more" means two similarities and one difference. One must observe the severity of the condition to adjust additions and reductions. However, if full Indirect Treatment is indicated, one should naturally follow all similarities without doubt. My commentary: Treatment involves Opposing and Following because diseases vary in severity. Severity varies because symptoms have true and false aspects. Cold and Heat have true and false aspects; Deficiency and Excess also have true and false aspects. True conditions are treated directly, which is not difficult. False conditions require Indirect Treatment, which is difficult. For example, regarding the true/false nature of Cold/Heat: True Cold presents with deep, fine, weak, or slow pulses,厥逆 (cold limbs), vomiting, abdominal pain, undigested stool diarrhea, clear and frequent urination. Even if fever occurs, the patient desires clothing. This indicates floating heat on the exterior and sinking cold within. True Heat presents with rapid, forceful, slippery, large, and solid pulses, restlessness, panting, fullness, loud voice, constipation, or dark/scanty urine, fever pushing off clothes, abdominal distension/pain/thirst. These are true diseases. True Cold requires warming the cold; True Heat requires clearing the heat. This is Direct Treatment. As for False Cold, Yang conditions resemble Yin, extreme fire resembles water. Although the exterior feels cold, the interior is hot. Pulses are rapid and forceful, or deep and striking. The body feels cold and dislikes clothing, or stool is hot and constipated, or there is irritability/thirst/drinking, or intestinal discharge is foul-smelling. This indicates that aversion to cold is not true cold but clearly a Heat condition, known as "extreme heat assuming cold transformation," also called "Yang excess blocking Yin." False Heat, Yin conditions resemble Yang, extreme water resembles fire. Although the exterior feels hot, the interior is cold. Pulses are faint and weak, or rapid but empty, or floating and large without root, or wiry and hollow/intermittent. The body is intensely hot but the spirit is quiet; speech is delirious but the voice is weak; or there is virtual mania/restlessness that stops when restrained; or mosquito-bite-like spots that are pale red and fragmented; or preference for cold water but drinking little; or red tongue coating but keeping clothes/blankets on; or frequent urination; or loose stools. This indicates that aversion to heat is not true heat but clearly a Cold condition, known as "extreme cold assuming heat transformation," also called "Yin excess blocking Yang." These are false conditions. For False Cold, clear the internal heat; once internal heat is cleared, floating Yin retreats. For False Heat, warm the true Yang; once the middle is warmed, deficient fire returns to its source. This is Indirect Treatment. Regarding Deficiency/Excess treatment: Excess is drained, Deficiency is tonified. This is an unchanging principle. However, extreme Deficiency may present with Excess symptoms (False Excess); extreme Excess may present with Deficient symptoms (False Deficiency). In summary, Deficiency is a lack of Zheng Qi (Upright Qi), manifesting as pale complexion, fatigue, weak spirit, shortness of breath, spontaneous sweating, incontinence, seminal emission, vomiting/blockage, prolonged illness with excessive treatment, shortness of breath resembling asthma, overwork, sudden exhaustion/loss of will. Although external symptoms resemble Excess, if the pulse is weak and spiritless, it is a Deficient condition requiring tonification. Excess is an abundance of Xie Qi (Pathogenic Qi), either blocking meridians externally or knotting in organs internally, Qi stagnation, or blood stasis. Only when both pulse and symptoms are robust is it an Excess condition requiring attack. However, Deficiency and Excess are often similar and confusing, requiring careful differentiation of truth. As *Tongping Xu Shi Lun* states: "When pathogenic Qi is abundant, it is Excess; when essence and Qi are depleted, it is Deficiency." This is the general rule for Deficiency and Excess. Suppose a person whose Zheng Qi is depleted but Xie Qi is currently abundant: Should one protect Zheng Qi and tonify, or first attack Xie Qi? If judgment is inaccurate, life and death depend on it, hence caution is required. Zheng is the root; Xie is the branch. If Zheng Qi is already deficient, even if Xie Qi is abundant, one must not attack, lest Zheng Qi collapse before Xie Qi is expelled, leading to sudden changes that cannot be handled. Therefore, in treating Deficiency with Pathogens, one must first protect Zheng Qi. If Zheng Qi exists, harm will not occur. Moreover, tonification contains the intent of draining; tonifying Yin drains Heat, tonifying Yang drains Cold. There is no case where Zheng Qi recovers yet Xie Qi remains, nor where Zheng Qi exhausts yet life is preserved. If absolutely necessary, one must weigh urgency, temporarily adopt expedients, follow less or more, and embed attack within defense. This is the way to treat Deficiency. If Zheng Qi is undamaged, even slight Xie Qi should not be treated with tonification, for tonifying would aid Zheng without helping it, allowing Xie Qi to flourish, effectively giving weapons to bandits and grain to thieves. Thus, for Excess conditions, one should directly remove Xie Qi. Once Xie is gone, the body is safe. Methods must be precise and focused for rapid effect. This is the way to treat Excess. Ultimately, only those capable of withstanding attack are Excess conditions; Excess can be attacked, why worry? Those incapable of withstanding attack are Deficient conditions; if Qi departs and does not return, one should be terrified. This is the fundamental distinction between Xie and Zheng, which must be known. False Deficiency is rare, while False Excess is common. False Cold is easy to treat, while False Heat is often misdiagnosed. Generally, Excess involves Heat, and Deficiency involves Cold. Zhu Danxi said: "Excess Qi becomes Fire," thus Excess can tolerate Cold. I add: "Deficient Qi becomes Cold," thus Deficiency can tolerate Heat. I dare not endorse those who claim to understand medicine without distinguishing the true/false and root/branch.)

The Yellow Emperor asked: What is meant by Indirect Treatment?
Qibo said: Heat treated with Cold administration, Cold treated with Heat administration, Obstruction treated with Obstruction methods, Diarrhea treated with Draining methods. One must subdue the primary cause and address the etiology first. Initially, the approach seems similar, but ultimately differs. This can break down accumulations, dissolve hardness, harmonize Qi, and ensure cure. (This section cites notes from Wang Bing and New Corrections: "Heat treated with Cold administration": For example, severe cold knotting internally requires Heat treatment. However, if cold is severe and repels Heat, preventing Heat from entering, one administers Hot medicines Cold. After swallowing, the cold temperature dissipates, and the hot nature activates. The patient's sensation does not conflict, yielding great benefit. This is the method of Heat treated with Cold administration. "Cold treated with Heat administration": For example, severe heat in the center cannot be entered by Cold medicines, and Heat medicines would increase the disease. Thus, Cold medicines are administered Hot. After entering the abdomen, the heat dissipates, and the cold nature acts. The sensation harmonizes, and the disease decreases. This is the method of Cold treated with Heat administration. As *Wuchang Zheng Da Lun* states: "Treat Heat with Cold, administer warmly; treat Cold with Heat, administer coolly." This also embodies the meaning of Cold treated with Heat administration and Heat treated with Cold administration. "Obstruction treated with Obstruction": For example, lower Qi deficiency with middle Jiao Qi stagnation. To scatter fullness would further deplete the lower; to tonify the lower would worsen middle fullness. If treatment ignores the root and attacks fullness first, medicine may reduce symptoms temporarily, but upon cessation, Qi becomes more deficient, and the disease worsens. One must realize that small doses nourish stagnation, while large doses promote circulation. Tonifying the lower severely to open the middle results in lower deficiency becoming solid and middle fullness resolving. This is the method of Obstruction treated with Obstruction. "Diarrhea treated with Draining": For example, internal accumulation of severe Heat or severe Cold, with stagnation and persistent diarrhea. For Cold stagnation, use Hot purgatives; for Heat stagnation, use Cold purgatives. This is the method of Diarrhea treated with Draining. For these four treatments, one must subdue the primary cause (the root of the disease) and address the etiology (the origin of the disease). Having obtained the root, one treats the true with the true and the false with the false. Initially, the treatment appears similar, but ultimately, the pathology changes differently. This is the method of Indirect Treatment, capable of breaking accumulations, dissolving hardness, harmonizing Qi, and ensuring cure. "Se" is pronounced with the entering tone.)

The Yellow Emperor said: Excellent. How about conditions cured by regulating Qi?
Qibo said: Opposing and Following, Opposing then Following, Following then Opposing. Unblocking Qi to achieve harmony is the principle. (Conditions cured by regulating Qi refer to situations where Qi is harmonious but disease occurs occasionally due to seasonal changes or unexpected factors. The treatment methods do not exceed Opposing and Following. Whether one can Oppose or Follow, or Oppose then Follow, or Follow then Oppose, as long as pathogenic Qi is unblocked and harmonized, the therapeutic principle is complete.)