The Back chapter opens with two very different maps of the same anatomy. First the spine is counted and measured vertebra by vertebra; then, in a section drawn entirely from Daoist internal alchemy, the same spine becomes a road with three gates along it by which essence and Qi ascend. Heo Jun sets the two side by side without comment, which is characteristic of a book that treats medicine and self-cultivation as one subject. The clinical core is the pain section, which assigns the shoulder and upper back to the Lung, names overwork as the common cause, and closes with a case in which a line of pain from scapula to ribs is traced back to a business deal that failed.
The Vertebrae of the Spine Have a Count 背脊骨節有數
膂骨以下至尾骶二十一節, 長三尺. 《靈樞》
From the spine bone down to the coccyx is twenty-one vertebrae, three cheok in length.
Yeongchu 靈樞
上七顀, 每顀一寸四分一釐, 共九寸八分七釐, 中七顀, 每顀一寸六分一釐, 共一尺一寸二分七釐, 下七顀, 每顀一寸二分六釐, 共八寸八分二釐. 《神應》
For the upper seven vertebrae, each is 1 chon 4 pun 1 ri, together 9 chon 8 pun 7 ri. For the middle seven, each is 1 chon 6 pun 1 ri, together 1 cheok 1 chon 2 pun 7 ri. For the lower seven, each is 1 chon 2 pun 6 ri, together 8 chon 8 pun 2 ri.
Sineung 神應
二十一顀長三尺, 校之則上七顀共九寸八分七釐, 中七顀, 下七顀, 共二尺一分三釐, 合爲三尺. 《資生》
Twenty-one vertebrae come to three cheok. Checking the figures: the upper seven total 9 chon 8 pun 7 ri, and the middle seven together with the lower seven total 2 cheok 1 pun 3 ri, making three cheok in all.
Clinical note Three sources, and the third exists only to verify the arithmetic of the second against the first — a small piece of textual auditing preserved in the compilation. The counting convention should be noted: twenty-one vertebrae from the first thoracic to the sacrum, divided into three sevens, which is the scheme by which back transport points (兪穴) are located. Modern anatomy counts twelve thoracic and five lumbar, so the classical twenty-one includes sacral segments; the measures are proportional and scale to the individual, as with the limb measures elsewhere.
Jasaeng 資生
The Back Has Three Passes 背有三關
問背後三關. 答曰, 腦後曰玉枕關, 夾脊曰轆轤關, 水火之際曰尾閭關, 乃精氣升降之道路也. 《正理》
Question: what are the three passes behind the back? Answer: behind the brain is the Jade Pillow Pass (玉枕關); alongside the spine is the Windlass Pass (轆轤關); at the boundary of water and fire is the Caudal Gate Pass (尾閭關). These are the road by which essence and Qi ascend and descend.
Clinical note This section is drawn from Daoist internal alchemy (內丹) rather than from the medical classics, and it should be read on its own terms. In neidan practice the practitioner circulates refined essence up the spine along the governing vessel and down the front along the controlling vessel — the circuit later called the lesser heavenly circuit. The three passes are the points where that ascent is felt to meet resistance, and much of the training literature concerns how to get through them. The names are physical: a windlass hauls a bucket up a well, which is what the mid-spine section is imagined to do.
Jeongni 正理
人之脊骨, 二十四節, 節之末, 名曰尾閭穴, 又名龍虎穴, 又名曹溪路, 又名三岔路, 又名河車路, 又名朝天嶺, 又名上天梯.
A person's spine has twenty-four segments, and at the end of the last is the point called the Caudal Gate (尾閭穴). It is also called the Dragon-Tiger Point, the Caoxi Road, the Three-Fork Road, the River-Cart Road, the Ridge Facing Heaven, and the Ladder to Heaven.
Clinical note Seven names for one place, which is itself informative — a site accumulates synonyms in proportion to how much attention it receives, and the tailbone is where the alchemical ascent begins. The Caoxi Road (曹溪路) is the same term that appears in the Neck chapter, in Heo Sukmi's case history for Chobu-san, where Kidney Qi rising up the spine is described as unable to get through Caoxi. That a physician reached for a neidan term to explain a stiff neck shows how thoroughly the two vocabularies interpenetrated. Note also the vertebral count here — twenty-four, against the twenty-one of the preceding section. Different traditions counted differently and the compilation does not reconcile them.
Jeongni 正理
尾閭穴之骨頭, 圓如潼金, 上有九竅, 內外相連, 卽泥丸宮也.
The bone head at the Caudal Gate is round like cast metal; above it are nine apertures, connecting inner and outer — this is the Mud Pill Palace (泥丸宮).
Clinical note Two difficulties here. 潼金 is likely a graphic error, with 童金 or a similar form intended; the sense is a rounded piece of cast metal, and the comparison is to the shape of the sacrococcygeal bone. More substantially, the closing identification with the Mud Pill Palace sits oddly, since the Mud Pill Palace is consistently the cranial centre elsewhere in this very section — the sentence appears to have suffered in transmission. Left as printed rather than emended.
Jeongni 正理
脊骨兩傍, 三條逕路, 上衝直至頂門泥丸宮, 下降復至丹田, 復連至尾閭穴.
On both sides of the spine run three pathways, surging straight up to the Mud Pill Palace at the crown, descending again to the cinnabar field, and connecting once more to the Caudal Gate.
Jeongni 正理
尾閭穴, 乃下關也. 從下至上十八節, 乃中關也. 泥丸宮爲上關, 此三關也. 《正理》
The Caudal Gate is the lower pass. Eighteen segments up from below is the middle pass. The Mud Pill Palace is the upper pass. These are the three passes.
Clinical note A closing restatement that quietly relocates the upper pass from the Jade Pillow at the occiput to the Mud Pill Palace at the crown, which is the more usual alchemical scheme. Read as a whole, the section describes a closed circuit rather than a set of landmarks. Its clinical utility is indirect but real: it is the reason a Korean physician thinks of spinal complaints as obstructions along a route of ascent, and it stands behind the Kidney-Qi formulas that appear in this chapter and the last.
Jeongni 正理
Pulse Methods 脉法
靈樞曰, 腎脉緩甚, 爲折脊.
The Divine Pivot says: when the kidney pulse is extremely moderate, there is a spine that feels broken.
Yeongchu 靈樞
內經曰, 寸口脉中手促上擊者, 曰肩背痛.
The Inner Classic says: when the inch-opening pulse strikes upward against the fingers in a hurried manner, there is shoulder and back pain.
Naegyeong 內經
脉大者, 心下有留飮, 其人背寒冷. 《仲景》
When the pulse is large, there is rheum lodged below the heart, and such a person has cold in the back.
Sanghallon 傷寒論
凡背惡寒甚者, 脉浮大而無力, 是陽虛也. 《丹心》
Whenever aversion to cold in the back is severe and the pulse is floating and large but forceless, this is yang vacuity.
Clinical note The last two passages set up the fork that the next section develops: a large pulse with lodged rheum, versus a large but forceless pulse with yang vacuity. Both give a cold back, and the discriminating feature is force on pressure — which is why the pulse section is placed before the symptom sections rather than after.
Dansim 丹心
Cold in the Back 背寒
內伏寒痰, 則寒從背起, 冷如掌大. 《直指》
When cold phlegm lies hidden within, cold arises from the back, an area of chill about the size of a palm.
Jikji 直指
背惡寒, 是痰飮. 仲景云, 心下有留飮, 其人背惡寒, 冷如氷, 茯苓丸方見痰飮主之. 《綱目》
Aversion to cold in the back is phlegm-rheum. Zhang Zhongjing says: when there is rheum lodged below the heart, the person has aversion to cold in the back, cold as ice; Bokryeong-hwan 茯苓丸 formula in the Phlegm-Rheum chapter governs it.
Gangmok 綱目
背心常一片氷冷者, 痰飮也. 導痰湯方見痰飮, 合蘇子降氣湯方見氣門服之. 《入門》
When the centre of the back is constantly one patch of ice-cold, it is phlegm-rheum. Take Dodam-tang 導痰湯
formula in the Phlegm-Rheum chapter combined with
Sojaganggi-tang 蘇子降氣湯 formula in the Qi chapter.
Immun 入門
凡人每日, 背上一條如線而寒起者, 痰也. 宜吐下之. 《丹心》
When a person feels cold rising daily along a line on the back as thin as a thread, it is phlegm. It should be treated by ejection and precipitation.
Clinical note Three descriptions of the same sign at increasing precision — a palm-sized patch, a constant patch at the centre, a thread-thin line — and all three are read as phlegm. The specificity is the point: a patient who can outline the cold area with a finger is describing something quite different from generalized chilliness, and the classical literature treats that localizability as diagnostic. **Modern correspondence: localized cold dysesthesia of the back; the thread-like distribution suggests a dermatomal or referred pattern.**
Dansim 丹心
背寒有陰有陽. 傷寒少陰證, 背惡寒者, 口中和, 陽明證, 背惡寒者, 口中乾燥, 此寒熱之辨也. 《入門》
Cold in the back may be yin or yang. In the lesser yin pattern of cold damage, aversion to cold in the back comes with a mouth that is bland and comfortable; in the yang brightness pattern, aversion to cold in the back comes with a dry mouth. This is how cold and heat are distinguished.
Clinical note A one-question differential of the kind worth memorizing: same back symptom, opposite pattern, and the mouth settles it. A bland comfortable mouth points to true cold; dryness points to heat with the cold sensation as a secondary phenomenon. The treatments are opposite, so the question is not optional.
Immun 入門
背寒, 宜貼禦寒膏. 《醫鑑》
Uigam 醫鑑
Pain in the Back 背痛
肩背痛, 屬肺分野. 內經曰, 西風生於秋, 病在肺, 兪在肩背. 故秋氣者, 病在肩背. 又曰, 秋脉太過, 則令人逆氣背痛, 慍慍然. 《綱目》
Shoulder and back pain belongs to the Lung's domain. The Inner Classic says: the west wind arises in autumn, the disease is in the Lung, and its transport point is in the shoulder and back — therefore the Qi of autumn brings disease to the shoulder and back. It also says: when the autumn pulse is excessive, it causes counterflow Qi and back pain, with a smouldering discomfort.
Clinical note The seasonal claim is testable and worth testing: upper back and shoulder pain that flares in autumn, in a patient with a respiratory history, is a pattern many practitioners will recognize from their own caseload. 慍慍然 describes a discomfort that smoulders rather than stabs — a useful qualitative marker that separates this from the sharp fixed pain of the following passages.
Gangmok 綱目
肺病者, 喘咳逆氣, 肩背痛, 汗出. 又曰, 邪在腎, 則病肩背頸項痛. 《靈樞》
In Lung disease there is panting and cough with counterflow Qi, shoulder and back pain, and sweating. It is also said: when evil is in the Kidney, there is pain of the shoulder, back, neck and nape.
Yeongchu 靈樞
肩背痛, 宜用通氣防風湯. 脊痛項强, 腰似折, 項似拔, 宜羌活勝濕湯方見頸項.
Donguibogam · Bae
背心一點痛, 宜三合湯. 《醫鑑》
Uigam 醫鑑
脊骨胛眼痛, 宜蒼朮復煎湯. 《丹心》
Dansim 丹心
臀尖痛者, 陰虛而膀胱有火也. 四物湯方見血門, 加知母ㆍ黃柏, 及桂少許. 有痰, 合二陳湯方見痰飮, 加澤瀉ㆍ前胡ㆍ木香爲引, 痛甚, 加乳香ㆍ沒藥. 《入門》
Pain at the point of the buttock is yin vacuity with fire in the bladder. Use
Samul-tang 四物湯 formula in the Blood chapter with the addition of anemarrhena, phellodendron, and a little cinnamon. If there is phlegm, combine with
Ijin-tang 二陳湯 formula in the Phlegm-Rheum chapter, adding alisma, peucedanum and costus root as conductors; if the pain is severe, add frankincense and myrrh.
Clinical note The only passage in the chapter to reach below the lumbus, and it treats buttock pain as a Blood and yin problem rather than a channel problem — a Samul-tang base with the anemarrhena and phellodendron pair that clears vacuity fire, plus a trace of cinnamon to keep the cooling from congealing. **Modern correspondence: gluteal and sacroiliac pain.**
Immun 入門
背疼, 乃作勞所致, 技藝之人, 與士女刻苦者, 多有此患. 色勞者, 亦患之, 惟灸膏肓穴爲妙. 《資生》
Aching of the back comes from overwork. Craftsmen, and scholars and women who apply themselves painstakingly, commonly suffer it; those exhausted by sexual excess suffer it too. Only moxibustion at Gohwang (膏肓, BL43) is truly excellent for it.
Clinical note The most contemporary passage in the chapter. Craftsmen and people who work bent over a task in sustained concentration — the classical description of occupational upper back pain, and it needs no translation into modern terms because it already is one. Gohwang is the point named, and it remains the standard moxibustion site for chronic interscapular pain and depletion. The chapter returns to it in the acupuncture section, which is unusual emphasis for a compilation this terse.
Jasaeng 資生
一男子患背胛縫, 有一線痛起, 上肩跨至胸前側脇而止, 其痛晝夜不歇. 診其脉弦而數, 重取豁大, 左大於右. 予意背胛, 小腸經也. 胸脇, 膽經也. 此必思慮傷心, 心藏未病而小腸府先病, 故痛從肩胛起, 及慮不能決, 乃歸之膽, 故痛至胸脇而止. 乃小腸火乘膽木, 子來乘母, 是爲實邪, 詢之, 果因謀事不成而病. 用人參四分, 木通二分煎湯, 呑龍薈丸方見五藏數服而愈. 《丹溪》
A man suffered at the seam of the scapula, where a line of pain arose, crossed up over the shoulder and ran to the front of the chest and the lateral ribs, where it stopped; the pain did not let up day or night. On examination his pulse was stringlike and rapid, and on heavy pressure open and large, the left larger than the right. I considered that the scapula belongs to the small intestine channel and the chest and ribs to the gallbladder channel. This must be anxious thought damaging the Heart: the Heart viscus was not yet diseased but the small intestine bowel had fallen ill first, so the pain began at the scapula; and when deliberation could not reach a decision, it returned to the gallbladder, so the pain ran to the chest and ribs and stopped. This is small intestine fire overwhelming gallbladder wood — the child coming to overwhelm the mother, which constitutes a repletion evil. On inquiry, it turned out he had indeed fallen ill because a business venture had failed. Ginseng 0.4 don and akebia 0.2 don were decocted, and Yonghoe-hwan 龍薈丸 formula in the Five Viscera chapter was swallowed down with it; after several doses he recovered.
Clinical note The best case history in either of the upper-body chapters, and worth reading slowly. Zhu Danxi reasons from the anatomy of the pain outward: the path it traces crosses two channels, so two organs are implicated; the sequence of channels tells him which came first; five-phase relations tell him it is a repletion rather than a vacuity. Only then does he ask the patient what happened, and the history confirms the reasoning rather than supplying it. Note that the prescribed decoction is minute — 0.4 and 0.2 don — serving as a vehicle to carry a bitter cold pill rather than as treatment in itself.
Dangye 丹溪
Stiff Spine 脊强
督脉之別, 名曰長强, 其病實則脊强. 《靈樞》
The divergence of the governing vessel is called Jangang (長强, GV1); when its disease is repletion, the spine is stiff.
Yeongchu 靈樞
足太陽之脉病, 腰脊强痛. 《靈樞》
In disease of the foot greater yang vessel, there is stiffness and pain of the lumbus and spine.
Yeongchu 靈樞
膀胱腎間冷氣, 攻衝背膂腰脊, 强俛仰不利, 宜烏沈湯方見氣門.
When cold Qi between the bladder and kidney assails the back, spine and lumbus so that they are stiff and bending forward or back is difficult, use Ochim-tang 烏沈湯 formula in the Qi chapter.
Donguibogam · Bae
脊痛項强, 背痛不可回顧, 此足太陽手太陽經中濕氣, 鬱不行也. 宜羌活勝濕湯方見頸項.
Spinal pain with stiff nape, and back pain with inability to turn and look behind — this is damp Qi striking the foot greater yang and hand greater yang channels, constrained and not moving. Use
Ganghwalseungseup-tang 羌活勝濕湯 formula in the Neck and Nape chapter.
Clinical note The second citation of this formula in the chapter, which together make it the most-referenced prescription across the neck and back sections. Note how the two differ: at 背痛 above the picture is lumbus-as-though-snapped and nape-as-though-wrenched, and here it is restriction of rotation with damp constraint. The formula covers the greater yang from occiput to lumbus, which is why it serves both.
Donguibogam · Bae
Hunched Back 背傴僂
中濕, 背傴僂, 足攣成廢, 甘遂一錢爲末, 入猪腰子內煨食之, 上吐下瀉卽愈. 《入門》
For damp strike with a hunched back and the feet cramped to the point of disability: powder kansui 1 don, put it inside a pig's kidney, roast it in embers and eat it; there is vomiting above and diarrhoea below, and it resolves.
Clinical note Kansui is a toxic drastic purgative and the described response — vomiting and diarrhoea — is the intended action, not an adverse effect. The pig's kidney is a delivery vehicle that moderates the assault on the stomach. This is not a usable prescription; it is recorded to show what the classical repertoire considered proportionate to a disabling condition.
Immun 入門
一人背傴僂, 足攣, 脉沈弦而細. 以煨腎散與之, 上吐下瀉, 凡三服乃愈. 方見三法《丹心》
A man had a hunched back and cramped feet, with a pulse sunken, stringlike and fine. He was given
Oesin-san 煨腎散; there was vomiting above and diarrhoea below, and after three doses in all he recovered.
Formula in the Three Methods chapter Dansim 丹心
腰脊間, 骨節突出, 亦是中濕. 內經曰, 濕熱不攘, 大筋緛短, 小筋弛長, 緛短爲拘, 弛長爲痿. 註曰, 大筋受熱則縮而短, 小筋得濕則引而長. 是故, 背傴僂而骨節突出也. 依上法治之. 《綱目》
When the bone joints protrude between the lumbus and spine, this too is damp strike. The Inner Classic says: when damp-heat is not expelled, the great sinews shrink and shorten while the small sinews slacken and lengthen; shrunken and short becomes tautness, slack and long becomes wilting. The annotation says: great sinews receiving heat contract and shorten, small sinews receiving damp draw out and lengthen. Therefore the back hunches and the bone joints protrude. Treat according to the method above.
Clinical note A mechanical account of deformity that holds up remarkably well: some muscle groups shorten while their antagonists lengthen, and the resulting imbalance produces the visible curve with the spinous processes standing out. The classical text attributes the asymmetry to heat acting on one group and damp on the other; a modern reader would describe the same observation as adaptive shortening with antagonist inhibition. **Modern correspondence: kyphosis with prominent spinous processes.**
Gangmok 綱目
老人傴僂, 乃精髓不足, 而督脉虛也. 宜用補腎益精髓之劑. 《類聚》
Hunching in the aged is insufficiency of essence and marrow with vacuity of the governing vessel. Use medicinals that supplement the Kidney and boost essence and marrow.
Clinical note The chapter's one concession that not every hunched back is damp. Age-related kyphosis is separated out and assigned to Kidney and marrow depletion, with supplementation rather than purgation — the opposite treatment from the two cases above, and the distinction is essential. **Modern correspondence: osteoporotic kyphosis; the classical reading of bone as governed by Kidney essence maps closely onto the modern account.**
Yuchwi 類聚
Simple Medicinals 單方
凡四種.
Four kinds in all.
Donguibogam · Bae
羌活. 治風濕脊痛, 項强不可回顧. 剉, 水煎服之. 《湯液》
Notopterygium (羌活): treats wind-damp spinal pain and a stiff nape that cannot turn to look behind. Cut it, decoct in water and take.
Tangaek 湯液
獨活. 治中濕頸項難舒. 剉, 酒水煎服. 《本草》
Aralia (獨活): treats damp strike with the neck and nape hard to loosen. Cut it, decoct in wine and water, and take.
Boncho 本草
烏藥. 治膀胱腎間冷氣攻衝背膂. 剉, 水煎服, 或末服之. 《湯液》
Lindera (烏藥): treats cold Qi between the bladder and kidney assailing the back and spine. Cut it, decoct in water and take, or take as a powder.
Clinical note The single-herb counterpart to Ochim-tang above, for the same indication. Where the four simple medicinals in this section are concerned, the first two treat the damp exterior pattern and these last two the interior cold pattern — the section is organized by the same fork the chapter uses throughout.
Tangaek 湯液
膃肭臍. 主治背髆勞悶, 或痛. 酒灸末服, 或丸服. 《本草》
Fur-seal genitalia (膃肭臍): governs taxation oppression of the back and shoulder blade, or pain there. Roast with wine and take as a powder, or take as pills.
Clinical note Prohibited and unobtainable — fur seals are listed on CITES Appendix II and protected in the United States under the Marine Mammal Protection Act. Recorded as documented. The indication is notable, though: 勞悶, taxation oppression, describes the heavy weary ache of the overworked upper back rather than a sharp pain, and it connects this entry to the overwork passage at 背痛. Where the classical intent is to supplement Kidney yang in a depleted worker, the contemporary route is the ordinary Kidney-supplementing materia medica.
Boncho 本草
Acupuncture and Moxibustion Methods 鍼灸法
脊膂强痛, 取人中. 《綱目》
For stiffness and pain of the spine, select Injung (人中, GV26).
Clinical note A single distal point on the face for a spinal complaint, and the logic is the governing vessel — Injung sits on that vessel above, the spine lies along it below. It is commonly needled with the patient moving the back, in the same manner as Hugye for the neck in the previous chapter.
Gangmok 綱目
肩背疼, 取手三里. 《綱目》
For aching of the shoulder and back, select Susamni (手三里, LI10).
Gangmok 綱目
背痛連胛, 取五樞ㆍ崑崙ㆍ懸鍾ㆍ肩井, 及胛縫穴, 在背端骨下, 直腋縫尖, 及臂, 取二寸半, 瀉六吸. 《綱目》
For back pain extending to the scapula, select Osu (五樞, GB27), Gollyun (崑崙, BL60), Hyeonjong (懸鍾, GB39) and Gyeonjeong (肩井, GB21), together with the Gapbong point (胛縫穴), which lies below the end of the scapular bone, level with the tip of the axillary fold and toward the arm; take it at 2.5 chon and drain for six breaths.
Clinical note Gapbong is an extraordinary point with no standard code, which is why the text supplies locating instructions rather than a name alone — below the scapular border, level with the axillary fold tip. The draining technique is specified in breaths, an older method of quantifying manipulation. Note that three of the four named points are on the leg or shoulder rather than the back itself.
Gangmok 綱目
背疼, 乃作勞所致, 惟膏肓爲要穴, 或背上先疼, 遂牽引肩上而疼者, 乃膏肓爲患, 當灸膏肓兪, 及肩井可愈. 《資生》
Aching of the back comes from overwork, and Gohwang (膏肓) alone is the essential point. When the back aches first and the pain then drags upward to the shoulder, the trouble is at Gohwang; moxa Gohwangsu (膏肓兪, BL43) together with Gyeonjeong (肩井, GB21) and it can be cured.
Clinical note The chapter closes by returning to the point and the cause it named at 背痛 — overwork, and Gohwang. The added diagnostic detail is the direction of spread: pain that starts in the back and travels up to the shoulder localizes the problem to Gohwang, whereas the reverse direction would suggest otherwise. For a compilation that rarely repeats itself, giving this point two separate passages amounts to an endorsement.
Jasaeng 資生