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Diseases manifest as either excess (Shi, 实证) or deficiency (Xu, 虚证). "Regulation" (Tiao, 调) refers to suppressing the excess and tonifying the deficiency. However, both excess and deficiency are associated with specific meridians; therefore, to treat disease, one must regulate the meridians. This applies to diseases that have already occurred. For prevention prior to illness onset, nothing is better than guarding the Jing Sui (Meridian Passages, 经隧).

Huangdi asked: I have heard from acupuncture methods that excess should be drained (Xie, 泻) and deficiency should be tonified (Bu, 补). What constitutes excess? What constitutes deficiency? Qibo replied: There are five types of excess and five types of deficiency. Which aspect does Your Majesty wish to inquire about? Huangdi said: I wish to hear them all in detail. Qibo said: There is excess and deficiency of Shen (Spirit, 神), Qi (Vital Energy, 气), Xue (Blood, 血), Xing (Form/Body, 形), and Zhi (Will/Fear, 志). These ten conditions involve an imbalance of Qi. (Note: Shen belongs to the Heart, Qi to the Lungs, Blood to the Liver, Form to the Spleen, and Zhi to the Kidneys. Because each has its own master, their Qi is imbalanced.)

Huangdi said: Humans possess Jing Qi (Essence and Qi, 精气), Jin Ye (Body Fluids, 津液), four limbs, nine orifices, five Zang organs, sixteen parts, and three hundred and sixty-five joints, through which a hundred diseases arise. The generation of these diseases involves both deficiency and excess. Now you speak of five types of excess and five of deficiency; how do they arise? (Commentary: The "sixteen parts" refer to the combination of hands, feet, nine orifices, and five Zang organs. The "three hundred and sixty-five joints" are described in some notes as places where Shen Qi enters and exits, not bone joints. However, later in this chapter it states, "The twelve main meridians connect with the three hundred and sixty-five joints; if a joint is diseased, the meridian is affected," confirming they are indeed bone joints. If they were not bone joints, why use the term "connect"? ) Qibo said: They all originate from the Five Zang Organs. The Heart stores Shen, the Lungs store Qi, the Liver stores Xue, the Spleen stores flesh, and the Kidneys store Zhi, thereby forming the physical body. ... The pathways of the Five Zang Organs all emerge from the Jing Sui to circulate Xue and Qi. When Xue and Qi are disharmonious, a hundred diseases arise through transformation; thus, one must guard the Jing Sui. (Commentary: Sui means a hidden passage. Meridians run deep and are invisible, hence called Jing Sui. Xue and Qi are the spirit of humans; when pathogenic factors invade, Xue and Qi become disordered, leading to disease. Commentary: Jing Sui is the pathway for blood circulation. Healthy Qi exits here, while pathogenic factors enter. To prevent invasion, one must be cautious with Qi. If Qi is excessive, symptoms include panting, chest fullness, and仰息 (breathing with difficulty lying on back).)

Huangdi said: How should tonification and drainage be performed? Qibo said: For excess Qi, drain the Jing Sui without damaging the main meridian itself, without releasing blood, and without leaking Qi. For deficient Qi, tonify the Jing Sui without leaking Qi. (Commentary: Yang Shangshan stated: "Jing Sui refers to the collateral branches of the Hand Taiyin Lung Meridian running towards the Hand Yangming Large Intestine Meridian. To guide Yin and Yang of the Zang-Fu, tonification and drainage should be performed via these collateral branches, draining the divergent paths of the Yin meridians without harming the main meridians.")

Huangdi said: Excellent! How about excess and deficiency of Xue? Qibo said: Excess Xue leads to anger; deficient Xue leads to fear. (Commentary: This relates to the Liver. The Classic of Acupuncture states: "The Liver stores Xue. Deficient Liver Qi causes fear; Excess Liver Qi causes anger." Note: In the Jia Yi Jing, Tai Su, and Quan Yuanqi's version, "fear" is written as "sadness".)

Huangdi said: How should tonification and drainage be performed? Qibo said: For excess Xue, drain the full meridians and release blood. For deficient Xue, observe the deficient meridians, insert the needle into the vessel, and retain it for a long time to preserve blood. (Commentary: Wang Bing's text says "retain and observe"; Jia Yi Jing and Tai Su say "retain blood". We follow the latter. If the pulse is large, remove the needle quickly to prevent excessive blood loss. Commentary: A large pulse indicates Qi deficiency. If needling is too prolonged, Qi will scatter and fail to control blood, so the needle should be removed quickly. The note interpreting this as two separate actions is incorrect.)

Huangdi said: How to puncture retained blood? Qibo said: Observe the blood collaterals, puncture to release blood, preventing evil blood from entering the meridians and causing disease. (Commentary: Stagnant blood becomes evil blood. If not released from collaterals, it enters meridians and causes pathology. Commentary: While Heart, Lung, Spleen, and Kidney have minor puncturing methods, the Liver is specifically addressed regarding retained blood, likely because the Liver governs the storage of blood.)

Huangdi said: Excellent! How about excess and deficiency of Xing (Form)? Qibo said: Excess Xing leads to abdominal distension and difficult urination and defecation. Deficiency leads to inability to use the four limbs. (Commentary: This relates to the Spleen. The Classic of Acupuncture states: "Deficient Spleen Qi leads to inability to use the four limbs and unrest of the five Zang organs. Excess Spleen leads to abdominal distension and difficult urination/defecation." Jing refers to stool; Sou refers to urine. Commentary: Yang Shangshan noted "Jing" can mean menstruation, which is also valid.)

Huangdi said: How should tonification and drainage be performed? Qibo said: For excess Xing, drain the Yang meridians; for deficiency, tonify the Yang collaterals. (Including the stomach's meridians and collaterals.)

Huangdi said: Excellent! How about excess and deficiency of Zhi (Will)? Qibo said: Excess Zhi leads to abdominal distension and undigested diarrhea; deficiency leads to Jue (Cold extremities/reversal). (Commentary: This relates to the Kidneys. The Classic of Acupuncture states: "The Kidneys store Essence, Essence houses Zhi. Deficient Kidney Qi leads to Jue; Excess Kidney leads to distension." Distension refers to swelling; Jue refers to rebellious upward rushing. The Foot Shaoyin Kidney Meridian descends; due to Qi deficiency, it reverses along the Chong Mai and rushes upward.)

Huangdi said: How should tonification and drainage be performed? Qibo said: For excess Zhi, drain the blood at Ran Gu (然谷穴); for deficiency, tonify Fu Liu (复溜穴). (Commentary: Xin Zheng Jiao notes: "Jia Yi Jing and Tai Su state 'drain the blood at Ran Gu'. Yang Shangshan says 'Ran Jin' should be 'the tendon below Ran Gu'. Further investigation suggests 'Gu Zhi' might be missing, and 'Qian' might be miswritten as 'Jin'.) Ran Gu is the Ying-Spring point of the Foot Shaoyin Meridian, located anterior to the medial malleolus, below the large bone, in the depression. If blood vessels are full, drain them; needle 0.3 cun, retain for three breaths, moxa 3 cones. Fu Liu is on the Foot Shaoyin Meridian, 2 cun above the medial malleolus in the depression. Needle 0.3 cun, retain for three breaths, moxa 5 cones.)

Huangdi said: Excellent! I have heard of the forms of deficiency and excess, but not how they arise. Qibo said: When Qi and Xue merge (Bing, 并), Yin and Yang incline unevenly. Qi becomes chaotic in the Wei Qi (Defensive Qi, 卫气), and Xue rebels in the meridians. Xue and Qi separate and dwell apart, resulting in one area of excess and one of deficiency. (Wei Qi moves outside the vessels, so Qi chaos occurs there. Blood moves inside the meridians, so blood rebellion occurs there. Disharmony leads to deficiency and excess.) When Xue merges into Yin and Qi merges into Yang, it results in Jing Kuang (Startled Mania, 惊狂). (Qi merging into Yang causes external Yang excess, leading to mania.) When Xue merges into Yang and Qi merges into Yin, it results in Jiong Zhong (Heat in the Middle, 炅中). (Qi merging into Yin causes internal Yang excess, leading to heat. Jiong means heat. Note: Pronounced Jing.) When Xue merges into the upper part and Qi merges into the lower part, it causes mental distress and irritability. When Xue merges into the lower part and Qi merges into the upper part, it causes confusion and forgetfulness. (Commentary: Normal health requires circular flow of Qi and Xue between upper and lower. Merging creates bias and disease. Blood is born in the Heart and stored in the Liver. Blood merging upward causes blood excess and Qi sinking downward; lower Qi rushing up agitates Heart and Liver, causing distress. Qi accumulates in the Dantian, clarifying Spirit. Qi merging upward causes all Qi to rise and blood to sink; separation of upper and lower scatters Spirit, causing confusion.)

Huangdi said: When Xue merges into Yin and Qi merges into Yang, with Xue and Qi separated, what is excess and what is deficiency? Qibo said: Xue and Qi prefer warmth and dislike cold. Cold causes stagnation and immobility; warmth causes dispersion and movement. (Stagnation is like snow in water freezing; movement is like melting.) Therefore, where Qi merges, Xue is deficient; where Xue merges, Qi is deficient. (Commentary: Qi merging upward leaves Xue deficient below; Xue merging upward leaves Qi deficient below.)

Huangdi said: Humans possess only Xue and Qi. You say merging leads to deficiency; is there no excess? Qibo said: Presence constitutes excess, absence constitutes deficiency. Thus, where Qi merges, Xue is absent; where Xue merges, Qi is absent. Since Xue and Qi lose each other, it is called deficiency. (Commentary: Qi merging with Xue makes Xue lose its Qi; Xue merging with Qi makes Qi lose its Xue. Merging creates separation, defining deficiency and excess. Only merging creates the condition of "having" (excess) and "not having" (deficiency). Loss implies a great disparity.) Collaterals and Sun Collaterals transport to the main meridians. When Xue and Qi merge, it becomes excess. If Xue and Qi both rush upward, it causes Da Jue (Great Reversal/Syncope, 大厥), sudden death. If Qi returns, life is preserved; if not, death ensues. (Commentary: This highlights the danger of simultaneous merging of Xue and Qi upward.)

Huangdi said: Where does excess come from? Where does deficiency go? I wish to hear the principle. Qibo said: Yin and Yang both have Shu-Hui points. Yang flows into Yin, Yin overflows outward. When Yin and Yang are balanced, the form is filled, and the Nine Pulses are uniform, called a Ping Ren (Healthy Person, 平人). Pathogens arise from Yin or Yang. Those arising from Yang come from Wind, Rain, Cold, and Heat (external pathogens). Those arising from Yin come from Diet... and Joy/Anger (internal pathogens). (Commentary: Yin governs interior, Yang governs exterior. Wind/Rain/Cold/Heat are external, hence from Yang. Diet/Joy-Anger are internal injuries, hence from Yin.)

Huangdi said: How do Wind and Rain injure the body? Qibo said: Wind and Rain first lodge in the skin, then transmit to Sun Collaterals. When Sun Collaterals are full, they transmit to Luo Collaterals. When Luo Collaterals are full, they transmit to Main Meridians. Xue and Qi merge with pathogens in the Fen Cou (Interstices, 分腠). The pulse is firm and large, hence called Excess. Excess manifests as external hardness and fullness, painful upon pressure. (Commentary: This is external excess pathogen, requiring dispersal.)

Huangdi said: How do Cold and Dampness injure the body? Qibo said: Cold and Dampness cause skin contraction, muscles to become firm and tight, Ying Blood to stagnate, and Wei Qi to depart, hence called Deficiency. Deficiency manifests as timidity and Qi insufficiency. Pressure generates Qi to warm the area, bringing comfort and relieving pain. (Commentary: Nie Pi means timid/weak. Cold binds the muscle interstices, Ying stagnates, Wei departs. Pressure activates blood and Qi, transforming cold to warmth.)

Huangdi said: Excellent! How does Yin generate Excess? Qibo said: Unregulated Joy and Anger cause Yin Qi to rebel upward. Upward rebellion causes lower deficiency; lower deficiency allows Yang Qi to rush in, hence called Excess.

Huangdi said: How does Yin generate Deficiency? Qibo said: Joy causes Qi to descend; Grief causes Qi to dissipate. Dissipation leaves vessels empty. Combined with cold food/drink, cold Qi fills the interior, causing blood stagnation and Qi departure, hence called Deficiency. (Commentary: Yin/Yang diseases have both excess/deficiency, but here only Yin is discussed because Yang's patterns are obvious externally, while Yin's are subtle and variable. Joy/Anger/Grief are three of the Five Emotions. Extremes cause Qi to float up (appearing like excess) or sink/dissipate (causing deficiency/cold). This describes Yin transforming into other syndromes.)

Huangdi said: The classics state: Yang deficiency causes external cold; Yin deficiency causes internal heat; Yang excess causes external heat; Yin excess causes internal cold. I have heard this, but not the mechanism. Qibo said: Yang receives Qi from the Upper Jiao to warm the skin and muscles. Now, if Cold is external, the Upper Jiao is blocked. Blockage prevents warming, leaving Cold alone externally, causing shivering. (Commentary: Yang excess provides sufficient defense; deficiency allows pathogen attack, causing cold.)

Huangdi said: How does Yin deficiency generate internal heat? Qibo said: Fatigue deforms Qi and reduces vitality; Grain Qi is insufficient. The Upper Jiao fails to function, and the Lower Wan (Stomach outlet) is blocked. Stomach Qi becomes hot, steaming the chest, causing internal heat. (Commentary: Overwork causes fatigue; neglecting food causes insufficient Grain Qi. Fatigue weakens Qi, failing to transform food, blocking Jiao, accumulating Stomach heat. This is mild Yin deficiency internal heat from fatigue/diet. Severe cases: Yin refers to Water, generated by Tian Yi, the True Yin. Water contains Yin-Yang: Essence is Yang within Yin; Blood is Yin within Yin. People often equate Yin with Blood. Originally, Qi and Blood are balanced. Parental constitution or early indulgence may cause imbalance. Middle-aged people may exhaust Essence/Blood through overuse, causing Fire to rise and Water to decline, depleting True Yin. Water controls Fire. As Water declines, Fire flares internally. This internal heat is not true Fire excess, but lack of Water to control it, similar to consumption diseases. Ignorant practitioners use bitter-cold herbs. Some use Gui Zhi Tang (Cinnamon Twig Decoction) or Fu Zi Li Zhong Wan (Aconite Root Pill to Restore the Middle) to guide fire back to its source. Alas! Neither orthodox nor counter-treatment is suitable here. Internal heat stems from Yin deficiency; lower water is exhausted, allowing fire to rise. Using Gui Zhi/Fu Zi to suppress fire when water is absent causes fire to rise again. This differs from guiding fire back in Yin-excess resembling Yang. One should use pure Yin-water tonics to nourish Yin and suppress fire, allowing True Yin to fill and floating flames to subside. Wang Bing said: "Strengthen the master of Water to control the sunlight." This is an eternal method. Modern practitioners mistake this for true cold/false heat, using Ginger/Cinnamon and Ginseng/Aconite, adding fire instead of water, turning mild cases severe and fatal. It is like throwing wood on a fire!)

Huangdi said: How does Yang excess generate external heat? Qibo said: If the Upper Jiao is unsmooth, skin becomes dense, pores close, and Wei Qi cannot vent, causing external heat. (Commentary: External cold toxins constrain Yang. Cold contracts skin/pores, trapping Wei Qi. Cold presses externally, Yang contends internally, accumulating fire, causing external heat.)

Huangdi said: How does Yin excess generate internal cold? Qibo said: Jue Qi rebels upward, Cold accumulates in the chest without discharge. Lack of discharge causes Warm Qi to depart, leaving Cold alone. Blood stagnates, vessels block, pulse is large and choppy, causing internal cold. (Commentary: Wen Qi refers to Yang Qi. Yin rebellion fills the interior, driving Yang Qi outwards.)

Huangdi said: You mentioned ten types of excess/deficiency from the Five Zang. The Five Zang correspond to five pulses. The twelve meridians generate a hundred diseases. Why focus only on the Five Zang? The twelve meridians connect with 365 joints; joint disease affects meridians, which have excess/deficiency. How do they integrate? Qibo said: The Five Zang... have Yiu-Fu partners. Meridians and joints generate excess/deficiency. Treat according to location. Disease in Pulse, regulate Blood. (Pulse is the house of Blood; pulse excess reflects blood excess, etc. Note: Jia Yi Jing says "Disease in Blood, regulate Pulse", which may duplicate the next line. Wang Bing's version is preferred.) Disease in Blood, regulate Collaterals. (Commentary: Blood nourishes the whole body, not just collaterals. Regulating collaterals addresses blood flow from collaterals to meridians.) Disease in Qi, regulate Wei Qi. (Wei governs Qi.) Disease in Flesh, regulate Fen Rou (Muscle Intervals, 分肉). (Flesh covers the body; regions correspond to meridians. Identify the meridian based on location, then use medicine or needles.) Disease in Sinews, regulate Sinews. Disease in Bone, regulate Bone... using Cui Zhen (Fire Needles, 淬针) and Yao Wei (Medicated Compresses, 药熨). (Commentary: This treats sinew/bone. Cui is fire needle; Yao Wei is medicated compress. The note dividing sinew/bone is incorrect.) Disease with unknown pain location, prioritize the Two Qiao Vessels. (Yin Qiao originates at Zhao Hai; Yang Qiao at Shen Mai.) Body pain with normal Nine Pulses, use Miao Ci (Mistaken Puncture/Lateral Puncture, 缪刺). (Commentary: Miao Ci involves puncturing collaterals, left pain treated on right, right on left. If pulse is normal but body hurts, the disease is superficial; lateral puncture stops the pain.)