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A guest was surprised to see that in the medical cases I compiled, some treatments began immediately with tonification, some occasionally used tonics while pathogenic factors were not yet fully eliminated, and others used potent tonics as soon as the pathogenic factors had just been cleared. I told him: Among famous physicians throughout history, none surpasses Zhang Zhongjing; and among diseases, none involves more severe pathogenic factors than Cold Damage (Shanghan). Zhang Zhongjing established 113 formulas, more than 70 of which employ Ren Shen (Ginseng Radix et Rhizoma). This is because "where pathogenic factors gather, Qi must be deficient." Therefore, he included Ren Shen in exterior-releasing formulas, in heat-clearing and draining formulas, and in warming formulas. My practice of occasionally using tonics when pathogenic factors are not yet fully eliminated follows the method of Zhang Zhongjing. Among later famous physicians, Li Dongyuan of the Jin Dynasty and Zhao Xianke (courtesy name Jiebin) of the Ming Dynasty are also outstanding figures. Li Dongyuan's formulas such as Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) treat fatigue-induced internal injury with miraculous efficacy; Zhao Xianke's formulas from Yi Guan (The Canon of Medicine), specifically Cong Yi Yin Jian (One-Yin Decoction) to Si Yin Jian (Four-Yin Decoction), treat blood-deficiency fever with equally miraculous efficacy. My practice of beginning treatment immediately with tonification follows the methods of Li Dongyuan and Zhao Xianke. As for using tonics only after pathogenic factors have been completely eliminated, that is merely the skill of mediocre physicians, hardly worth debating. Generally, my treatments often address patients who are impoverished, whose illnesses frequently arise from fatigue and overwork. The Pi Wei Lun (Treatise on the Spleen and Stomach) discusses this in great detail. I shall briefly restate the essentials here to clarify my intent.

The key points for beginning treatment immediately with tonification are threefold: First, observe the complexion; if there is no dark, stagnant, or oily luster on the face. Second, inquire carefully about symptoms of fever and aversion to cold; if the patient feels no coldness while lying under blankets, or experiences spontaneous sweating without desire to eat, and even if they do eat, it tastes bland, accompanied by soft limbs and weak Qi, a slightly thick tongue coating without thirst, a floating, large, and soft pulse, and slightly red but long urine, this precisely constitutes fatigue-induced internal injury, suitable for Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). If the patient has fever without aversion to cold, night sweats, a crimson tongue with scant coating, a preference for drinking water but inability to transform fluids, a slightly reddish facial hue, and a fine, rapid, and forceless pulse, this indicates Yin deficiency causing fever, suitable for Si Wu Tang (Four-Substance Decoction) combined with Si Yin Jian (Four-Yin Decoction) or similar formulas. For those with both fatigue and blood deficiency, where the above symptoms appear intermittently, Ba Wu Tang (Eight-Ingredient Decoction) or Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) can be used, adding Sheng Di Huang (Rehmanniae Radix), Dang Gui (Angelicae Sinensis Radix), and Mai Dong (Ophiopogonis Radix). Regarding chronic illnesses or cases where treatment has not yet achieved full recovery, if Zheng Qi (Righteous Qi) is already deficient and residual pathogenic factors remain, one should assist with tonification while using heat-clearing and draining methods, or assist with eliminating pathogens while using tonic formulas. When differentiation is slightly ambiguous, not only can improper use of tonics harm people, but so too can inappropriate use of heat-clearing, draining, warming, or purging methods. Moreover, my attitude of humility and caution is something you cannot fully perceive. Whenever I prescribe attacking or tonifying, cooling or warming agents, I maintain a separate ledger recording the treatment plans. If there is a follow-up visit, I must ascertain the entire situation; if there is no follow-up, I must repeatedly inquire until the patient recovers after taking the medicine, at which point my heart finds peace. The medical cases recorded are all like this. Upon hearing this, the guest nodded in agreement and withdrew.