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Pain is a symptom of acute and unbearable severity. Since pain manifests differently, the Emperor inquired about its specific categories, and Bo Gao listed them one by one in response. However, this chapter is titled "Exemplifying Pain" (Ju Tong Lun), yet the latter half further discusses the nine qi transformations; its meaning is particularly profound and constitutes a core principle for physicians. This chapter contains two layers of meaning, appearing inconsistent between the front and back, which is exactly what this text refers to.

The Yellow Emperor asked: I have heard that those who are good at discussing the Way of Heaven must have verification in human beings; those who are good at discussing ancient matters must align with the present; and those who are good at discussing human affairs must find confirmation within themselves. In this way, the Way will not be confused, and the key principles can be grasped, which is called clarity. (Note: Yan means sufficient, implying thorough understanding.) Now I ask you, Master, hoping to hear knowledge that can be known through words, seen through observation, and obtained through palpation, allowing me to verify it on myself, enlighten the ignorant, and resolve doubts. May I hear this? Qibo bowed twice and kowtowed, replying: What kind of question is this?

The Emperor said: I wish to hear why sudden pain occurs in the five zang organs, and what qi causes it? Qibo replied: The flow of qi and blood in the meridians never ceases, circulating around the body without rest. When cold pathogen enters the meridians, its movement becomes sluggish, and blood stagnates and fails to flow. If cold lodges outside the vessels, blood volume decreases; if cold lodges inside the vessels, qi mechanism becomes obstructed. Therefore, sudden pain occurs. (Note: Meridians are the pathways for the circulation of qi and blood, hence described as flowing endlessly and circling continuously. Healthy individuals typically exhibit this state. If cold pathogen takes advantage of an opening to enter the meridians, qi and blood become stagnant, resulting in pain. This briefly outlines the general causes of pain, mostly rooted in cold. Qi sounds like 'se'.)

The Emperor said: Some pain stops suddenly, while some pain is severe and unceasing. Some pain is so severe it cannot be pressed, while pressing relieves others. Pressing has no effect on some, while on others, pulsation is palpable. Some pain radiates between the heart and the back, some between the hypochondrium and the lower abdomen, some abdominal pain radiates to the inner thigh. Some pain persists for days forming masses. Some cause sudden death-like unconsciousness, recovering after a short time. Some pain is accompanied by vomiting, some by diarrhea following abdominal pain, and some by constipation. All these pains differ in form. How should they be distinguished? Qibo said: When cold lodges outside the vessels, the vessels become cold. Cold vessels contract and cramp. Cramping pulls on the small collaterals externally, causing sudden pain. Upon receiving warmth (Jiong), the pain stops immediately. (Note: Vessels refer to the network throughout the body. Cold enters from the skin and hair, which are outside the vessel network, hence "outside the vessels." As cold penetrates inward, tendons and vessels contract and cramp, causing pain; this is a liver disorder. Liver belongs to Wind-Wood, treatment favors dispersal. Pain stopping with warmth indicates dispersion of cold. Cold causes contraction due to its nature; heat promotes qi movement, relieving pain. Quan sound. Chu sounds like Qu. Jiong, pronounced Ju Yong.) If struck repeatedly by cold, the pain will persist for a long time. (Note: If cold strikes again just as pain subsides, the pain naturally lingers.)

When cold lodges within the meridians and contends with warm qi, the vessels become full. Fullness causes pain that cannot be pressed. If cold remains stagnant and warm qi rises from above, the vessels become enlarged and qi and blood become chaotic, leading to severe pain that cannot be pressed. (Note: Internal heat combined with external cold leads to cold-heat conflict and chaotic qi and blood, representing excess-type pain. Treatment should differentiate severity. The commentary states: "When vessels are full and large, and qi and blood are chaotic, pressing drives the pathogen inward, hence it cannot be pressed." This explanation of internal attack is accurate.)

When cold lodges between the intestines and stomach, below the membrane origin, blood cannot disperse, and small collaterals contract, causing pain. Pressing disperses qi and blood, thus relieving pain. (Membrane refers to the diaphragmatic membrane; Origin refers to the source of the diaphragm's blind area. Note: Blood flows with heat and coagulates with cold. Pressing promotes qi movement and blood circulation, relieving pain. Without pressing, pain recurs. The commentary incorrectly attributes "blood unable to disperse" solely to blood in the small collaterals within the diaphragmatic membrane.)

When cold lodges in the meridians flanking the spine, the location is deep, beyond the reach of pressure, so pressing is ineffective. (Note: Palpation force only reaches superficial levels; deep structures are inaccessible. "Flanking the spine" refers to the back. The back is thick and deep in the body, so pressing yields little result. The commentary incorrectly identifies flanking the spine as the Du Mai and Tai Yang channels. If these channels were painful, they would be relatively superficial, treatable by sweating alone, not described as deep. Here, "pressing" refers specifically to the muscles of the back.)

When cold lodges in the Chong Mai (Penetrating Vessel), which originates at Guanyuan (CV4, three cun below the umbilicus) and ascends straight up the abdomen, cold lodging causes vessel obstruction. Obstruction impedes qi flow, causing pulsation palpable to the hand. (Chong Mai is one of the Extraordinary Vessels. Guanyuan is an acupoint three cun below the navel. Saying it originates here means it ascends from this point, not that it is born there. Its true origin is below the kidney. Note: "Qi follows it" means qi cannot move because the vessel is blocked. Qi moves with the vessel, operating invisibly. Now, cold blocks the Chong Mai, causing qi stagnation and internal movement during inhalation, making it palpable.)

When cold lodges in the Back-Shu vessels, blood stagnates. Stagnation leads to blood deficiency, causing pain. These Shu points connect to the Heart, causing mutual牵引 (traction/pulling) pain between the heart and back. Pressing brings warmth, which stops the pain. (Back-Shu refers to Xin Shu (BL15), also part of the Foot-Tai Yang channel. Shu points connect internally to the zang organs, hence connecting to the Heart. Pressing introduces warm qi, which stimulates Heart qi to emerge outward, relieving pain.)

When cold lodges in the Jue Yin vessels, which connect to the genitalia and attach to the Liver, cold inside the vessels causes blood stagnation and vessel cramping, leading to pulling pain between the hypochondrium and lower abdomen. (Jue Yin is the Liver meridian, entering the pubic region, circling the genitalia, reaching the lower abdomen, piercing the diaphragm, and spreading over the hypochondrium. Hence, it connects to the genitalia and attaches to the Liver. Vessel cramping pulls on the hypochondrium and lower abdomen.)

Jue Qi lodges in the inner thigh, and cold ascends to the lower abdomen. Blood stagnates below, causing mutual traction, so abdominal pain radiates to the inner thigh. (This is also the qi of the Jue Yin Liver meridian. Because its pathway runs along the inner thigh, into the pubic region, circles the genitalia, and reaches the lower abdomen, this is stated.)

When cold lodges between the membranes of the Small Intestine and in the collateral blood, blood stagnates and cannot flow into the main meridians. Qi and blood stagnate, eventually forming masses over time. (Blood coagulates due to cold pathogen, forming masses.)

When cold lodges in the Five Zang organs, causing rebellious qi to escape upward, Yin qi is exhausted, and Yang qi fails to enter. This causes sudden severe pain, unconsciousness, and apparent death. Recovery occurs when qi returns. (Zang qi is blocked by cold and cannot move. When qi resumes flow, recovery happens. Note: Zang organs are inherently Yin. Combined with cold, extreme Yin condensation causes cold limbs and vomiting, termed "rebellious qi escaping upward." Although pure Yin dominates, saying "exhausted" implies Qi is depleted due to extreme abundance. Life depends on Yang, death on Yin.)

When cold lodges in the intestines and stomach, rebellious qi erupts upward, causing pain and vomiting. (Cold enters the intestines and stomach, suppressing Yang downward, creating cold-heat conflict causing pain. External cold cannot stay long, so it tries to exit upward, causing vomiting.)

When cold lodges in the Small Intestine... it cannot accumulate, causing diarrhea and abdominal pain. (The Small Intestine is the Fu organ of reception and transformation, governing discharge rather than storage. With external cold, it cannot retain contents, leading to loose stools and abdominal pain. Ultimately, the cold exits with the stool.)

When hot qi remains in the Small Intestine, intestinal pain occurs. Severe heat and thirst lead to dry, hard stool that cannot pass, causing pain and constipation. (The previous twelve cases all attribute pain to cold; this one attributes pain to heat. Heat accumulates in the Small Intestine, the Fire Fu organ. Fire trapped internally blocks both urination and defecation, termed "hard and dry." Hard refers to dry feces; dry refers to difficult urination. This is excess-type pain, requiring purgation.)

The Emperor said: Regarding knowing through words, how does one know? And regarding seeing through observation, how is it done? Qibo said: The Five Zang and Six Fu organs each have corresponding areas on the face. Observing the five colors: yellow and red indicate heat, white indicates cold, green and black indicate pain. This is what is meant by "visible through observation." (Note: Internal conditions manifest externally, a natural law. Internal heat causes yellow/red complexion, though Yin deficiency with floating Yang can also cause facial redness. Internal cold causes white complexion, though internal Fire depression can cause pale/cold color. Internal pain causes green/black, but green can also result from anger injuring the Liver, or black from blood disturbance/external shock, not necessarily always pain. Qibo describes the norm. Pathological variations require flexible learning.)

The Emperor said: How is knowledge obtained through palpation? Qibo said: By observing the main disease pulse being firm, and detecting bleeding or sunken pulses, one can obtain information through touch. (Note: Firm means rigid and non-supple. Bleeding refers to hemorrhage. Sunken refers to Qi sinking/prolapse. Hemorrhage and Qi sinking are severe deficiency patterns; a firm pulse in such cases indicates mismatch between disease and pulse. There are many pathological pulses; this lists only a few examples.)

The Emperor said: Excellent! I understand that hundred diseases arise from Qi. (Qi dysfunction, whether deficiency/excess, rebellion/compliance, or slack/tense, can cause disease.) Anger causes Qi to ascend, Joy causes Qi to slacken, Sorrow causes Qi to dissipate, Fear causes Qi to descend, Cold causes Qi to contract, Heat causes Qi to leak, Fright causes Qi to become chaotic, Labor causes Qi to consume, Thought causes Qi to knot. The nine Qi differ; what diseases do they generate? (Note: Tai Su reads "Worry" instead of "Fright," which is incorrect.) Qibo said: Anger causes Qi to rebel; severely, it causes hematemesis and undigested food diarrhea, hence Qi ascends. (Anger causes Yang Qi to rebel upward, and Liver Qi invades the Spleen, causing severe hematemesis and diarrhea. Proof: Anger causes facial redness; severe anger causes pallor/greenish hue.) Joy harmonizes Qi and spirit, unblocking Ying and Wei, hence Qi slackens. (Note: When the Heart's desires are met, Qi flows freely, lacking caution, leading to laxity. Sorrow tightens the Heart ties, raises Lung leaves, blocking the Upper Jiao. Ying and Wei do not disperse, trapping heat in the center, dissipating Qi. Note: Sorrow stems from the Heart despite belonging to the Lung. Tightened Heart ties cause Qi to gather and fail to extend, swelling Lung leaves and blocking Upper Jiao. Bu means swelling; Ju means rising. Lung governs Upper Jiao and Qi. Lung fears Fire; if Qi doesn't extend, internal heat damages Metal, weakening Lung Qi. The commentary's explanation of "Bu" as large leaf is obscure.) Fear causes Essence to retreat; retreat closes the Upper Jiao; closure forces Qi to return; returning causes Lower Jiao distension, hence Qi descends. (Note: Fear is dread; Retreat is shrinking. Fear makes Spirit timid and retreating, weakening Essence. Upper closure and Lower distension suppress extension, so Qi goes down, not up. Wang Ben reads "Qi does not move"; Xin Zheng Xiao correction reads "Qi descends," which is correct. Follow it.) Cold closes Cou Li (pores), blocking Ying and Wei, hence Qi contracts. (Cou refers to fluid excretion sites; Li refers to tissue textures. Closure is tight sealing. Qi refers to Wei Qi; Movement refers to circulation; Contraction refers to gathering. Body cold sinks Wei Qi, closing skin pores and textures, preventing circulation, gathering Wei Qi internally.) Heat opens Cou Li, unblocking Ying and Wei, causing profuse sweating, hence Qi leaks. (In Yang, one feels comfortable; in Yin, miserable. Heat opens skin pores, unblocks Ying and Wei, leaking fluids as sweat.) Fright leaves the Heart without support, Spirit without refuge, Thoughts without certainty, hence Qi becomes chaotic. (Note: Description is complete.) Labor causes panting and sweating, with internal and external leakage, hence Qi consumes. (Internal and external functions exceed normal limits, consuming Qi.) Thought fixes the Mind, halting Spirit, leaving Qi stagnant and unmoving, hence Qi knots. (Mind stays focused, so Qi also lingers. Note: Wang Ben reads "Spirit returns," "Righteous Qi stays." Jia Yi Jing reads "Stop" instead of "Return/Righteous," which is correct. Adopt it.)