Huangdi Neijing

Kong, Y.C.

Published by The Chinese University of Hong Kong Press

Kong, Y.C.
Huangdi Neijing: A Synopsis with Commentaries.
The Chinese University of Hong Kong Press, 2010.
Project MUSE.muse.jhu.edu/book/24634.

For additional information about this book

https://muse.jhu.edu/book/24634

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 3 Diagnosis by Inspecting the
Countenance
(Se Zhen 色診)

Exegesis

There are four principal diagnostic methods in Chinese medicine, viz.

visual inspection, auscultation and olfaction, interrogation and palpation.
Visual inspection involves observing all outward signs on the surface of
the body, especially the facial expression and radiance and the alertness
of the sensory organs on the face. This should also include inspection of
the tongue, a method unique to Chinese medicine. The title of this chapter
emphasises the hue of the skin, as different shades of colour may suggest
certain malfunctions within the body, interpreted through the affiliation of
colour to the “five elements”. In our daily lives, colour or hue is of
secondary importance. More important is the radiance, the exuberance of
a lively spirit or its absence, a joyful or sorrowful mood and the general
mental state (optimistic or pessimistic) of a person that is summarised by
the term qise 氣 色 (literally, “atmosphere and colour”). When a person is
joyful and optimistic, he is full of shenqi 神 氣 (shenqi huoxian 神 氣 活 現,
“vividly showing a full spirit”). When a person is sad and pessimistic, he
has lost his shenqi and his head droops (chuitou sangqi 垂頭喪氣). A clini-
cian [1] pays much attention to observing the countenance and mien of
the patient before asking any specific questions regarding his/her
complaint, and this is an important element of visual inspection. The
legendary Bianque 扁 鵲, also known as Qin Yue-ren 秦 越 人, was famous
for his ability to arrive at a prognosis by visual inspection alone. (For a
famous anecdote about Bianque’s consultation with the Duke of Qi see
ref. 53, Section 6.1, Inspection).

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 50 Neijing Zhiyao Yigu 內經知要譯詁

This chapter draws together excerpts from Suwen Chapters 10 and

17 and Lingshu Chapter 49. Together they cover three main steps: (1)
Observation of the shades of colour, their hues and locations, on the face
and in the eyes, to gauge the adequacy of the vitality (jingqi 精 氣, “qi of
essence”) in reserve. (2) Deduction of relevant pathological changes in
the visceral organs and limbs from the shades of colour on the face. (3)
Prognosis based on the above observations, and the adoption of any
action necessary.
Of course, diagnosis cannot rely on one method alone, and diagnosis
by pulse-taking is also employed (see the following chapter). But upon
seeing the patient, especially during the first consultation, the clinician
should be able to form a general idea of his/her suffering. This first impres-
sion has to be fine-tuned or corrected with the corroboration of other diag-
nostic methods. Though lacking the support of data from clinical analysis
and the various techniques of radio-imaging available to modern medicine,
Chinese medicine operates on these subjective assessments with impres-
sive efficacy and accuracy. In ancient times too, it was important to
provide a correct prognosis so as not to raise false hopes or to call the
clinician’s credibility into question. This is in sharp contrast to modern
practice, where terminaly ill patients turn to Chinese medicine for help
when they could have benefited from Chinese Medicine if consulted much
earlier.

Footnote

[1] clinician: A practitioner of Chinese medicine is translated here as “clinician”

(linchuangjia 臨 床 家), meaning someone who treats diseases professionally
(and in the context of this book, with Chinese medicine). This serves to distin-
guish them from all those who are interested in Chinese medicine, e.g. histo-
rians, anthropologists, sinologists and academics, but do not practise under
clinical conditions. There are also scholarly doctors (ruyi 儒 醫) who are well-
versed in the classics, including medical literature, but only practise once in
a while. In this context, a western doctor who wishes to treat patients with
Chinese medicine is also a clinician. Practitioners of Chinese medicine are
denied the title of “doctor” that implies professional medical recognition in
certain countries. Naturally, practitioners of Chinese medicine are “Chinese
doctors” (zhongyi 中 醫), but the term is only significant when compared to
“Western doctors” (xiyi 西 醫). The distinction between “Chinese” and

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 Diagnosis by Inspecting the Countenance 51

“Western” becomes blurred when all zhongyi in China (graduates of TCM

colleges or universities) can also employ modern methods and western-
trained doctors in many countries do not hesitate to use acupuncture and/or
herbal preparations inasmuch as the clinical results are satisfactory. In
between, there are many homeopaths, naturopaths, osteopaths and so on,
who are actually practising Chinese medicine without using that label. It is
self-degrading to accept the term “herbalist“ as equivalent to zhongyi or
zhongyi shi 中 醫 師; they may use herbs, acupuncture and massage, or any
combination of the three as clinical conditions may warrant. Today, when
holistic medicine has become fashionable, the term “clinician” seems neutral
but relevant. A doctor, in the archaic meaning of the word, is an erudite
teacher. See Suwen Chapter 75: “The medical practitioner must be knowl-
edgeable on astronomy, geography and the humanities. If this is the case,
there is no doubt the profession can last long and teach the public.”1

[Section 3.1] Suwen Chapter 17: On the Finer Points of

Pulse-taking

《素問．脈要精微論》曰：夫精明五色者，氣之華也。赤欲如白裹朱，不欲
如赭；白欲如鵝羽，不欲如鹽；青欲如蒼璧之澤，不欲如藍；黃欲如羅裹
雄黃，不欲如黃土；黑欲如重漆色，不欲如地蒼。五色精微象見矣，其壽
不久也。
夫精明者，所以視萬物、別黑白、審長短。以長為短，以白為黑，如
是則精衰矣。

The five colours on the surface of the body are manifestations of vitality. If the
colour is red, it should be vermilion like cinnabar [seen through] a white silk
wrapping [1] rather than a rusty red. If the colour is white, it should be soft
white like goose feathers instead of the [glaring] white of salt [2]. If the colour
is green [3], it should be green like a piece of translucent green jade [4] but
not blue like indigo [5]. If the colour is yellow, it should be yellow like realgar
[seen through] a gauze wrapping [6] but not like loess. If the colour is black, it
should be jet-black like multiple layers of varnish [7] but not dark like humus.
When these colours are showing on the surface, one will not live long.

1
《素問．著至教論》︰「上知天文，下知地理，中知人事。」

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 52 Neijing Zhiyao Yigu 內經知要譯詁

To have good eyesight, the eyes should be able to distinguish the colour
and size of an object. If a long object appears short, or a white object is
perceived as black, it indicates that vitality is much reduced.

Explanatory Notes
This is a short paragraph that underlines the importance of colour as an indi-
cator of health. According to the “five elements” theory, visceral organ func-
tion is represented by colour. This paragraph stresses the right kind of hue,
translucence, and diffused brilliance (as if seen through a wrapping) of each
colour for a normal organ. However, even when the right colour is showing,
this means the essence (vitality) of that specific organ is seeping out of the
body, because yangqi should be securely stored and should not be manifested
in this way. It follows that if more than one colour is showing, the organs are
losing their grip on their yangqi and health is compromised.
At the time when Neijing appeared, it was natural that the author of the
paragraph above relied on the colour of natural products as a reference. A
healthy red hue is represented by zhu 朱, notably zhusha 朱 砂 (mercuric
oxide). An unhealthy red hue is represented by “zhe” 赭, notably daizheshi 代
赭 石 (haematite). A healthy white colour should have the soft refringence of
goose feathers but not the glaring white of crystalline salt. A healthy green
should have a green hue rather than the blue hue of indigo. A healthy yellow
should be the colour of realgar (xionghuang 雄 黃, arsenic sulphite, which is a
tangerine kind of yellow) but not matte like loess (the yellow earth is used to
prepare a detoxicant called “dijiang” 地 漿, an earth drink). A healthy black is
one which shines like multiple layers of varnish (which is jet-black) and is not
matte like humus (dicang 地 蒼, “black earth, earth containing a large amount
of humus”). One notices at once that all these coloured items are medicinal
materials, familiar to the Daoists, the confrères of the authors of Neijing if not
actually responsible for it themselves, in their alchemical pursuits.

Footnotes

[1] white silk: The text only has “white” (bai 白), but this is assumed to be silk
rather than fabric from plant fibres, e.g. cotton. “Bai” 白 is also homopho-
nous with “bo” 帛, a generic name for all silk fabrics, which was often used
instead of paper (e.g. boshu 帛 書) for writing. Only a piece of thin silk will

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 Diagnosis by Inspecting the Countenance 53

give the sheen and translucence so much appreciated in this paragraph as an

indicator of vitality.
[2] white salt: Salts are halides, e.g. sodium chloride. Salt is white except for the
impurities it contains. Salt in Chinese pharmacology is “rongyan” 戎 鹽
(“barbarian salt,” basically sodium chloride) and is mentioned in Shen-nong
bencao jing 神 農 本 草 經 (the first bencao edition, compiled not much later
than Neijing. It is often abbreviated to Benjing 本 經. See ref. 53, Chapter 9,
Appendix). While China has produced sea salt since antiquity, salt was first
imported from the West (Persia and neighbouring countries) as rock salt.
Sichuan 四 川 and other provinces in southwest China produce salt from
underground brine. But rock salt lacks iodine and use over time leads to
goitre. The state monopoly on the salt trade contributed substantially to the
national coffers, and enriched many corrupt officials as well. There were
serious discussions about the advantages and disadvantages of the state
monopolies on salt and iron early in the Han dynasty (Huan Kuan 桓 寬,
Yantie lun 鹽鐵論, 81 bc)
[3] green: the Chinese word “qing” 青 is often translated as “green” (lü 綠), but it
is not actually the green of green leaves. (And of course, as the winter buds
burgeon into tender leaves, there are many different shades of green.) “Qing”
is closer to the bluish-green of a green hill after rain (qingshan 青 山) as
compared to its reflection in a dark green stream (綠 水 lü shui, where the
character 綠 lü is used to translate as “green”). Perhaps it can be better
described as the green-blue hue of a clear sky (tianqing 天 青, “azure”), like
lapis lazuli (tianqingshi 天 青 石). Many copper salts with the name qing are
listed in the Chinese pharmacopoeia. In clinical terms, the face is never really
green, but it can appear blue due to the lack of oxygenated blood (cyanosis).
[4] translucent green: The Chinese word cang 蒼 refers to a dark green colour,
like a sombrely blue sky (cangtian 蒼 天). But the word can also appear in
compounds meaning “greyish-white” (cangbai 蒼 白) or “immense” (cang-
mang 蒼 茫). Jade occurs in various shades of green, but the more precious
types, like chrysoprase (feicui 翡 翠), are dark green. The beauty of jade-
green, as of all other colours, lies in its translucence or soft and diffused
sheen.
[5] indigo: Indigo is prepared from a number of plants, notably Indigofera tinc-
toria (mulan 木 藍). The colour and the therapeutic effect are due to indigo,
from which a new anti-cancer drug, indirubin, has been obtained. Indigo is
an effective detoxicant, with anti-viral activity. A close congener, Isatis

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 54 Neijing Zhiyao Yigu 內經知要譯詁

tinctoria L. (banlangen 板 藍 根) was very much in demand during the SARS

epidemic. Before the advent of penicillin, a paste of indigo was smeared over
the cheeks to treat mumps.
[6] gauze: Here luo 羅 is translated as “gauze”, a thin piece of silk. The texture of
silk fabrics depends on the number of threads they contain, while the surface
pattern and sheen depend on the interplay between the wefts and the warps.
In the common phrase ling luo chou duan (綾 羅 綢 緞) the names of the
fabrics are usually translated as “damask” (because of the surface pattern),
“gauze” (which is thin and light), “chiffon” or “pongee” (more compact but
less smooth) and “satin” (which is thick, smooth and has a considerable
sheen). The Chinese have been producing silk products with very compli-
cated patterns since ancient times. As to brocade (jin 錦), it is woven to
produce a surface bas-relief, sometimes with the addition of fine metal
threads, always in brilliant colours. At one time, it was best from Sichuan
province (shujin 蜀錦).
[7] varnish: The use of varnish (qi 漆) from the varnish tree, Rhus verniciflua,
has been known to the Chinese since antiquity. (Zhuangzi’s official title was
“Superintendent of the Lacquer Tree Grove” (qiyuanli 漆 園 吏). Residues
from varnish (ganqi 乾 漆) were listed as ingredients in Benjing. Lacquer
poisoning must be one of the earliest occupational health hazards known.
Lacquer products were famous as long ago as the fourth century bc from the
Dukedom of Chu (楚), with its famous sons like Qu Yuan 屈 原 (a melan-
cholic poet cum statesman) and Xiang Yu 項 羽 (a tragic hero of Herculean
prowess). Another kind of varnish (chongjiao 蟲 膠, shellac) is prepared from
Laccifer lacca, a wingless insect and is also used in Chinese medicine.

[Section 3.2] Lingshu Chapter 49: The Five Colours

《靈樞．五色篇》曰：明堂者，鼻也；闕者，眉間也；庭者，顏也；蕃者，
頰側也；蔽者，耳門也。其間欲方大，去之十步，皆見於外。如是者，壽
必中百歲。

明堂骨高以起，平以直。五藏次於中央，六府挾其兩側。首面上於
闕、庭，王宮在於下極。五藏安於胸中，真色以致，病色不見，明堂潤澤
以清。

五色之見也，各出其色部。部骨陷者，必不免於病矣；其色部乘襲
者，雖病甚，不死矣。

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 Diagnosis by Inspecting the Countenance 55

青黑為痛，黃赤為熱，白為寒。

其色粗以明，沉夭者為甚。其色上者，病益甚；其色下行如雲徹散
者，病方已。

五色各有藏部，有外部，有內部也。色從外部走內部者，其病從外走
內；其色從內走外者，其病從內走外。病生於內者，先治其陰，後治其
陽，反者益甚；其病生於陽者，先治其外，後治其內，反者益甚。

常候闕中，薄澤為風，沖濁為痺，在地為厥，此其常也，各以其色言
其病。

大氣入於藏府者，不病而卒死矣。

赤色出兩顴，大如母指者，病雖小愈，必卒死；黑色出於庭，大如母
指，必不病而卒死。

庭者，首面也；闕上者，咽喉也；闕中者，肺也；下極者，心也；直
下者，肝也；肝左者，膽也；下者，脾也；方上者，胃也；中央者，大腸
也；挾 大 腸 者，腎 也；當 腎 者，臍 也；面 王 以 上 者，小 腸 也；面 王 以 下
者，膀胱、子處也。顴者，肩也；顴後者，臂也；臂下者，手也；目內眥
上 者，膺 乳 也；挾 繩 而 上 者，背 也；循 牙 車 以 下 者，股 也；中 央 者，膝
也；膝以下者，脛也；當脛以下者，足也；巨分者，股裡也；巨闕者，膝
臏也，各有部分。有部分，用陰和陽，用陽和陰。當明部分，萬舉萬當。
能別左右，是謂大道。男女異位。故曰陰陽。審察澤夭，謂之良工。

沉濁為內，浮澤為外，黃赤為風，青黑為痛，白為寒，黃為膏，潤為
膿，赤甚為血。痛甚為攣，寒甚為皮不仁。

五色各見其部，察其浮沉，以知淺深；察其澤夭，以觀成敗；察其散
摶，以知遠近；視色上下，以知病處。

色明不粗，（其病不甚）
；不明不澤，（沉夭為甚）。其色散，駒駒然未有
聚，其病散而氣痛，聚未成也。

腎乘心，心先痛，腎為應。色皆如是。

男子色在於面王，為小腹痛，下為卵痛。其圜直，為莖痛。高為本，
下為首，狐疝、疒貴 陰之屬也；女子在於面王，為膀胱、子處之病。散為
痛，摶 為聚，方員左右，各如其色形。其隨而下至胝，為淫，有潤如膏
狀，為暴食不潔。

色者，青、黑、赤、白、黃，皆端滿有別鄉。別鄉赤者，其色亦大如
榆莢，在面王為不日〔月〕
。其色上銳，首空上向，下銳下向，在左右如法。

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 56 Neijing Zhiyao Yigu 內經知要譯詁

The nose is called the “luminous hall” (mingtang 明 堂) [1]. What lies between
the eyebrows [the glabella] is called the “royal residence” [2]. The brow is like
the courtyard [3] while the cheeks are the screens [4]. These sites are sheltered
by the ear shell. These structures should be distinctive and discernible when
viewed from a distance of ten paces. In such case, [the person] is most likely to
live for a hundred years.
The luminous hall should lie on prominent bones so that the nose is
straight and square. The five zang-organs are placed in an orderly fashion
around the centre [where the nose is] with the six fu-organs guarding the two
sides. When inspecting the front of the head, pay attention to the upper part
of the face and the area between the eyebrows. The royal palace [representing
the heart] [5] lies at the lower end [at the level between the eyes]. When the
[five] zang-organs are lying peacefully in the chest [and abdomen], these
genuine colours will manifest accordingly, while the sickly-looking colours
will not appear. The luminous hall [nose] should look fresh and bright [6].
When the five [sickly] colours are showing [because the zang-organs are
not healthy], each will appear on their respective sites on the face. If the bone
underlying these sites appears to be subsiding [because of a dark colour on the
surface], disease is likely to occur. If the colour appearing [on a particular site]
is not specific for the relevant organ, but rather the colour of its “filial organ”
[7], the disease will not be fatal, even it is serious.
A bluish-green colour is a sign of pain. A reddish-yellow colour is a sign
of heat. White is a sign of cold [8].
A healthy colour should manifest itself as distinctive and bright. If it is
murky and indistinct, the disease is worsening. If the colour darkens or moves
higher, the disease is worsening. If the colour becomes lighter or moves to a
lower place, like clouds dissipating, the disease is remitting.
Each colour has its organ-specific site on the face. Even then, it belongs to
inner (zang) or outer (fu) organs respectively [9]. When the colour moves
from an outer site to an inner site, so does the disease [moving from a fu-organ
to a zang-organ]. The opposite is also the case, and when the colour moves
from an inner site to an outer site, so does the disease [moving from a zang-
organ to a fu-organ] [10]. If a disease is developing inside [among the zang-
organs], treat it as a disease of yin nature first; attend to the yang features later.
The reverse would only aggravate the disease. If a disease is developing among
the fu-organs, treat the outer symptoms first; attend to the inner symptoms
later. The reverse would only aggravate the disease.

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 Diagnosis by Inspecting the Countenance 57

Under normal circumstances, when inspecting between the eyebrows [the

glabella], a light sheen indicates an evil-wind induced disease whereas a
murky shade indicates arthralgia [11]. If the murky shade spreads to the chin
[12], it is a sign of [impending] syncope [13].
If there is an intense colour [indicating an aggressive pathogen] spreading
over the site of the relevant zang-organs, sudden death will occur [14] without
noticeable symptoms.
If a red colour [covering an area] the size of a thumb appears over
the cheekbone, even when the disease is remitting slightly, sudden death
will inevitably follow. If a black colour [covering an area] the size of a
thumb appears on the brow, there will be sudden death without any sign of
disease.
[In colour inspection] the brow represents the whole face. The site of the
throat lies at the upper part between the eyebrows, at the middle lies the site
of the lungs, the lower part at the level of the eyes is the site of the heart. Right
below this on the nose stem (dorsum nasi, biliang 鼻 梁) is the site of the liver.
On both sides of the liver site [nose stem] are sites of the gallbladder. At the
lower part of the nose stem lies the site of the spleen, whereas both sides of the
tip of the nose belong to the stomach. At the centre of the face [15] lies the site
of the large intestine; adjacent to this site lies the site of the kidney. Closely
lying under the site of the kidney is the site of the navel [16]. Right above the
tip of the nose [17] on both sides of the nose wings are the sites of the small
intestine. Right below the tip of the nose [i.e. the philtrum] is the site of the
bladder and the uterus. The cheek represents the shoulder; lateral to the
cheeks are the sites of the hands. Just above the inner canthus lies the site of
the breast. Going up the rim of the ear shell is the site of the back. Going
down to the jaw [18] is the site of the thigh. In the middle part of the jaw lies
the site of the knee. Below the knee site lies the site of the shin [19]; further
down lies the site of the foot. The line extending from the corner of the mouth
represents the inner side of the thigh. At the angle of the lower jaw lies the site
of the kneecap [patella] [20]. All sites are distinguishable from one another.
Because of this distinction, the clinician will [be able to tell the state of yin-
yang balance and] proceed to use yin [drugs] to complement the excess of
yang [symptoms] and vice versa. Therefore, it is imperative to discern the sites
and their indicative functions. To distinguish the left [yang] from right [yin]
[21], this is the basic approach in disease management. It must be noted that
site differentiation is different in men and women because male is yang and

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 58 Neijing Zhiyao Yigu 內經知要譯詁

female is yin. Careful observation of the radiance or murkiness on the face is

what a good clinician should do.
[When the countenance] is dark and murky, it signifies that the disease
lies in the interior. If it is bright and radiant, the disease lies at the surface. If
the countenance is reddish-yellow, it indicates wind affliction. By the same
token, bluish-green is pain, whitish is coldness, yellow and greasy is [an accu-
mulation of] pus and intense red is disease in the blood. When suffering from
intense pain, there will be cramps. Intense coldness will cause a loss of sensa-
tion [11].
The five colours will show up at their specific sites on the face. By
observing whether the colour is at or under the surface, one can tell whether
the disease lies at the surface or in the interior of the body. By the same token,
a radiant or murky countenance is correlated to prognosis. Dispersing or
aggregating colour indicates the time course of a disease. Find where the
colour is located; it indicates where the affliction lies.
If the colour is bright though not apparent, the disease is not serious. On
the contrary, if the colour is neither bright nor radiant, a murky countenance
indicates an aggravating disease. If the colour seems diffused, like colts
galloping in every direction, it is because stagnant qi movement is causing
pain and the disease is spreading rather than aggregating.
When the colour of the kidney [black] appears on the site of the heart
[lower end of the yintang 印 堂, between the eyes] [which should be red], the
heart will be aching first, only followed by the kidney [where the cause of
disease originates]. All other colours follow this rule.
In men, when the colour appears on the tip of the nose, it indicates pain
in the lower abdomen [22]. Below this [the philtrum], it indicates pain in the
testicles. If the groove of the philtrum is prominent with its relevant colour it
indicates pain in the penis. Colour lying at the upper part of the groove corre-
sponds to the penile shaft, the lower part to the glans. These signs are also
applicable to a “fox” [sliding] hernia [23] or swollen [scrotal] hernia. In
women, the tip of the nose is the site for the bladder and the uterus. If the
colour is diffused, it is due to stagnant qi. If the colour is patchy, it is due to
stagnant blood. Whether the colour is covering a round or square area, or
whether it is spreading to left or right, it follows the same interpretation as the
other colours. If the colour moves downwards from the tip of the nose to the
lip, it indicates excessive vaginal discharge [leucorrhoea]. If there are greasy
aggregates in the discharge, it is due to unscrupulous ingestion of dirty food.

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 Diagnosis by Inspecting the Countenance 59

The colours green [blue], black, red, white and yellow should be signifi-
cant and distinctive. They can appear in places other than their relevant site. If
the red colour appears elsewhere, and covering an area the size of an elm pod
[24] on the tip of the nose, it indicates amenorrhoea. When a colour spreads
upwards with a wedged front, it is because zhengqi is lacking in the head. Simi-
larly, when the wedged front points downwards, it indicates that zhengqi is
lacking there. Pointing to the left or right follows the same rules.

Explanatory Notes
This is the first quotation from Lingshu [25] and it helps to explain the rela-
tionship between Suwen and Lingshu. Generally speaking, the title Neijing, or
Huangdi Neijing, refers to the combined volumes of Suwen and Lingshu, each
in 81 chapters (known as pian 篇 in Suwen). Their allocation into different
volumes (juan 卷, of which there are 24 in Suwen and 12 in Lingshu) does not
matter to readers but their sequence is important. When Huangdi Neijing was
first mentioned in Ban Gu’s (32–92) Hanshu yiwenzhi 漢 書 藝 文 志 (Bibliog-
raphy of the Han Dynasty) it contained 18 volumes. Zhang Zhong-jing in his
preface to Shanghan lun 傷 寒 論, had been able to identify Suwen and Jiu juan
九 卷 (The Nine Volumes). Thereafter, Huang-Fu Mi 皇 甫 謐 (215–282),
author of the acupuncture classic Jiayi jing 甲 乙 經 called it Zhenjing 針 經
(Canon of Needles) and Wang Shu-he 王 叔 和 (180–270), author of Maijing
脉 經 (Canon of Pulses) called it Jiu juan. While the content of Suwen was
finalised definitively by Wang Bing in the Tang dynasty (762), and further
refined by Lin Yi and his colleagues in the Song dynasty (1057), no such atten-
tion was paid to the content of Lingshu during this time. It had to wait another
century before Shi Song 史 崧 , a resident of Jinguan 錦 官 , present-day
Chengdu, in Sichuan province, attempted to arrange the chapters and anno-
tate the contents of Lingshu, based on ancient scripts handed down in his
family. After consulting his medical colleagues, a final version was presented to
the Imperial Academy in 1155. Today, when one quotes Neijing, it is usually a
passage from Suwen. If one quotes Lingshu, it has to be made clear, because
many passages in Lingshu are similar to ones in Suwen. The content of Suwen
is mainly theoretical and the chapter titles are long and figurative; in quoting
Suwen, the number of the chapter is often mentioned. In Lingshu, on the other
hand, which deals mainly with the practical aspects of acupuncture, the
chapter titles are short (often just two words) and terse. Consequently, it is

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 60 Neijing Zhiyao Yigu 內經知要譯詁

often convenient to quote just the chapter title.

In Lingshu, Chapter 49: The Five Colours is a typical example of the “five
elements” theory that serves as the theoretical framework of Chinese medi-
cine. This is one of ten chapters, viz. 20, 34, 36, 37, 46, 49, 56, 61, 63 and 65,
that actually has the word “five” (五 wu) incorporated into the chapter title.
There are also other chapters that discuss the subject matter under five catego-
ries, even though the word “five” is not mentioned in the chapter title. They
are chapters 7, 44, 72 and 78; of these, the last on wu se is of particular impor-
tance because of the many examples of phenomena divided into five catego-
ries. A similar situation can be found in Suwen, where there are altogether
seven chapters (4, 5, 10, 22, 67, 70 and 77) dealing, partly or wholly, with cate-
gorisation into fives. Of these, the most important is Chapter 5: On the
Phenomena of Yin Yang from which one paragraph was cited in Section 2.1.
Categorisation into fives is a human invention and is far from perfect, but it
was the closest approximation to the natural order that our ancestors could
have perceived. It appeared at the dawn of Chinese history and has since
penetrated into every branch of Chinese culture, in particular in medical
practice, where it has lasted up to this day. As far as Lingshu Chapter 49: The
Five Colours is concerned, the basic idea is that each of the five zang-organs
can be represented by a specific colour (wu se ming zang 五 色 命 臟) and that
this colour can indicate the state of health of this particular zang-organ (五 色
主病 wu se zhu bing). The pertinent parameters are as follows:

Colour bluish-green red white yellow black

Zang-organ liver heart lung spleen kidney
Symptom wind, cold, hot blood asthenia, wet pain,
pain, fright cold blood
stasis,
consump-
tion

To apply this correlation to the clinical situation, the colour must show a
certain quality, such as brightness, radiance, translucence, sheen or the absence
thereof. Furthermore, the colour should appear on the specific site relevant to
that organ. If the colour spreads to other sites, or displaces from left to right
or the other way round, or appears to be diffused or concentrated, these

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 Diagnosis by Inspecting the Countenance 61

nuances reveal the colour as healthy, or sick, and provide hints for the
prognosis.
These discussions are bordering on the practice of the physiognomist.
Indeed, many terms, like “luminous hall”, “celestial palace” (tianting 天 庭, the
brow) and “pavilion on the ground” (dige 地 閣, the chin) remain in current
use today by the physiognomist. It seems odd to designate a certain area on
the face or head as an organ-specific site without being able to delineate the
boundary. But there are sufficient surface markers like nose wing, nasolabial
grooves, lines (corners of the mouth), angles (jaw, cheek), and attachment
points of facial muscles (that give facial expression), and also underlying
bones that allow a fairly precise designation of an organ-specific site. Having
said that, it is apt to note that “the blood and qi from the 12 regular conduits
and their 365 branches all flow to the face, seeking an exit through the aper-
tures” (Lingshu Chapter 4). So, on the assumption that colour can be organ-
specific according to the “five elements” theory, the colours and their hues
have sufficient connection with the visceral organs through conduits and the
circulating media (blood and qi) to provide a true reflection of the state of
health. After all, there are common expressions in English to describe a person
as green with envy, red with anger (or shame), in a black (bad) mood, white
(pale, ashen) with apprehension or yellow with jaundice (bad liver). It was
only finely elaborated in Neijing with vital consequences. In fact, colour and
hue on the face and elsewhere depend on pigmentation and local circulation,
compounded by skin texture and translucence. The specificity of colour at
different locations, especially on the face, may find some support from the
jingluo theory. As each regular conduit is organ-specific, when they pass
through the facial area, they must have some effect on local/regional colour
and hue, according to the amount of blood and qi they can bring there. This is
like when a stream, running through a prairie, renders its banks a lush green
or wilting brown, depending on the volume of water flowing through. It
should be possible to quantify the site-specific changes in colour and intensity,
as it has been done with tongue inspection today, while needling the relevant
conduits. Unfortunately, such an experimental approach has not been
attempted.
One last remark about the literary style of Lingshu Chapter 49. In Neijing,
usually it is Huangdi who asks the questions and Qibo 岐 伯 who provides the
answers, with great deference. Huangdi also sought enlightenment from some
of his ministers of health, among them Shaoyu 少 俞 (see Lingshu Chapter 46)

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 62 Neijing Zhiyao Yigu 內經知要譯詁

and Guiyuqu 鬼臾區 (see Suwen Chapter 66). But in this chapter, it is Leigong
雷公, the minister in charge of medicines, who asks the question, very humbly,
and Huangdi who expounds the answer in great detail. The last four chapters
of Suwen, on medical ethics, all involve Leigong. But Leigong was reputed to
be a theoretician and expert acupuncturist, while Qibo was the generalist who
knew everything about the practice of medicine. Consequently, it is the
discussion between Huangdi and Qibo that forms the substance of Neijing, so
much so that Chinese medicine is also known as “the craft of Qibo and
Huangdi” (Qi Huang zhi shu 岐黃之術).
Qibo is referred to in Shiji as the chief pharmacist in charge of medicines.
But Si-Ma Qian was quoting from an essay written by Si-Ma Xiang-ru, which
describes a fantasy kingdom to entertain the emperor. So Qibo, though repre-
senting medicine, was not necessarily a real person like Bianque and Cang-
gong, who earned biographies in their own right in Shiji.2

Footnotes

[1] luminous hall: The term “luminous hall” appears repeatedly in Neijing. It
originally referred to the hall where the emperor held court. It is described as
luminous, or illuminated (ming 明) because there were shafts of light coming
down from the roof. The emperor conferred with his ministers at dawn,
listening to them and making decisions in an autocratic manner. The nose is
called the “luminous hall” because it is centrally located and raised, resem-
bling the emperor sitting on his throne. In many passages in Neijing,
Huangdi sits in the luminous hall and conducts a conversation with Qibo or
Leigong who are standing below his throne. While the latter figures can be
construed as the ministers of health, the role of Huangdi serves only to give
an air of authority. In all probability, Huangdi was not a person but an indi-
cation of antiquity, and in this context, should not be identified with Yandi
炎帝 or Huangdi 黃帝, the early tribal leaders.
[2] royal residence: The term “royal residence” (que 闕) is a metaphor to signify
the site on the face which corresponds to the heart. “Que” means the empty
space between two tall towers guarding the main entrance of the royal resi-
dence, where royal decrees are posted. Thus facing the “que” demonstrates
loyalty to the sovereign, as in the idiom xin cun wei que 心 存 魏 闕 (“always

2
Shiji: Si-Ma Xiangru liezhuan 史記．司馬相如列傳.

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 Diagnosis by Inspecting the Countenance 63

keep the lofty royal towers in the heart,” from Zhuangzhi: Rang Wang 莊子．
讓 王), or que men zhi wai 闕 門 之 外 ( “far away from the capital [centre of
power]”, from Shiji: Wei shijia 史 記．魏 世 家). In the language of the physi-
ognomists, this is called yintang 印堂. Literally the “seal hall”, the place where
one imprints the seal, it is the signature of good health. In topical anatomy,
“que” corresponds to the smooth bump between the eyes, more prominent
in men.
[3] courtyard: The word “ting” 庭 means “courtyard” (see Section 1.3, first para-
graph). It is used here to mean part of a building compared with other terms
in this paragraph. But it is also an abbreviation of tianting 天 庭 (“celestial
palace”), which according to the physiognomists is the brow.
[4] screens: The word fan 蕃 (“flourish, prolific growth”) is extended to mean
fan 藩 (“hedge, screen, sheltering wall”). The screening effect of the cheeks is
likened to the tall and ornate screens pingfeng 屏 風 (“a screen to prevent
draughts”) that are placed on either side of the master’s seat centrally located
in a hall. Thus the vassal states lying on the periphery of the nation are called
fan zhen 藩 鎮 or fan guo 藩 國, as if they are a screen protecting the central
government. It was a system that brought about the downfall of the Tang
Empire.
[5] royal palace: Because the heart is likened to the king among the twelve
visceral organs, and his residence is the royal palace (wang gong 王 宮), the
colour that appears here closely reflects the conditions of the heart.
[6] fresh and brilliant: The term runze 潤 澤 is hard to translate in one or two
words. It refers to an object steeped in liquid so that it presents a kind of
translucence, as in the idiom zhu yuan yu run 珠 圓 玉 潤 (“round pearls and
translucent jades”). Ze 澤 is literally “marsh”, or “sheen”, referring to the scin-
tillating surface of a water landscape. The term runze has a positive meaning
for jade because it can impart these beneficial qualities to the persons
adorned with it.
[7] filial organ: In the language of the “five elements”, fire (heart, red) generates
earth (spleen, yellow); so the spleen is the “filial” organ (zizang 子 臟) of the
heart because heart and spleen are in a generative relationship (xiangsheng
相 生). Hence, a red colour appearing between the eyes (yintang) indicates a
function of the heart. If instead of red, the colour is yellow, it means the
colour of the spleen has taken over the heart site; the prognosis is good.
[8] bluish-green: Literally “green and black”, it is actually blue with cyanosis.
Pain is a result of stagnant circulation of qi that drives the blood circulation;

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 64 Neijing Zhiyao Yigu 內經知要譯詁

the lack of oxygenated blood gives a blue hue to the skin. It was a long-held
belief that “stagnation [of qi] leads to pain” (bu tong ze tong 不 通 則 痛), as
postulated by Wang Ken-tang 王肯堂 (1549–1613).
[9] inner/outer organs: The nose and the sites around the nose represent the
inner-lying zang-organs. The surrounding areas with the nose at the centre
represent the out-lying fu-organs. Of course, the fu-organs (bowels and blad-
ders) are not actually lying on the surface. Here “out-lying”, or “surface-lying”,
refers to the fact that the activities of these organs are more easily appreci-
ated than those of the inner-lying zang-organs. The exterior-interior relation-
ship (biaoli 表 裡) refers to the ease of detection, not a physical location. So
the term “exterior” (surface, outer) means “beginning, light, remitting” and
is in general representative of fu-organs. By the same token, “interior” (inside,
inner) means “progressing, serious, worsening” and is in general representa-
tive of zang-organs.
[10] inside/outside movement: This follows the same argument as in footnote [9]
above. It is easy to observe that pathogens first affect the bowels due to inges-
tion of food and drink, or surface exposure to the skin. When a disease gets
worse, it begins to affect systemic physiological functions represented by the
zang-organs. So when the disease lies with the fu-organs, or at the surface of
the body (e.g. the beginning of a cold), treat it as a yang disease. The reverse
is true for yin diseases. Neijing emphasises repeatedly that it is impossible to
practise medicine without knowing yin from yang. Zhang Jie-bin 張 介 賓
said in Quanzhong lu 存 忠 錄: “The art of medicine seems complicated. But
one word suffices to say it all, i.e. yin and yang” (醫道雖繁，曰陰陽而已。)
[11] arthralgia: Literally the word bi 痺 means “numbness”. Due to an attack of
wind, wet and/or cold, the joints and other parts of the body become
swollen, losing tactile sensation (ma mu bu ren 麻 木 不 仁) as happens in
rheumatism. Hence bi is generally translated as “arthralgia”, pain in the
joints, but this is only the signature symptom.
[12] chin: In the text, only di 地 (“earth, ground”) is mentioned, but this is taken
to mean dige 地 閣 (“pavilion on flat ground”), a term used by the physiog-
nomist to refer to the chin. This is in contrast to the term tianting 天 庭
(“celestial palace”), which means the brow (see Footnote [3] above). So the
face is likened to the sky (brow) and earth (chin). The chin can be further
subdivided into jufen 巨 分, the lines extending from the corner of the
mouth, and juqu 巨屈, the bend at the jaw (submaxillary angle).
[13] syncope: The word jue 厥 means “devoid of, emptied of ”. It refers to a

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 Diagnosis by Inspecting the Countenance 65

temporary loss of consciousness, often fainting with rigid limbs. In the

theory of conduits (jingluo 經絡), the yin conduits are divided into jueyin 厥
陰, shaoyin 少 陰 and taiyin 太 陰, with an increasing degree of yin, in that
order.
[14] sudden death: The term sudden death (zusi 卒 死; zu 卒, homonym of cu 猝,
sudden death) is best translated as mort subite, a sudden death with unknown
cause. There is a Belgian beer by this name, a fine example of black humour.
This short paragraph was the answer from Huangdi to Leigong, who asked
why there was sudden death without any apparent sign of disease. Huangdi
explained that there was always a harbinger of death if one took the trouble
to observe carefully. That is why Bianque could foretell the death of the Duke
of Qi who was feeling apparently well during the consultation. This is also
the cryptic message encoded in this long paragraph from Lingshu, that
careful inspection is the first step prior to treatment.
[15] centre of the face: The text just reads “centre”, presumably the centre of the
face. This site is located lateral to the nostrils (acupoint yingxiang LI-20) and
below the cheekbone.
[16] navel: The navel (qi 臍, “umbilicus”) is the scar left after cutting the umbilical
cord at birth. It is a soft structure that serves no particular purpose. However,
Chinese medicine attaches much importance to the navel, possibly because it
is a reminder of its linkage to the maternal body. Here lies the acupoint
shenjue 神 厥 (RN-8), which is unique in the sense that unlike most other
acupoints it is not associated with any palpable hard structure underneath.
Neonatal tetanus (qifeng 臍 風) is well known in Chinese medicine, and is
treated conveniently with Chaenomeles—Evodia powder (木萸散 muyu san).
[17] tip of the nose: The word mianwang 面 王 (“king of the face”) refers to the
tip of the nose. It occupies the very centre of the face, like a king sitting in
court.
[18] jaw: The term yache 牙 車 refers to the jaw bones where teeth are implanted.
The point of reference is marked by the acupoint jiache 頰 車 (ST-6), where
the jaw muscles are attached to the lower jaw.
[19] shin: The word jing 脛 refers to the shin, represented by the tibia (jinggu 脛
骨), where the shank means the leg together with the muscles, hence lamb
shank, not lamb shin.
[20] kneecap: The word bin 臏 refers to the kneecap with the patella as its main
structure. In ancient times, an atrocious punishment involved cutting off the
kneecap. Si-Ma Qian told the story of 舉 鼎 絕 臏 ju ding jue bin (lift a tripod

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 66 Neijing Zhiyao Yigu 內經知要譯詁

so heavy that one breaks the shin), but here it means the upper end of the
tibia, as it is unlikely to break the patella. Sun Bin 孫 臏, the famous military
strategist during the Spring and Autumn period, had his leg cut off by his
rival, which prompted him to perfect his art.
[21] left and right: If a certain colour is displaced from left to right on the face (the
right side gets darker as the sites are bilateral), in males this is a sign that the
disease is remitting. Going the other way signifies that the disease is wors-
ening. The contrary is true for females. This is simply a convention, because
left is yang. A sick colour leaving the left side is moving from the yang
domain into the yin domain in males.
[22] lower abdomen: The term xiaofu 小 腹 (“lesser abdomen”) may mean shaofu
少腹 ( “the inguinal region”). This makes sense in connection with the testes,
mentioned below.
[23] fox (sliding) hernia: Hushan 狐 疝 (literally “fox hernia,”) describes the
sliding hernia as if a fox is creeping in and out of its burrow.
[24] elm pod: The term yujia 榆 莢 (“elm pod” or yuqian 榆 錢, “elm coin”) refers
to the young pale green fruit of the elm, which is round like a coin and
slightly sweet. It is an important food substitute in times of famine, and
provided succour to the author at a difficult moment in the past.
[25] Lingshu: Often translated as the “Spiritual Axis”, it refers to the constellation
of Ursa Major. The alpha star is tianshu 天 樞 (“celestial pivot”), and points
to the polar star. Because the constellation revolves around the polar star
during the night, ancient astronomers believed that it controlled the move-
ment of other stars and constellations. Needham translated it as “Vital Axis”,
recognising the vital role it plays in Chinese medicine. The author has tried
to emphasise the pivotal role of Lingshu in Chinese medicine and translates
it as “Pivotal Axis”. It focuses on the vital link of a hinge (shu 樞). The term
shuji 樞 機 or shumi 樞 密 describes the centre of administration, like the
secretariat at the imperial court (shumiyuan 樞 密 院). The Chinese transla-
tion for a red-cloaked cardinal in the Vatican is shuji zhujiao 樞機主教.

[Section 3.3] Suwen Chapter 10: Genesis of the Five Solid

Visceral Organs

《素問．五藏生成篇》曰：面黃目青，面黃目赤，面黃目白，面黃目黑者，
皆不死；面青目赤，面赤目白，面青目黑，面黑目白，面赤目青，皆死。

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 Diagnosis by Inspecting the Countenance 67

[A patient] who has a yellow face with green or red, or white, or black eyes will
not die [unless not treated]. [A patient] who has a green face with red or black
eyes, or a red face with white or green eyes, or a black face and white eyes will
die.

Explanatory Notes
Yellow is the colour of the spleen, generally taken in Chinese medicine as
including the digestive system. The spleen is the source of post-natal essence,
i.e. the energy and nutrients that sustain life. So the colour yellow is a good
sign that one is well fed and life is in full swing. This “yellow” colour is a refer-
ence to the skin colour of people of the Han race (Hanzu 漢族), the dominant
ethnic group in China. It is not yellow in the strict sense as in a patient with
jaundice, or a vegetarian who drinks too much carrot juice. The colours of the
eyes are actually the colour of the iris. Most people in China have brown eyes,
rarely black, but never green (blue) except in some ethnic minorities on the
western frontier (from Persian and Turkic influence). Red can only refer to the
colour of vasodilation on the sclera, and is never like that of the eyes of a
white rabbit. Ethnic Chinese of the Bai race (Baizu 白 族) in Yunnan have a
fair complexion, but they do not have white irises (see ref. 53, fig. 26). “White
eye” (baiyan 白 眼), which means looking upwards so the eyeball shows more
white (sclera) than usual, is a metaphor to describe an attitude of disdain or
contempt. The antonym is “green eye” (qingyan 青 眼, actually “black of the
eye”), to look intently and with admiration (a dilated iris, as if the eye is
blacker than usual). Yuan Ji 阮 籍 (210–263), one of the “Seven Sages of the
Bamboo Grove” (zhulin qi xian 竹 林 七 賢), used to stare at people with his
black or white eye to show approval or disapproval. This section of the text
should be taken to mean that if the yellow colour persists on the face (good
nutrition), one will live, albeit indisposed; the colour of the eye does not
matter. On the contrary, if the yellow colour is no longer there (a sign of
malnutrition ), it is a premonition of death and the colour of the eye does not
matter. However, in the Chinese language having a green/red/black face is not
an expression of emotion. A white face is a sign of apprehension due to vaso-
constriction. That is why no “white face” is referred to in the text.

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