灵枢经·终始 The End and the Beginning

The Way of needling in its entirety is comprehended within the doctrine of the End and the Beginning (zhongshi — the complete course of a disease and its treatment, from onset to resolution). When one clearly understands the End and the Beginning, the five viscera serve as the guiding framework, and yin and yang become fixed and determinate. Yin governs the viscera, and yang governs the bowels; yang receives its qi from the four extremities, and yin receives its qi from the five viscera. Hence in draining one meets the qi head-on, and in supplementing one follows along with it; only by knowing how to meet it and how to follow it can the qi be brought into harmony. The method for harmonizing the qi must penetrate through to yin and yang. The five viscera are yin, and the six bowels are yang; this teaching has been handed down to later generations sealed with a covenant of blood. Those who revere it will flourish; those who treat it with contempt will perish. To act without the Way, in pursuit of private ends, will surely bring premature death and calamity.

In reverent accord with the Way of Heaven, let me speak of the End and the Beginning. In this doctrine, the channel vessels serve as the guiding framework. By taking hold of the wrist pulse (cunkou) and the renying pulse (taken at the neck), one may know whether yin and yang are in surplus or insufficiency, and whether the body is level or unlevel — and thus the Way of Heaven is fully comprehended. The one called the 'level person' is a person free of illness; being free of illness means that the wrist pulse and the renying pulse respond in accordance with the four seasons, that upper and lower correspond to one another and move back and forth together, that the vessels of the six channels do not knot or stir abnormally, and that the cold and warmth of root and branch maintain their mutual charge over one another. The flesh, blood, and qi must all be commensurate with one another — this is called the level person. In one with insufficient qi, the wrist pulse and the renying pulse are both diminished, and fail to match the proper measure at the cubit and the inch. In such a case, both yin and yang are insufficient; to supplement the yang would exhaust the yin, and to drain the yin would cause the yang to collapse. In such a case, one may treat with sweet, mild medicinals, but must not administer strong, potent decoctions, nor should one apply moxibustion. If the condition does not resolve and one goes on to drain it regardless, the qi of the five viscera will be ruined.

When the renying pulse is one degree greater than the wrist pulse, the disease is located in the foot lesser yang; if it is one degree greater and also agitated, the disease is located in the hand lesser yang. When the renying pulse is two degrees greater, the disease is located in the foot greater yang; if it is two degrees greater and also agitated, the disease is located in the hand greater yang. When the renying pulse is three degrees greater, the disease is located in the foot yangming; if it is three degrees greater and also agitated, the disease is located in the hand yangming. When the renying pulse is four degrees greater, and moreover large and rapid, this is called 'overflowing yang'; overflowing yang results in outer blockage (waige).

When the wrist pulse is one degree greater than the renying pulse, the disease is located in the foot jueyin; if it is one degree greater and also agitated, the disease is in the hand ruler of the heart (the pericardium channel). When the wrist pulse is two degrees greater, the disease is located in the foot lesser yin; if it is two degrees greater and also agitated, the disease is in the hand lesser yin. When the wrist pulse is three degrees greater, the disease is located in the foot greater yin; if it is three degrees greater and also agitated, the disease is in the hand greater yin. When the wrist pulse is four degrees greater, and moreover large and rapid, this is called 'overflowing yin.' Overflowing yin results in inner closure (neiguan); when inner closure fails to open, the case is fatal and cannot be treated. When the renying pulse and the greater yin wrist pulse are both enlarged fourfold or more, this is called 'closure and blockage' (guange). One afflicted with closure and blockage will be given but a short span of time to live.

When the renying pulse is one degree greater, drain the foot lesser yang and supplement the foot jueyin — two parts draining to one part supplementing — treating once a day. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious. When the renying pulse is two degrees greater, drain the foot greater yang and supplement the foot lesser yin — two parts draining to one part supplementing — treating once every two days. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious. When the renying pulse is three degrees greater, drain the foot yangming and supplement the foot greater yin — two parts draining to one part supplementing — treating twice a day. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious.

When the wrist pulse is one degree greater, drain the foot jueyin and supplement the foot lesser yang — two parts supplementing to one part draining — treating once a day. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious. When the wrist pulse is two degrees greater, drain the foot lesser yin and supplement the foot greater yang — two parts supplementing to one part draining — treating once every two days. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious. When the wrist pulse is three degrees greater, drain the foot greater yin and supplement the foot yangming — two parts supplementing to one part draining — treating twice a day. One must press the pulse and verify it, needling only intermittently, and stop once the qi above has become harmonious. The reason one treats twice daily in this case is that the greater yin and the yangming govern the stomach, and are exceptionally rich in grain qi; hence it is permissible to treat them twice a day.

When the renying pulse and the wrist pulse are both enlarged threefold or more, this is called 'yin and yang both overflowing.' In such a case, if the blockage is not opened, the blood vessels become closed and obstructed, the qi has nowhere to travel, and it flows and spreads excessively within, injuring the five viscera internally. If, in such a case, one goes on to apply moxibustion, the condition will change and transform into some other disease.

In the general Way of needling, one stops once the qi has been regulated. By supplementing yin and draining yang, the voice and qi become ever more vigorous, and the ears and eyes become sharp and clear. To act contrary to this causes the blood and qi to cease flowing.

What is called the arrival of qi with therapeutic effect is this: when draining, the condition becomes ever more deficient — deficient meaning that the pulse remains as large as before but is no longer firm. If the pulse remains as firm as before, then even though the patient may say he feels as he did, the disease has not yet been removed. When supplementing, the condition becomes ever more replete — replete meaning that the pulse remains as large as before but becomes ever firmer. But if the pulse remains as before without becoming firmer, then even though the patient may say he feels pleased, the disease has not yet been removed. Hence supplementing should result in repletion, and draining should result in depletion; even though the pain may not vanish the instant the needle is withdrawn, the disease is bound to wane and depart. One must first thoroughly understand the diseases that arise from each of the twelve channel vessels, and only then can one attain transmission in the doctrine of the End and the Beginning. Thus, when yin and yang do not encroach upon one another, and deficiency and excess do not overturn one another, one should select points along the corresponding channel.

Among the general categories of needling, there is the method of three punctures to bring the grain qi (guqi — the nourishing qi derived from digested food and drink) to arrive. When deviant evil qi has wrongly commingled with the body, yin and yang exchange their proper places, contrary and compliant movements run counter to each other, and sinking and floating occupy each other's positions, so that the qi fails to correspond to the four seasons, and evil lingers and stagnates in excess — this must be removed by the needle. Thus at the first puncture, the yang evil is expelled; at the second puncture, the yin evil is expelled; at the third puncture, the grain qi arrives, and once the grain qi arrives, one should stop. What is called the arrival of grain qi is this: once supplementing has been done, the area becomes replete; once draining has been done, the area becomes deficient — and thus one knows that the grain qi has arrived. If only the evil qi departs while yin and yang have not yet become harmonized, the disease is nevertheless known to be on the way to recovery. Hence it is said: supplementing results in repletion, and draining results in depletion; even though the pain may not vanish the instant the needle is withdrawn, the disease is bound to wane and depart.

When yin is in excess and yang is deficient, first supplement the yang, and afterward drain the yin, so as to bring about harmony. When yin is deficient and yang is in excess, first supplement the yin, and afterward drain the yang, so as to bring about harmony.

Three vessels pulsate between the great toes; one must carefully discern whether they are excess or deficient. To drain a vessel that is deficient is called 'doubling the deficiency,' and doubling the deficiency makes the disease all the more severe. In needling this region, one should press it with the finger; where the pulsation is replete and rapid, drain it swiftly; where it is deficient and slow, supplement it. To act contrary to this makes the disease all the more severe. Of these pulsations, the yangming is uppermost, the jueyin is in the middle, and the lesser yin is lowest.

For disorders of the chest, select the chest transport points; for disorders of the back, select the back transport points; where the shoulder and upper back are deficient, select points in the upper region.

For 'doubled tongue' (a swelling beneath the tongue resembling a second tongue), puncture the sublingual frenulum with the pi needle (a broad, sword-like lancet used for lancing swellings).

When the hand can flex but not extend, the disease lies in the sinews; when it can extend but not flex, the disease lies in the bones. When the disease is in the bone, treat the bone; when the disease is in the sinew, treat the sinew.

In supplementing, one method calls for this: where the region is replete, needle deeply, and press the puncture wound only sparingly, so as to allow the evil qi to be expelled fully. Another method calls for this: where the region is deficient, needle shallowly, so as to nourish the vessel, and press the puncture wound promptly, so as not to let evil qi gain entry. The arrival of evil qi feels tight and rapid; the arrival of grain qi feels slow and mild. Where the pulse is replete, needle deeply, so as to drain off its qi; where the pulse is deficient, needle shallowly, so that the essence qi is not drained away, thereby nourishing the vessel while expelling only the evil qi.

In all cases of needling for pain, the pulse is invariably replete.

Hence it is said: for regions from the waist upward, the hand greater yin and yangming both govern; for regions from the waist downward, the foot greater yin and yangming both govern.

When the disease is located above, select points below; when the disease is located below, select points above; when the disease is in the head, select points in the foot; when the disease is in the lower back, select points in the popliteal fossa.

When the disease arises in the head, the head feels heavy; when it arises in the hand, the arm feels heavy; when it arises in the foot, the foot feels heavy. In treating disease, one must first needle the place from which the disease arose.

In spring, the qi resides in the body hair; in summer, the qi resides in the skin; in autumn, the qi resides in the interstices of the flesh; in winter, the qi resides in the sinews and bones. In needling disease, one should in each case take the corresponding season as the standard for depth. Thus in needling a stout, fleshy person, one uses the standard of autumn and winter; in needling a thin, lean person, one uses the standard of spring and summer.

Disease marked by pain is yin in nature; pain that does not yield when pressed with the hand is also yin, and should be needled deeply. Disease located above is yang; disease located below is yin. Itching is yang in nature, and should be needled shallowly.

When a disease first arises in yin, first treat the yin, and afterward treat the yang; when a disease first arises in yang, first treat the yang, and afterward treat the yin.

In needling heat reversal, retaining the needle will, on the contrary, produce cold; in needling cold reversal, retaining the needle will, on the contrary, produce heat. In needling heat reversal, one should needle yin twice for every once one needles yang; in needling cold reversal, one should needle yang twice for every once one needles yin. What is meant by 'twice yin' is puncturing the yin points twice; 'once yang' means puncturing the yang points once.

In chronic, long-standing disease, the evil qi has penetrated deeply. In needling such disease, insert the needle deeply and retain it for a long time, needling again every other day. One must first regulate the left and right sides, and remove any stagnant blood vessels — and thus the Way of needling is complete.

In the general method of needling, one must examine the patient's physical form and qi. If the flesh has not yet wasted away, but the qi is scant and the pulse is agitated — a case of agitated reversal — one must apply contralateral needling (miu ci, needling points on the side opposite the disease); by this means, scattered qi can be gathered in, and pent-up qi can be dispersed and spread.

The practitioner should dwell in a deep and quiet place, observing the coming and going of the patient's spirit; doors and windows should be closed, so that the ethereal and corporeal souls do not scatter. He should focus his intention and unify his spirit, attending to the movement of essence qi, and should not be disturbed by the voices of others, so as to gather in the patient's essence. He must unify his own spirit, and fix his will upon the needle.

Needle shallowly and retain the needle; needle gently and float it near the surface, so as to shift the patient's spirit — and only when the qi arrives should one stop.

In men, the qi tends inward; in women, it tends outward. Guard it firmly so that it does not escape outward; watch over it carefully so that nothing further enters — this is called 'obtaining the qi.'

The general prohibitions of needling are these: one who has just engaged in sexual intercourse should not be needled; one who has just been needled should not engage in intercourse. One who is already intoxicated should not be needled; one who has just been needled should not become intoxicated. One who has just been enraged should not be needled; one who has just been needled should not become enraged. One who has just exerted himself to exhaustion should not be needled; one who has just been needled should not exert himself to exhaustion. One who has just eaten to satiety should not be needled; one who has just been needled should not eat to satiety. One who is hungry should not be needled; one who has just been needled should not be allowed to become hungry. One who is thirsty should not be needled; one who has just been needled should not be allowed to become thirsty. One who has suffered great fright or great fear must have his qi settled before being needled. One who has just arrived by carriage should lie down and rest, and only be needled after a period equal to the time it takes to eat a meal. One who has just arrived on foot from a distant journey should sit down and rest, and only be needled after a period equal to the time it would take to walk a thousand li. In all of these twelve prohibited circumstances, the pulse is disordered and the qi is scattered, the nutritive and defensive qi run contrary to their proper course, and the qi of the channels loses its proper sequence. If one goes on to needle under such conditions, a disease in the yang will enter into the yin, and a disease in the yin will emerge as yang, so that evil qi is generated anew. If the unskilled practitioner fails to discern this, it is called 'assaulting the body' — the physical form becomes excessive and disordered, the brain and marrow are thereby depleted, the body fluids fail to transform properly, the essence of the five flavors is lost, and this is called 'losing the qi.'

When the vessel of the greater yang reaches its termination, the eyes roll upward and stare fixedly, the back arches backward, there is tugging and slackening convulsion, and the complexion turns white; the skin gives out, and then the sweat gives out — and when the sweat gives out, life comes to its end.

When the lesser yang reaches its termination, the ears become deaf, all the joints of the body go completely slack, and the connecting vessel of the eye is severed. Once the connecting vessel of the eye is severed, death follows within a day and a half. At the moment of death, the complexion turns green-blue and white, and then death occurs.

When the yangming reaches its termination, the mouth and eyes twitch and move, the patient is prone to fright and to speaking wildly, and the complexion turns yellow. When the channels above and below become full and cease to flow, life comes to its end.

When the lesser yin reaches its termination, the face turns black, the teeth appear to lengthen and become caked with grime, the abdomen becomes distended and blocked, and the upper and lower parts of the body fail to communicate — and thus life comes to its end.

When the jueyin reaches its termination, heat fills the interior and the mouth and throat become parched and dry, the patient is prone to frequent urination, and the heart is vexed; in severe cases the tongue curls and the testicles draw upward — and thus life comes to its end.

When the greater yin reaches its termination, the abdomen becomes distended and blocked, breathing becomes impossible, belching occurs, and the patient is prone to vomiting; when vomiting occurs, the qi rebels upward, and when it rebels the face turns red; when it does not rebel, the upper and lower parts of the body fail to communicate, and when the upper and lower fail to communicate, the face turns black, and the skin and body hair wither — and thus life comes to its end.