十一难曰∶经言脉不满五十动而一止，一脏无气者，何脏也？
然∶人吸者随阴
入，呼者因阳出，今吸不能至肾，至肝而还，故知一脏无气者，肾气先尽也。
《灵枢·根结篇》曰∶
人一日一夜五十营，以营五脏之精，不应数者，名曰狂生。所谓五十营者，五脏皆受气，持其脉口，
数其至也。五十动而不一代者，五脏皆受气；四十动一代者，一脏无气；三十动一代者，二脏无气，
二十动一代者，三脏无气；十动一代者，四脏无气，不满十动一代者，五脏无气，予之短期。止
与代同，此引经文而约言之也。吸者阳随阴入，呼者阴因阳出，今吸不能至肾，惟至肝而还者，因
肾位最下，吸气较远，脉若不满五十动而一止，知肾气衰竭，则不能随诸脏气而上矣。
十二难曰∶经言五脏脉已绝于内，用针者反实其外；五脏脉已绝于外，用针者反实其内。内
外之绝，何以别之？
然∶五脏脉已绝于内者，肾肝脉已绝于内也，而医反补其心肺，五脏脉已绝于
外者，其心肺脉已绝于外也，而医反补其肾肝。阳绝补阴，阴绝补阳，是谓实实虚虚，损不足，益
有余，如此死者，医杀之耳。
《灵枢·九针十二原篇》曰∶凡将用针，必先诊脉，视气之剧易，乃可以治也。五脏之气已绝
于内，而用针者反实其外，是谓重竭，重竭必死，其死也静，治之者辄反其气，取腋与膺；五
脏之气已绝于外，而用针者反实其内，是谓逆厥，逆厥则必死，其死也躁，治之者反取四末。此内竭
为阴虚，故补腋与膺，以其为脏气之所出也。外绝为阳虚，故补四末，以其为诸阳之本也。小针解
曰∶所谓五脏之气已绝于内者，脉口气内绝不至，反取其外之病处，与阳经之合，有留针以致阳气，
阳气至则内重竭，重竭则死矣，其死也无气以动，故静。所谓五脏之气已绝于外者，脉口气外绝不
至，反取其四末之输，有留针以致其阴气，阴气至则阳气反入，入则逆，逆则死矣，其死也阴气有
余，故躁。此以脉口内外言阴阳内外虚实，不可误也。越人以心肺肾肝别阴阳者，以心肺在膈上，通
于天气，心主脉为营，肺主气为卫，营卫浮行皮肤血脉之中，故言外也。肾肝在膈下，通于地气，以
藏精血，以充骨髓，故言内也。冯氏谓此篇合入用针补泻之类，当在六十难之后，以例相从也。其说
亦是。
第十一难说：医经上说，脉搏不满五十次就出现一次间歇，说明有一脏没有真气了，这是哪一脏呢？
回答说：人吸气时，气随阴经深入体内；呼气时，气因阳经排出体外。现在吸气不能到达肾脏，只到达肝脏就返回了，所以知道有一脏没有真气的，是肾气最先耗尽。
《灵枢·根结篇》说：
人在一天一夜中呼吸五十营（周次），用来滋养五脏的精气，如果不合这个数目的，名叫狂生（指生命垂危或异常）。所说的五十营，是指五脏都接受了气，诊察寸口脉，计算其搏动次数。脉搏跳动五十次而没有一次间歇的，说明五脏都接受了气；四十次搏动中出现一次间歇的，说明有一脏没有气；三十次搏动中出现一次间歇的，说明有两脏没有气；二十次搏动中出现一次间歇的，说明有三脏没有气；十次搏动中出现一次间歇的，说明有四脏没有气；不满十次搏动就出现一次间歇的，说明五脏都没有气，预示患者即将死亡。止脉与代脉相同，这里引用经文并加以概括说明。吸气时阳气随阴气进入体内，呼气时阴气因阳气排出体外。现在吸气不能到达肾脏，只到达肝脏就返回，是因为肾脏位置最下，吸气距离较远，如果脉搏不满五十次就出现一次间歇，可知肾气衰竭，就不能随着其他脏腑之气上行了。
第十二难说：医经上说，五脏的脉象在内侧已经绝灭，用针的人反而充实外侧；五脏的脉象在外侧已经绝灭，用针的人反而充实内侧。内侧和外侧的绝灭，如何区别呢？
回答说：五脏脉象在内侧已经绝灭的，是肾和肝的脉象在内侧已经绝灭，而医生反而补益心和肺；五脏脉象在外侧已经绝灭的，是心和肺的脉象在外侧已经绝灭，而医生反而补益肾和肝。阳绝却补阴，阴绝却补阳，这叫做“实实虚虚”（使实证更实，虚证更虚），损害不足的正气，增加有余的邪气，像这样导致死亡的，是医生杀死了病人。
《灵枢·九针十二原篇》说：凡是准备使用针刺，必须先诊察脉象，观察病气的轻重难易，然后才可以治疗。五脏的气如果在内部已经绝灭，而用针的人反而充实外部，这叫重竭，重竭必然死亡，死时神情安静，治疗的人反而逆乱其气，选取腋部和胸部穴位；五脏的气如果在外部已经绝灭，而用针的人反而充实内部，这叫逆厥，逆厥必然死亡，死时神情躁动，治疗的人反而选取四肢末端的穴位。这种内部竭尽是阴虚，所以补益腋部和胸部，因为这些部位是脏气发出的地方。外部绝灭是阳虚，所以补益四肢末端，因为这些部位是诸阳经的根本。《小针解》说：所谓五脏之气在内部已经绝灭，是指寸口脉的内部气息绝灭不至，反而取其外部的病处以及阳经的合穴，留针以引导阳气，阳气到来则内部更加枯竭，内部枯竭就会死亡，死时因为没有气机活动，所以安静。所谓五脏之气在外部已经绝灭，是指寸口脉的外部气息绝灭不至，反而取其四肢末端的输穴，留针以引导阴气，阴气到来则阳气反而内入，内入则造成逆乱，逆乱就会死亡，死时因为阴气有余，所以躁动。这是以寸口脉的内外部来论述阴阳、内外、虚实，不可误治。越人（秦越人/扁鹊）用心肺和肾肝来区分阴阳，是因为心肺位于膈肌之上，通应于天气，心主脉为营气，肺主气为卫气，营卫之气浮行于皮肤血脉之中，所以说是在外。肾肝位于膈肌之下，通应于地气，负责储藏精血，用以充养骨髓，所以说是在内。冯氏认为这一篇应当归入用针补泻的内容，应该在第六十难之后，以便同类相从。他的说法也是正确的。
Chapter 11 states: The classic texts say that if the pulse beats fewer than fifty times before there is one pause, it indicates that one Zang organ lacks Qi. Which Zang organ is it?
The response is: When a person inhales, Qi follows the Yin meridians into the interior; when exhaling, Qi exits via the Yang meridians. Now, if inhalation cannot reach the Kidney and returns only upon reaching the Liver, we know that the Zang organ lacking Qi is the Kidney, as its Qi has been exhausted first.
The *Ling Shu · Gen Jie* chapter says:
In one day and night, a person circulates Qi fifty times (Ying cycles) to nourish the essence of the five Zang organs. If this number is not met, it is called "Kuang Sheng" (a state of critical vitality or abnormality). The so-called fifty Ying cycles mean that all five Zang organs receive Qi. By holding the Cun Kou pulse point and counting the beats: if there are fifty beats without any intermission, all five Zang organs have received Qi; if there is one intermission in forty beats, one Zang organ lacks Qi; if there is one intermission in thirty beats, two Zang organs lack Qi; if there is one intermission in twenty beats, three Zang organs lack Qi; if there is one intermission in ten beats, four Zang organs lack Qi; if there is an intermission in fewer than ten beats, all five Zang organs lack Qi, indicating a short life expectancy (impending death). A "Zhi" (stop) pulse is similar to a "Dai" (intermittent) pulse. This passage cites the classic text and summarizes it. Inhalation involves Yang following Yin into the interior; exhalation involves Yin exiting due to Yang. Now, if inhalation cannot reach the Kidney and returns only at the Liver, it is because the Kidney is located lowest, making the distance for inhalation longer. If the pulse shows an intermission before fifty beats, it indicates that Kidney Qi has failed and cannot ascend along with the Qi of the other Zang organs.
Chapter 12 states: The classic texts say that if the pulses of the five Zang organs are already extinct internally, the acupuncturist instead tonifies the exterior; if the pulses of the five Zang organs are already extinct externally, the acupuncturist instead tonifies the interior. How can one distinguish between internal and external extinction?
The response is: When the pulses of the five Zang organs are extinct internally, it refers to the pulses of the Liver and Kidney being extinct internally, yet the physician erroneously tonifies the Heart and Lung. When the pulses of the five Zang organs are extinct externally, it refers to the pulses of the Heart and Lung being extinct externally, yet the physician erroneously tonifies the Liver and Kidney. Tonifying Yin when Yang is extinct, and tonifying Yang when Yin is extinct, is termed "Shi Shi Xu Xu" (making the excess more excessive and the deficiency more deficient), damaging what is insufficient and augmenting what is already in excess. Death resulting from such actions is considered murder by the physician.
The *Ling Shu · Jiu Zhen Er Shi Yuan* chapter says: Whenever one intends to use acupuncture, one must first diagnose the pulse, observe the severity and ease of the Qi condition, and then proceed with treatment. If the Qi of the five Zang organs is already extinct internally, but the acupuncturist instead tonifies the exterior, this is called "Chong Jie" (double exhaustion). Chong Jie leads to death, and the deceased appears quiet. The practitioner who treats this wrongly reverses the Qi, selecting points in the axilla and chest. If the Qi of the five Zang organs is already extinct externally, but the acupuncturist instead tonifies the interior, this is called "Ni Jue" (reverse cold syndrome). Ni Jue leads to death, and the deceased appears restless. The practitioner who treats this wrongly selects the extremities. Internal exhaustion is Yin deficiency, so one tonifies the axilla and chest, as these are where Zang Qi emerges. External extinction is Yang deficiency, so one tonifies the extremities, as these are the roots of all Yang meridians. The *Xiao Zhen Jie* explains: The so-called extinction of Zang Qi internally means the Qi at the Cun Kou pulse point does not reach internally. Instead, taking external disease sites and the He-Sea points of Yang meridians, and retaining the needle to draw in Yang Qi, causes the Yang Qi to arrive, leading to double internal exhaustion. Double internal exhaustion leads to death; since there is no Qi to move, the body is quiet. The so-called extinction of Zang Qi externally means the Qi at the Cun Kou pulse point does not reach externally. Instead, taking the Shu points of the extremities and retaining the needle to draw in Yin Qi, causes the Yin Qi to arrive, forcing Yang Qi to enter inward. Inward entry leads to reversal, and reversal leads to death; since there is excess Yin Qi, the body is restless. This discusses Yin-Yang, interior-exterior, and deficiency-excess based on the interior and exterior of the Cun Kou pulse, which must not be mistaken. Yué Rén (Bian Que) distinguishes Yin and Yang using the Heart/Lung and Liver/Kidney because the Heart and Lung are above the diaphragm, connecting with Heaven's Qi; the Heart governs the vessels and constitutes Ying Qi, while the Lung governs Qi and constitutes Wei Qi. Ying and Wei Qi float within the skin and blood vessels, hence they are said to be "external." The Liver and Kidney are below the diaphragm, connecting with Earth's Qi; they store essence and blood to nourish bone marrow, hence they are said to be "internal." Feng Shi stated that this chapter should be grouped with those on acupuncture tonification and reduction, likely placed after Chapter 60 for thematic consistency. His view is also correct.