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Chapter Four:

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On Illnesses, contd
(Difficult Issues 48-61, here 56-61)

THE FIFTY-SIXTH DIFFICULT ISSUE

Overview: Reinterpretation of terms and concepts related to accumulation illnesses, and introduction
of a systematic theory of the generation of the five accumulation illnesses.

The fifty-sixth difficult issue: (1) What are the names of all the accumulations in the five depots? (2)
In what month and on what day does one contract them?
(3) It is like this. Accumulations in the liver are called "fat influences." (4) They are located below the
ribs on the left side and resemble a cup turned upside down. (5) They have head and foot, and they
last a long time without healing. (6) They let the [afflicted] person develop a cough [with influences]
moving contrary to their proper direction, and they [cause] chieh and yao [fevers]. (7) Even after a
year, [such accumulations] do not yet come to an end. (8) [Such illnesses] are contracted in late
summer on a wu-chi day. (9) Why do I say so? When the lung is ill, it will transmit [evil influences]
to the liver, and the liver should transmit them to the spleen. In the last month of summer, however,
the spleen acts as king. A king does not accept evil. Therefore, the liver wishes to return [the evil
influences] to the lung, but the lung is unwilling to accept them. Hence [the evil influences] stay [in

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the liver] and conglomerate, causing accumulations. Hence one knows that "fat influences" are
acquired in late summer on a wu-chi day. (10) Accumulations in the heart are called "hidden beams."
(11) They rise above the navel and are as large as a
lower arm. (12) They extend upward to below the
heart and last a long time without healing. (13) They
let the [afflicted] person suffer from a feeling of
uneasiness in his heart. (14) [Such illnesses] are
contracted in autumn on a keng-hsin day. (15) Why
do I say so? When the kidneys are ill, they will
transmit [evil influences] to the heart, and the heart
should transmit them to the lung. In autumn,
however, the lung acts as king, and a king does not
accept evil. Therefore, the heart wishes to return [the
evil influences] to the kidneys, but the kidneys are
unwilling to accept them. Hence they stay [in the
heart] and conglomerate, causing accumulations.
Hence one knows that "hidden beams" are contracted
in autumn on a keng-hsin day.
(16) Accumulations in the spleen are called "blocked influences." (17) They are located in the
stomach-duct1 and are several times the size of a bowl.2 They last a long time without healing. (18)
They cause the [afflicted] person to be unable to pull in his four limbs, and they cause jaundice. (19)
They prevent the generation of flesh and skin from food and drink. (20) [Such illnesses] are
contracted in winter on a jen-kuei day. (21) Why do I say so? When the liver is ill, it will transmit
[evil influences] to the spleen, and the spleen should transmit them to the kidneys. In winter,
however, the kidneys act as king, and a king does not accept evil. Therefore, the spleen wishes to
return [the evil influences] to the liver, but the liver is unwilling to accept them. Hence they stay [in
the spleen] and conglomerate, causing accumulations. Hence one knows that "blocked influences" are
contracted in winter on a jen-kuei day. (22) Accumulations in the lung are called "rest and run." (23)
They are located below the ribs on the right side and are several times the size of a cup. They last a
long time without healing. (24) They let the [afflicted] person shiver due to [alternating perceptions
of] cold and heat, and [they let him] cough and develop blockages in his lung. (25) [Such illnesses]
are contracted in spring on a chia-i day. (26) Why do I say so? When the heart is ill, it will transmit
[evil influences] to the lung, and the lung should transmit them to the liver. In spring, however, the
liver acts as king, and kings do not accept evil. Therefore, the lung wishes to return [the evil
influences] to the heart, but the heart is unwilling to accept them. Hence they stay [in the lung] and
conglomerate, causing accumulations. Hence one knows that "rest and run" is contracted in spring on
a chia-i day. (27) Accumulations related to the kidneys are called "running piglets." (28) They
develop in the lower abdomen and extend upward to below the heart. (29) Like a piglet, they move up
or down unexpectedly. They last a long time without ending. (30) They let the [afflicted] person pant
due to [influences] moving contrary to their proper direction. (31) [They cause] the bones to weaken
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and to have few influences. (32) [Such illnesses] are contracted in summer on a ping-ting day. (33)
Why do I say so? When the spleen is sick, it will transmit [evil influences] to the kidneys, and the
kidneys should transmit them to the heart. In summer, however, the heart acts as king, and a king
does not accept evil. Therefore, the kidneys wish to return [the evil influences] to the spleen, but the
spleen is not willing to accept them. Hence they stay [in the kidneys] and conglomerate, causing
accumulations. Hence one knows that "running piglets" are contracted in summer on a ping-ting day.
(34) These are the important patterns of the five accumulations.3
Unschulds Footnotes
1. The entire stomach is understood here as a duct.
2. The wording of this last phrase may not reflect the original sequence of the characters. I suspect
that it corresponds to sentence 4 and should be read ju fu ta p'an ("they resemble a large bowl turned
upside down"). The same applies to sentence 3.
3. This difficult issue is another example of the consistent application of the Five Phases doctrine to
pathology. Once again, terms and concepts originating from the Nei-ching are systematically
redefined, a fact which irritated later conservative commentators, who considered the contents of the
Nei-chingheterogeneous and inconsistent as they areto be binding. Also, in the absence of any
tangible evidence, the author(s) of the Nan-ching again resorted to social symbolism to legitimise
their ideas. For some of the illness terms mentioned here, see Ling-shu treatise 13, "Ching Chin" and
Su-wen treatise 40, "Fu-chung lun".
THE FIFTY-SEVENTH DIFFICULT ISSUE
Overview: Introduction of a five-fold classification of different diarrheas.

The fifty-seventh difficult issue: (1) How many kinds of diarrhea exist; do they all have names?
(2) It is like this. Altogether, there are five kinds of diarrhea, and all are named differently. They
include the "diarrhea of the stomach," the "diarrhea of the spleen," the "diarrhea of the large
intestine," the "diarrhea of the small intestine," and the "diarrhea of large concentrations." [Another]
designation [for the latter] is "heavy behind." (3) In case of a diarrhea of the stomach, food and drink
are not transformed, and the color [of the stools] is yellow. (4) In case of a diarrhea of the spleen, the
abdomen is swollen and full. Liquid diarrhea rushes down; solid food is vomited, proceeding
contrary to its proper course.

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(5) In case of a diarrhea of the large intestine, one

has cramps [in the abdomen] after having consumed
food. The stools are white. One hears sounds in the
intestines and feels a cutting pain. (6) In case of a
diarrhea of the small intestines, one passes pus and
blood with the urine and with the stools, and one
feels pain in the lower abdomen. (7) In case of a
diarrhea of large concentrations, one feels tensions
inside [the abdomen] and heaviness at the behind.
One goes to the latrine frequently and is still unable
to pass any stools. Pain is felt in one's stalk. (8)
These are the important patterns of the five kinds of
diarrhea.

THE FIFTY-EIGHTH DIFFICULT ISSUE

Overview: Introduction of a fivefold classification of "harm caused by cold" illnesses and of the
different movements in the vessels resulting from these illnesses. Also, a list of signs and symptoms
allowing for a diagnosis of illnesses caused by heat and cold.

The fifty-eighth difficult issue: (1) How many kinds of "harm caused by cold" exist; are they
accompanied by any changes in the [movement of the influences in the] vessels?
(2) It is like this. There are five kinds of harm caused by cold. These include to be hit by wind, to
have been harmed by cold, moisture and warmth, the heat illness, and the warmth illness. In each

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case the complaints are different. (3) In case one was hit by wind, the [movement in the] vessels is at
the surface and smooth at the yang [section] while it is soft and weak at the yin [section].
(4) [The movement in the] vessels in case of moisture
and warmth is soft and weak at the yang [section]
while it is minor and tense at the yin [section]. (5) [The
movement that can be felt in the] vessels in case of
harm caused by cold is full, tight, and rough at both
the yin and yang [sections]. (6) [The movement that
can be felt in the] vessels in case of a heat illness is at
the surface at both the yin and yang [sections. If one
touches] the surface, [one perceives a] smooth
[movement; if one presses one's fingers to] the depth,
[the movement perceived there is] dispersed and
rough. (7) [The movement in] the vessels in case of a
warmth illness [is characterized by the fact that this
illness] proceeds through all conduits. It is impossible
to know to which [specific] conduit a movement is
related. In this case one takes [the evil influences]
away from the specific conduit where they just happen
to be.
(8) In case of harm caused by cold, one may induce
sweating and a cure will be achieved, but if one
induced purging [the patient would] die. There are
other cases where sweating causes death while purging
would lead to a cure. Why is that?
(9) It is like this. In case of a depletion of yang [influences] and an abundance of yin [influences],
sweating will lead to a cure and purging will lead to death. (10) In case of an abundance of yang
[influences] and a depletion of yin [influences], sweating will lead to death and purging will bring
about a cure.
(11) How can the [different] cold-heat illnesses be diagnosed?
(12) It is like this. When cold and heat have affected the skin, the skin will not approach the mat, the
hair will be scorched, and the nose will be dry. One must not induce sweating. (13) When cold and
heat have affected the flesh, pain will be felt in the skin. The lips and the tongue will dry out, and
there will be nothing that could be sweated. (14) When cold and heat have affected the bones, one
suffers from unrest all over [the body]. Sweat will flow ceaselessly; the roots of the teeth will dry out
and be in pain.
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THE FIFTY-NINTH DIFFICULT ISSUE

Overview: How to distinguish falling sickness from madness.

The fifty-ninth difficult issue: (1) By what [criteria] can the illnesses
of madness and falling sickness be distinguished?
(2) It is like this. During the initial development of madness, one
rests only rarely and does not feel hungry. One will [speak of]
oneself as occupying a lofty, exemplary position. One will point out
one's special wisdom, and one will behave in an arrogant and
haughty way. One will laughand find joy in singing and making
musicwithout reason, and one will walk around heedlessly without
break. (3) During the initial development of falling sickness, one's
thoughts are unhappy. One lies down and stares straight ahead. (4)
The yin and the yang [movements in the] vessels are full in all three
sections.

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THE SIXTIETH DIFFICULT ISSUE

Overview: Discussion of the concepts of "stagnant pain" and "true pain" in head and heart.

The sixtieth difficult issue: (1) Among the illnesses of head and
heart are "recurrent pain" and "true pain." What does that mean?
(2) It is like this. When the three hand-yang vessels have received
[influences of] wind-coldwhich remain hidden where they are
and do not move awaythat is called "recurrent headache." (3)
When [these influences] enter and join with the brain, that is called
"true headache." (4) When the influences of [any of] the five depots
turn against [the heart], that is called "recurrent heartache." (5)
When the pain is extreme, and when it is limited to the heart, while
the hands and the feet are virid,1 that is called "true heartache." (6)
When the onset of true heartache is in the morning, death will occur
at night; when the onset is at night, death will occur in the morning.
Unschulds Footnotes
1. The character ch'ing ("virid") may be a mistake for ch'ing
("cool"), as some commentators have assumed, because the
corresponding passage in the Nei-ching (see Ling-shu treatise 24,
"Cheh-ping") says: "In case of true heartache, hands and feet are
cool." However, one should be cautious in interpreting changes in
the Nan-ching on the basis of the Nei-ching. Interestingly enough,
Hs Ta-chun accepted the reading of ch'ing as "virid."

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THE SIXTY-FIRST DIFFICULT ISSUE

Overview: Introduction of a categorization of healers as "spirits'" "sages," "artisans," and
"workmen," based on their respective approaches to diagnosing an illness.

The sixty-first difficult issue: (1) The scripture states:

Anybody who looks and knows it is to be called a spirit;
anybody who listens and knows it is to be called a sage;
anybody who asks and knows it is to be called an artisan;
anybody who feels the vessels and knows it is to be called
a skilled workman. What does that mean?
(2) It is like this. Those who "look and know it" are those
who look for the five colors [in a person's complexion] in
order to know his illness. (3) Those who "listen and know
it" are those who listen to the five notes [in a person's
voice] in order to distinguish his illness. (4) Those who
"ask and know it" are those who ask [the patient which of]
the five tastes he longs for in order to know where his
illness has emerged and where it is located now. (5) Those
who "feel the vessels and know it" are those who examine
the [patient's] inch-opening and see whether he is marked
by depletion or repletion in order to know in which depot
or palace his illness is located.1
(6) That is [what is] meant when the scripture states: Those who know the [illness] from its external
[manifestations] are called sages; those who know the [illness] from its internal [manifestations] are
called spirits.
Unschulds Footnotes
1. Most later editions have omitted one of the two consecutive characters ping ("illness") in this
sentence. I have retained both in the text, but have disregarded one in my translation.

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