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Chapter 46 of 81
黄帝内经·灵枢
Textual Revisions Several textual errors in the transmitted version of this chapter have been corrected against the standard edition of Ling Shu · Five Variations: "gǔ lǐ" (股理) should read "còu lǐ" (腠理); "yān ròu" (烟肉) should read "jùn ròu" (䐃肉); "xiāo zhàng" (消瘴) and "xiāo jīn" (消津) should read "xiāo dān" (消瘅); "xì hàn" (戏汗) should read "lù hàn" (漉汗); "wú" (吴) should read "yǐ" (矣).
Overall Paraphrase
The Yellow Emperor asked Shao Yu: I have heard that when various diseases first arise, they are mostly due to external pathogens such as wind, rain, cold, and summer heat, which enter through the sweat pores into the interstices of the skin and muscles (còu lǐ). After entering, some resolve on their own, some remain lodged, some form wind-edema with sweating, some form consumptive-thirst (xiāo dān, diseases involving internal heat consuming the body fluids), some become alternating chills and fever (hán rè), some become persistent bi-obstruction (liú bì, numbness and pain in the limbs and joints), and some become accumulations (jī jù, masses in the abdomen). Strange pathogens flow and spread everywhere, too numerous to count. Why is it that when people fall ill at the same time, some contract one disease while others contract another? Could it be that Heaven's wind is partial to certain people? Why is the difference so great?
Shao Yu replied: The wind generated by Heaven is not partial toward any of the people; it operates with fairness and rectitude. Those who offend against it fall ill; those who avoid it remain safe and well. It is not that the wind deliberately seeks out any particular person—rather, the person offends against it themselves.
The Yellow Emperor asked again: When people encounter wind at the same time and fall ill simultaneously, yet each person's disease is different—what is the reason for this?
Shao Yu said: An excellent question! Allow me to use an analogy with craftsmen. A craftsman sharpens his axe and blade, then uses them to fell timber. The sunny and shady sides of a tree differ in hardness and fragility; hard places are not easy to cut into, fragile places have loose bark, and when the blade strikes tangled knots, it may even chip. Even within a single tree, hardness and fragility differ—the hard parts are strong, and the fragile parts are easily injured—let alone among different species of trees, where bark thickness and sap quantity vary even more greatly.
Let me further draw five analogies of trees being harmed by pathogenic influences: A tree that flowers and leafs early, when struck by spring frost and fierce wind, will shed its blossoms and wilt. After prolonged scorching drought, trees with brittle bark and thin skin will have branches with little sap and withered leaves. In prolonged overcast rainy weather, trees with thin bark and abundant sap will have rotting, oozing bark. When a sudden violent wind arises, rigid and brittle trees may suffer broken branches and damaged trunks. When autumn frost and swift winds arrive, rigid and brittle trees may have shaken roots and falling leaves. These five situations each involve different causes and manifestations of damage—how much more so for human beings?
The Yellow Emperor asked: Then how can people be compared to trees?
Shao Yu replied: When trees are injured, the injuries are mostly on the branches; if the branches are firm and resilient, they are not easily damaged. That people frequently have illnesses is likewise because their bones, joints, skin, and interstices are not solid, making them places where pathogens can lodge—hence they fall ill frequently.
The Yellow Emperor asked: How can one diagnose a person prone to wind-counterflow with drenching sweat (fēng jué lù hàn, qi counterflow and uncontrollable sweating after exposure to wind)?
Shao Yu replied: If the flesh is not firm and the interstices are loose, the person is prone to wind disorders.
The Yellow Emperor asked: How does one diagnose flesh that is not firm?
Shao Yu replied: The prominent muscles (jùn ròu, raised fleshy areas) are not firm, without clear striations, with coarse texture, skin not dense, and interstices loose and open. This is speaking of the general state of the flesh throughout the body.
The Yellow Emperor asked: How can one diagnose a person prone to consumptive-thirst?
Shao Yu replied: Those in whom all five viscera are weak are prone to consumptive-thirst.
The Yellow Emperor asked: How does one know the five viscera are weak?
Shao Yu replied: People with weak viscera often have a strong and unyielding aspect; the strong are prone to anger, and the weak viscera are easily injured.
The Yellow Emperor asked: How does one diagnose this weakness paired with strength?
Shao Yu replied: Such people have thin skin, deep-set eye sockets, long eyebrows that are straight and upright, and a will that is strong and unyielding; being strong, they are prone to anger, and anger causes qi to flow upward in rebellion, leading to stagnation in the chest, turbulent blood and qi lodging, malnourishment and loosening of the skin and muscles, impeded flow of blood in the vessels, which transforms into heat🔥. The heat scorches the flesh, so consumptive-thirst forms. This indicates a person of fierce and rigid temperament but with weak and fragile flesh.
The Yellow Emperor asked: How can one diagnose a person prone to alternating chills and fever?
Shao Yu replied: People with small bones and weak muscles are prone to alternating chills and fever.
The Yellow Emperor asked: How does one diagnose bone size, muscle firmness or fragility, and discrepancies in complexion?
Shao Yu replied: The cheekbones serve as the external primary indicator of the skeletal frame. Prominent cheekbones indicate a large frame; small cheekbones indicate a small frame. Thin skin with insubstantial flesh, weak and limp arms, a dull and lusterless complexion on the lower part of the face (the chin region) that fails to harmonize with the normal complexion of the forehead, appearing uniquely turbid—these are the signs. Additionally, those with thin muscle on the arms have insufficient marrow and essence, so they are prone to alternating chills and fever.
The Yellow Emperor asked: How can one diagnose a person prone to bi-obstruction?
Shao Yu replied: Those with coarse skin texture and infirm flesh are prone to bi-obstruction.
The Yellow Emperor asked: Do bi-obstructions occur at different heights or locations on the body?
Shao Yu replied: To know the level, one must observe the corresponding region.
The Yellow Emperor asked: How can one diagnose a person prone to accumulations in the intestines?
Shao Yu replied: Those with thin, lusterless skin and flesh that is not firm yet moist have poor stomach and intestinal function; when the stomach and intestines are weak, pathogens easily lodge there, and accumulations form. When cold and warmth are not balanced between the spleen and stomach, pathogens gradually invade; when essence and pathogen accumulate together, large masses formed.
The Yellow Emperor said: I now understand the manifestations of disease. I would also like to hear about the relationship between disease onset and time.
Shao Yu replied: First, determine the waxing and waning of the year's qi or movement, and from this understand what is favorable or unfavorable for the season. When the seasonal qi is high, disease arises readily; when it is low, the condition is critical. Even in times when there is no opposing decline, if in the given year there is a clashing or overpowering influence, disease is certain to arise. This is the principle governing how disease arises from body constitution and the outline of the five variations.
The core of this chapter is constitution determines disease tendency. When people are exposed to the same external pathogen, some fall ill with one condition and others with another. The key lies not in "Heaven's wind showing partiality," but in whether each person's bones, joints, skin, interstices, viscera, muscles, and skeletal frame are solid. This resonates with the principle repeatedly emphasized in the Huangdi Neijing: "Where pathogens gather, there must be deficiency of qi." External pathogens are merely the condition; the root of disease lies in the body's internal weak points.
Shao Yu uses the analogy of a craftsman felling wood: the same axe, applied to different trees—or even different parts of the same tree—yields different results because of the differences in hardness, fragility, and thickness of the wood. Likewise with people: those with loose interstices are prone to wind disorders; those with weak viscera but a strong, anger-prone heart are prone to consumptive-thirst; those with small bones and weak flesh are prone to alternating chills and fever; those with coarse interstices and infirm flesh are prone to bi-obstruction; and those with lusterless skin and weak stomach-intestine function are prone to accumulations. These five categories form the outline of the "five variations."
The final passage also touches on the temporal factor: disease onset is related not only to constitution but also to the waxing and waning of the year's qi movement and the height of seasonal qi, reflecting the ancients' holistic understanding of the relationship between "the body, time, and disease."
This text is a major early source of constitutional theory in Chinese medicine. The ideas of "individual susceptibility" and "weak points determining disease type" bear comparability with modern preventive medicine's concepts of "risk factors" and "individualized risk assessment." For instance, weakened skin barriers, low muscle mass, chronic emotional tension, and subpar gastrointestinal function may indeed influence susceptibility to certain conditions.
However, historical limitations should be acknowledged: observations such as "large cheekbones indicate a large frame, small cheekbones a small one" and discerning conditions from the facial complexions are rooted in direct empirical observation and lack modern anatomical and laboratory support. Moreover, terms like xiāo dān, hán rè, bì, and jī jù are broad symptomatic categories from antiquity and cannot be simplistically equated with specific modern disease entities. Bugu suggests that this content may be referenced for cultural understanding and constitutional observation, but should not be treated as modern diagnostic criteria.
Bugu's Note: This content is based on classical Chinese medicine texts and is provided solely for the study of traditional cultural heritage. It does not constitute any medical diagnosis, medication prescription, or treatment advice. Please consult a qualified healthcare professional if you are unwell.