Author: Zheng Hongbin, Zhejiang University of Traditional Chinese Medicine
• The discussions on the pathogenesis of deficiency and excess in the Huangdi Neijing can be found in the dedicated chapter on deficiency and excess in the Suwen: General Discussion on Deficiency and Excess, as well as scattered throughout the Ling Shu: On the Spirit and Su Wen: On Regulating the Menstrual Cycle, among others. The content is quite rich and comprehensive, prominently reflecting the manifestations of deficiency and excess in the five organs, six qi, four seas, and the internal and external aspects of yin and yang, providing a theoretical basis for the clinical differentiation of deficiency and excess and the application of tonifying deficiency and draining excess treatment principles in later generations.
The Su Wen: On Regulating the Menstrual Cycle states: “All diseases arise from deficiency and excess.” The formation of deficiency and excess syndromes during the occurrence and development of diseases is primarily due to the struggle between the righteous and the evil and the comparison of their strengths. The Su Wen: General Discussion on Deficiency and Excess states: “When evil qi is strong, it is excess; when vital essence is depleted, it is deficiency.” It is generally believed that strong evil qi refers to the strong pathogenic power of the six excesses invading the human body, presenting a state of excess after invasion, and also refers to the pathological products resulting from the dysfunction of the organs under the influence of internal and external evils, including blood stasis, phlegm, food accumulation, and various parasites that cause harm within the body; the depletion of vital essence mainly refers to the loss of spirit, qi, blood, and body fluids, as well as the weakness of organ functions, including deficiency of yin, yang, qi, blood, and weakness of the organs.
Characteristics and Manifestations of Deficiency and Excess Pathogenesis
Deficiency and Excess of the Five Organs
The Huangdi Neijing contains numerous discussions on the deficiency and excess syndromes of the five organs, with representative discussions found in the Ling Shu: On the Spirit, Su Wen: On Regulating the Menstrual Cycle, and Su Wen: On the True Storage of the Jade Machine, which discuss the manifestations of deficiency and excess syndromes of the five organs and the symptoms and prognosis of the five excesses and five deficiencies.
The Ling Shu: On the Spirit states: “The liver stores blood, and blood houses the soul. When liver qi is deficient, there is fear; when it is excessive, there is anger. The spleen stores nutrients, and nutrients house intention; when spleen qi is deficient, the limbs are weak, and the five organs are unsettled; when it is excessive, there is abdominal distension and difficulty in urination. The heart stores the pulse, and the pulse houses the spirit; when heart qi is deficient, there is sadness; when it is excessive, there is unending laughter. The lungs store qi, and qi houses the corporeal soul; when lung qi is deficient, there is nasal congestion and shortness of breath; when it is excessive, there is wheezing and fullness in the chest. The kidneys store essence, and essence houses will; when kidney qi is deficient, there is cold extremities; when it is excessive, there is distension and unsettledness of the five organs.” The amount of qi in the five organs varies, and their clinical manifestations differ. The liver stores blood, and blood houses the soul; in terms of intention, it manifests as anger. When liver qi is deficient, it steals maternal qi, and kidney water overflows, leading to fear; when liver blood is abundant, wood qi is overly vigorous, leading to easy anger. The spleen stores nutrients, and nutrients house intention; when spleen qi is deficient, it fails to transform and transport, cannot ascend and disperse the essence, and nourish the limbs and five organs, leading to weakness in the limbs and unsettledness of the five organs; when the spleen is excessive, the middle burner fails to function, and turbid qi does not descend, leading to abdominal distension and irregular bowel movements. The heart stores the pulse, and the pulse houses the spirit; in terms of intention, it manifests as joy. When heart qi is deficient, the spirit is not nourished, leading to sadness, depression, and lethargy; when heart fire is excessive, the spirit is overly excited, leading to unending laughter. The lungs govern qi, and qi houses the corporeal soul; when lung qi is deficient, qi has no master, and the regulation of inhalation and exhalation fails, leading to nasal congestion and shortness of breath; when the lungs are invaded by evil, lung qi is obstructed, leading to wheezing and chest tightness. The kidneys store essence, and essence houses will; when kidney qi is deficient, the original yang is not vigorous, leading to cold extremities; when kidney essence is excessive, cold water accumulates internally, leading to abdominal distension, edema, and unsettledness of the five organs. Notably, when discussing the deficiency and excess syndromes of the spleen and kidneys, abdominal distension and unsettledness of the five organs are mentioned, indicating that in the differentiation of deficiency and excess syndromes of the five organs, especially concerning the normal functioning of the five organs and the ascending and descending of the middle burner qi mechanism, the spleen and kidneys are extremely important organs. This also provides a strong basis for the later theory that the spleen is the foundation of postnatal life and the kidneys are the foundation of prenatal life.
Similar discussions on the deficiency and excess syndromes of the five organs can also be found in the Su Wen: On Regulating the Menstrual Cycle. The text states: “When the spirit is abundant, there is unending laughter; when the spirit is insufficient, there is sadness… When qi is abundant, there is wheezing and coughing; when it is insufficient, there is shortness of breath… When blood is abundant, there is anger; when it is insufficient, there is fear… When the body is abundant, there is abdominal distension and difficulty in urination; when it is insufficient, the limbs are weak… When intention is abundant, there is abdominal distension and diarrhea; when it is insufficient, there is cold extremities.” The spirit, qi, blood, body, and intention correspond to the heart, lungs, liver, spleen, and kidneys, respectively, and their abundance or insufficiency represents the changes of deficiency and excess in the five organs, which are clinical manifestations of dysfunction in the five organ systems. It can be seen that the pathogenesis of deficiency and excess in the five organs has already taken shape in the Huangdi Neijing, thus laying a solid foundation for the later differentiation and treatment of organ syndromes. Therefore, Yang Shangshan stated: “In the way of healing, one must first recognize the deficiency and excess of the qi of the five organs, and understand the diseases arising from deficiency and excess, before prescribing needles and herbs, and carefully adjusting them.”
The Su Wen: On the True Storage of the Jade Machine states: “When the pulse is strong, the skin is hot, there is abdominal distension, and there is no passage before and after, this is called five excesses; when the pulse is thin, the skin is cold, there is little qi, and there is diarrhea before and after, and food does not enter, this is called five deficiencies.” A strong pulse, hot skin, abdominal distension, and no passage before and after represent the excess of evil in the five organs; while a thin pulse, cold skin, little qi, diarrhea before and after, and food not entering represent the deficiency of the five organs. As Zhang Zicong stated: “The heart governs the pulse; a strong pulse indicates heart qi is excessive; the lungs govern the skin and hair; hot skin indicates lung qi is excessive; the spleen governs the abdomen; abdominal distension indicates spleen qi is excessive; the kidneys open to the two yin; no passage before and after indicates kidney qi is excessive; dizziness indicates the eyes are not clear, and the liver opens to the eyes; dizziness indicates liver qi is excessive. A thin pulse indicates heart qi is deficient; cold skin indicates lung qi is deficient; the liver governs the spring energy; little qi indicates liver qi is deficient; diarrhea before and after indicates kidney qi is deficient; food not entering indicates spleen qi is deficient.” This indicates that the five excess syndromes are manifestations of strong evil qi in the five organs, resulting from the excess of evil qi, which obstructs and accumulates internally, filling the five organs, leading to dysfunction. Due to the strong power of the pathogenic evil, and the righteous qi being relatively sufficient, it manifests as a fierce struggle between the righteous and the evil, with the evil not being able to escape outward, thus the disease is more dangerous and has a poor prognosis. Conversely, the five deficiency syndromes represent the decline of the essence and qi of the five organs, with the righteous qi being exhausted and unable to resist the evil, compounded by increasing consumption and insufficient nourishment, leading to a lack of source for transformation and a difficulty in restoring the functions of the five organs, making these syndromes also very dangerous. Therefore, the Su Wen: On the True Storage of the Jade Machine states: “Five excesses lead to death, and five deficiencies lead to death,” indicating that the deficiency and excess of the five organs have significant guiding implications for judging changes in pathogenesis and prognosis.
Deficiency of the Six Qi
The six qi refer to the six essential substances: essence, qi, fluids, blood, pulse, and marrow, which are the products of the activities of the organs and are also important substances that constitute and maintain human life activities. The Huangdi Neijing believes that the six qi originate from true qi, are transformed from true qi, and are based on prenatal factors while developing in the postnatal period. The excessive depletion of the six qi is a significant cause of the weakening of the body’s righteous qi and is a key mechanism for the formation of deficiency syndromes. As stated in the Ling Shu: On Deciding Qi: “When essence is depleted, there is deafness. When qi is depleted, there is dimness of vision. When fluids are depleted, the pores open, and there is profuse sweating. When liquid is depleted, the bones are stiff and difficult to move, the complexion is pale, the brain marrow is depleted, the shins are weak, and there is tinnitus. When blood is depleted, the complexion is pale, and there is no luster; the pulse is empty and weak.” Since the kidneys store essence, and the ears are the orifices of the kidneys, when essence is depleted, there is tinnitus and deafness, often accompanied by dizziness, weakness in the lower back and knees, and premature ejaculation; the eyes are nourished by the essence and qi of the five organs and six viscera, so when yang qi is deficient, there is dimness of vision and blurred sight, often accompanied by fatigue, shortness of breath, and lethargy; fluids arise from the pores, and profuse sweating is a result of yang acting on yin, so when fluids are depleted, the pores open, and there is profuse sweating, often accompanied by dryness of the mouth and throat, fatigue, and shortness of breath; liquid is transformed from the essence of food and drink, nourishing the bones and benefiting the brain marrow, so when liquid is depleted, the marrow, skin, and ear orifices cannot be nourished, leading to stiffness of the bones, withered and dry skin, weakness in the shins, and often accompanied by emaciation, dizziness, and weakness in the lower back; blood is transformed from the essence of food and drink, and circulates in the vessels, so when blood is depleted, its nourishing and moistening functions are impaired, leading to a pale complexion, lack of luster, often accompanied by pale nails and lips; the pulse is the vessel of blood, distributed throughout the body, serving as the channel for blood circulation, so when the pulse is depleted, blood is lost, and the pulse is empty and weak; in cases of significant blood loss, a hollow pulse is often observed.
The manifestations of the deficiency of the six qi further confirm the significant meaning of the pathogenesis of “when essence and qi are depleted, there is deficiency,” providing clinical evidence for the generation and development of deficiency syndromes. Additionally, it confirms the importance of the existence of life substances in affecting the activities of the organs and meridians from the perspective of the depletion of the basic substances of the human body, providing theoretical guidance for the clinical diagnosis and treatment of syndromes related to deficiency of essence, qi, blood, and fluids. For example, treating deafness with kidney tonification and essence replenishment, treating dimness of vision with qi tonification, treating profuse sweating with qi tonification and fluid generation, treating liquid depletion with yin tonification and fluid replenishment, treating blood deficiency with blood tonification and nourishment, and treating bleeding with hemostatic methods are all effective treatment methods guided by the theory of the deficiency of the six qi in the Huangdi Neijing, worthy of further research and exploration.
Deficiency and Excess of the Four Seas
The seas refer to the places where all rivers converge and are also the sources of life for living beings. The Huangdi Neijing discusses the four seas, which are divided into the sea of food and grain, the sea of qi, the sea of blood, and the sea of marrow, paralleling the four seas of the natural world (east, west, south, and north), and explaining the significance of the existence of these four substances in the human body. It also includes a dedicated chapter in the Ling Shu: On the Seas that elaborates on their physiology, pathology, symptoms, and treatment principles, particularly regarding the syndromes of excess and deficiency of the four seas, which is an important aspect of the pathogenesis of deficiency and excess and has significant guiding implications for clinical practice.
The Ling Shu: On the Seas states: “When the sea of qi is excessive, there is fullness in the chest, and the face is red; when the sea of qi is deficient, there is insufficient qi to speak. When the sea of blood is excessive, one often feels large in body, and is unaware of the disease; when the sea of blood is deficient, one often feels small in body, and is melancholic and unhappy. When the sea of food and grain is excessive, there is abdominal fullness; when the sea of food and grain is deficient, there is hunger and inability to accept food. When the sea of marrow is excessive, there is excessive energy and strength, leading to overexertion; when the sea of marrow is deficient, there is dizziness, tinnitus, weakness in the shins, and dimness of vision.” The four seas are the places where the essence and qi of the human body converge; excess indicates stagnation of evil qi, while deficiency indicates weakness of essence and qi. For example, when the sea of qi is excessive, there is chest fullness and shortness of breath, indicating a syndrome of heart and lung excess heat; when the sea of qi is deficient, there is shortness of breath and inability to continue speaking, indicating a syndrome of heart and lung deficiency. When the sea of blood is excessive, there is a feeling of being large in body, indicating stagnation of essence and blood; when the sea of blood is deficient, there is a feeling of being small in body, indicating liver blood deficiency. When the sea of food and grain is excessive, there is abdominal fullness and belching, indicating food accumulation in the stomach; when the sea of food and grain is deficient, there is hunger and lack of desire for food, indicating spleen and stomach deficiency. When the sea of marrow is excessive, there is excessive energy and strength, indicating phlegm-heat stagnation; when the sea of marrow is deficient, there is dizziness, tinnitus, weakness in the shins, indicating kidney essence deficiency. Therefore, the manifestations of excess and deficiency in the four seas reflect the changes in the pathogenesis of deficiency and excess in the Huangdi Neijing, serving as an important theoretical and methodological basis for clinical differentiation of deficiency and excess syndromes.
The theory of deficiency and excess in the four seas also guides clinical treatment methods and has significant implications for later generations of physicians in the clinical differentiation and treatment of syndromes of excess and deficiency in the four seas. For example, during the Ming Dynasty, Yu Chang created the “Great Qi Theory” based on the deficiency and excess of the sea of qi, believing that the great qi in the chest governs the operation of the nutritive and defensive qi, organs, and meridians, circulating without interruption, and is the most important qi for the activities of life, which must not be deficient or obstructed. In the Qing Dynasty, Zhang Xichun used this theory to create the “Rising and Falling Decoction” to treat the sinking of the great qi in the chest, which was very effective. Additionally, the theory of excess and deficiency of the sea of marrow is used to guide the treatment of brain diseases; excess of the sea of marrow often corresponds to manic disorders, while deficiency often corresponds to dizziness and tinnitus, indicating that the Huangdi Neijing has provided considerable observations and understanding of the functions and diseases of the brain, offering theoretical guidance for the diagnosis and treatment of such diseases in later generations.
Internal and External Cold and Heat, Deficiency and Excess of Yin and Yang
The theory of deficiency and excess in the Huangdi Neijing also analyzes the changes of deficiency and excess in conjunction with the internal and external aspects of cold and heat, deeply grasping the intricate changes in pathogenesis, to elucidate the internal laws of the occurrence and development of syndromes, thus laying a theoretical foundation for the later establishment of the eight principles of differentiation.
The Su Wen: On Regulating the Menstrual Cycle states: “When yang is deficient, there is external cold; when yin is deficient, there is internal heat; when yang is excessive, there is external heat; when yin is excessive, there is internal cold.” The text states that “when yang is deficient, there is external cold,” referring to the invasion of cold evil, obstructing the defensive yang qi, preventing it from reaching the skin surface, leading to an external cold syndrome; thus it states: “Yang receives qi from the upper burner to warm the skin and flesh. Now, if cold qi is outside, the upper burner is obstructed, and if the upper burner is obstructed, cold qi remains outside, leading to chills.” The phrase “when yin is deficient, there is internal heat” refers to excessive labor and fatigue damaging the spleen qi, causing the clear yang to fail to rise, the turbid yin to fail to descend, and the qi of food to stagnate, leading to a qi deficiency heat syndrome; thus it states: “With excessive labor and fatigue, the body qi weakens, the qi of food is not abundant, the upper burner fails to function, the lower burner is obstructed, and the stomach qi becomes hot, leading to internal heat.” The phrase “when yang is excessive, there is external heat” refers to the obstruction of the upper burner, leading to the closure of the pores and the stagnation of the defensive qi, resulting in an external heat syndrome; thus it states: “If the upper burner is not open, the skin becomes dense, the pores are closed, and the defensive qi cannot leak out, leading to external heat.” The phrase “when yin is excessive, there is internal cold” refers to the accumulation of cold qi in the chest, leading to the stagnation of blood vessels, which over time damages yang qi, resulting in a syndrome of chest yang obstruction; thus it states: “Rebellious qi rises, cold qi accumulates in the chest and does not disperse; if it does not disperse, warm qi departs, and cold remains, leading to blood stagnation and obstruction, resulting in a strong and tight pulse.” This discussion effectively combines the pathogenesis of deficiency and excess with the pathogenesis of internal and external cold and heat, laying the foundation for the later understanding of the pathogenesis of yin and yang excess and deficiency, cold and heat.
The theory of yin and yang posits that the opposition and interdependence of yin and yang, as well as their balance, are fundamental conditions for maintaining normal life activities. Once this balance is disrupted, pathological changes in yin and yang occur, and the relative excess or deficiency of yin and yang can manifest as different syndromes of either cold or heat, or deficiency or excess. Thus, Zhang Jiebin stated: “Cold and heat are the transformations of yin and yang.” This corresponds to the commonly stated pathogenesis of “when yang is excessive, there is heat; when yin is excessive, there is cold; when yang is deficient, there is cold; when yin is deficient, there is heat.” These four pathogenesis concepts have developed based on the Huangdi Neijing, and the resulting different syndromes of cold, heat, deficiency, and excess have significant differences in connotation from those discussed in the Huangdi Neijing. Among them, the phrase “when yang is deficient, there is cold” refers to the damage to the body’s yang qi, leading to a decline in warming functions, resulting in a deficiency-cold syndrome where the organs do not receive the warmth of yang qi; the phrase “when yin is deficient, there is heat” refers to the insufficiency of yin fluids in the heart, lungs, stomach, liver, and kidneys, leading to relative excess of yang and the internal generation of deficiency-heat; the phrase “when yang is excessive, there is heat” refers to the heat syndrome caused by the invasion of summer heat and other yang evils, including both exterior and interior heat; while the phrase “when yin is excessive, there is cold” refers to the excessive presence of cold evil and other yin evils, damaging yang qi and leading to a deficiency-cold syndrome. This illustrates the differences in the understanding of the pathogenesis of yin and yang excess and deficiency, cold and heat, from ancient to modern times, and it is essential to distinguish clearly in clinical practice to avoid confusion.
Different Meanings of Deficiency and Excess in the Huangdi Neijing
The Huangdi Neijing discusses the changes in deficiency and excess from different perspectives, and the meanings vary accordingly. The term deficiency and excess can be discussed from the perspective of the rise and fall of evil and righteous qi, where excess indicates that evil qi is dominant while righteous qi is not weakened; deficiency indicates that righteous qi is dominant while evil qi is not strong, which corresponds to the outline of the pathogenesis of deficiency and excess: “When evil qi is strong, it is excess; when vital essence is depleted, it is deficiency.” Secondly, it can be discussed from the perspective of the distribution of qi and blood in the meridians, where excess indicates the convergence of blood and qi, while deficiency indicates the separation of blood and qi. As stated in the Su Wen: On Regulating the Menstrual Cycle: “Qi and blood are combined, yin and yang are inclined, qi is chaotic in the defensive layer, blood is reversed in the channels, and blood and qi are separated; one is excess, and the other is deficiency… where there is presence, it is excess; where there is absence, it is deficiency; thus, when qi is combined, there is no blood; when blood is combined, there is no qi; now blood and qi are separated, thus it is deficiency.” This differs conceptually from the deficiency and excess of evil and righteous qi, as it is based on the different distribution of qi and blood in the meridians to determine the “deficiency” or “excess” of a certain part. This theory of deficiency and excess has significant academic value in explaining the pathogenesis of disorders related to the chaotic movement of qi and blood in the meridians, as well as the principles and methods of treatment in acupuncture, tuina, and other therapies.
Furthermore, from the perspective of the clinical significance of the pathogenesis of deficiency and excess, the concepts of deficiency and excess in the Huangdi Neijing regarding the rise and fall of evil and righteous qi and the distribution of qi and blood actually have an interpenetrating and overlapping relationship. Discussing deficiency and excess from the perspective of the rise and fall of evil and righteous qi is broad and applicable, serving as the general guideline for differentiation in traditional Chinese medicine, while discussing deficiency and excess from the perspective of the distribution of qi and blood is a specific discussion of the conditions of qi and blood deficiency and excess. For example, “qi convergence” often manifests as qi stagnation, qi counterflow, qi depression, qi blockage, and qi closure; “blood convergence” often manifests as blood stasis, blood heat, and blood cold; while “qi and blood convergence” can manifest as qi stagnation with blood stasis, qi counterflow with blood surging, and blood cold with qi blockage, all of which can be classified under the category of “when evil qi is strong, it is excess.” Due to the different locations of qi and blood convergence, various symptoms such as mania, anger, anxiety, forgetfulness, etc., can manifest, and appropriate treatment methods such as qi-moving and blood-activating can be selected under the guidance of the treatment principle of “for excess, drain it.” If qi and blood are dispersed in a certain area, it will lead to qi deficiency, qi consumption, qi sinking, qi depletion, or blood deficiency, blood desiccation, blood depletion, and even pathological phenomena such as qi not restraining blood, qi following blood depletion, and both qi and blood deficiency, which can be classified under the category of “when essence and qi are depleted, there is deficiency.” In clinical practice, it is advisable to select methods for tonifying qi and nourishing blood under the guidance of the principle of “for deficiency, tonify it.”
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