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Listen to the patient's voice to differentiate the disease. As stated in the *Classic of Internal Medicine*: If speech is faint and the patient can only speak again after a long pause throughout the day, this indicates **Qi depletion** (Qi deficiency/exhaustion). If there is fullness in the chest and distension in the viscera, and the voice sounds muffled as if coming from within a room, this indicates dampness in the middle **Jiao** (Middle Burner). If caused by summerheat with sweating, vexation, thirst, and panting, yet the patient speaks excessively when quiet, this indicates disturbance of the **Shen** (Spirit/Mind). If the patient cannot properly arrange clothing and bedding, and their speech is inappropriate regardless of kinship or strangers, this indicates chaos of the Shen. If the essence of the five Zang organs is severely depleted, the Shen cannot be retained, and the voice is hoarse, death ensues. If the patient picks at seams of clothes and speaks deliriously, it is incurable. In cases of internal injury due to diet and overexertion, the patient does not wish to speak; even if forced to speak, the voice will be timid, weak, and low, which is evidence of internal insufficiency.

In cases of external contraction of wind-cold, speech is initially light and becomes heavier later; the voice is high, vigorous, and powerful, which is evidence of excess (fullness).

Whenever the voice is hoarse, speech sounds resonant as if from an urn, starting light and becoming heavy, high-pitched and powerful, all are evidence of abundant pathogenic wind.

In cough due to phlegm-fire, if hoarseness persists for a long time and gradually progresses to aphonia, death is inevitable. Hearing that the patient speaks weakly and strongly desires not to speak, with difficulty in distributing breath, indicates internal injury. If the patient speaks forcefully and speaks incessantly, it indicates external contraction. If both Yin and Yang Qi are exhausted, causing confusion and inability to speak, death occurs within three days. If the patient rambles incoherently and is confused, or cannot speak, it is generally untreatable; however, if it is due to a heat disease, it may be treatable.

The Classic states: One must carefully inquire about the initial onset of the disease and the current symptoms, then palpate the pulse accordingly.

The *Suwen · Shu Wu Gu Pian* says: For patients not yet diagnosed, one must ask about past status of nobility followed by baseness; even without external pathogens, disease arises internally, named "Tuoying" (Depletion of Ying/Nutritive Qi). Formerly rich but now poor is named "Shijing" (Loss of Jing/Essence). The Five Qi remain stagnant for long periods, and pathogens combine. When physicians diagnose, they find no disorder in the Zang-Fu, nor changes in the body form, leading to doubt and uncertainty about the disease name. The body diminishes daily, Qi is empty and Essence is lost, the disease is deep with no Qi, and the patient feels chilly and startled intermittently. Deep disease results from external consumption of Wei (Defensive) Qi and internal depletion of Ying (Nutritive) Blood. Skilled physicians err because they do not understand the condition. It also says: There are three common aspects in diagnosis; one must ask about changes in social status, such as the fall of feudal lords or unfulfilled ambitions for power.

The *Lingshu* states: Entering a country, ask about customs; entering a home, ask about taboos; ascending the hall, ask about etiquette; facing a patient, ask about their comfort and preferences. This is utmost caution.

It further states: Any physician diagnosing illness must inquire about diet and daily routine, sudden joy or sorrow, or transition from joy to sorrow, all of which damage Essence and Qi. The *Zheng Si Shi Pian* says: Diagnosing illness without asking about the beginning, worrying thoughts, dietary irregularities, excessive living habits, or toxic exposure, and abruptly holding the Cun Kou (radial artery) pulse, how can one accurately identify the disease?

For all diseases, if symptoms worsen during the day and are quiet at night, it is excess Yang disease, indicating Qi pathology without Blood pathology. If symptoms worsen at night and are quiet during the day, it is excess Yin disease, indicating Blood pathology without Qi pathology. If fever occurs during the day and is quiet at night, Yang Qi is naturally flourishing in the Yang aspect. If quiet during the day and feverish/vexed at night, Yang Qi has sunk into the Yin aspect, named "Heat entering the Blood Chamber". If fever and vexation occur both day and night, it is extreme Yang without Yin; one should urgently drain Yang and vigorously tonify Yin. If aversion to cold occurs during the day and is quiet at night, Yin Blood is naturally flourishing in the Yin aspect. If quiet at night and aversion to cold during the day, Yin Qi is overflowing into the Yang aspect. If aversion to cold occurs both day and night, it is extreme Yin without Yang; one should urgently drain Yin and vigorously tonify Yang. If aversion to cold during the day and vexation at night, with inability to eat, the disease is named "Yin-Yang Jiao Bian" (Intertwining of Yin and Yang). Yin-Yang Jiao Bian leads to death.

Close doors and windows, focus on the patient. Ask repeatedly about their emotional state to align with their intentions. Those who possess Shen prosper; those who lose Shen perish.

The *Jiayi Jing* states: When questioning the patient, ask what they are thinking, fearing, desiring, and doubting. The key to inquiry is observing the deficiency and excess of Yin and Yang, and distinguishing the cold and heat of the Zang-Fu. Disease generation never departs from Yin and Yang. If the cold, heat, deficiency, and excess of Zang-Fu are clearly distinguished, treatment will be error-free.

Wang Haizang said: Ordinary people seeking diagnosis often stand silently, allowing only pulse taking to test the physician's ability. However, the pulse reflects Qi and Blood adhering to the meridians. Heat excess causes rapid pulse; cold excess causes slow pulse; excess presents with strength; deficiency presents with weakness. How can the cause of disease and specific injuries be known solely by pulse? Therefore, physicians must not fail to ask about the cause, and patients must not fail to explain the origin.

Sun Simiao said: Inquiry before diagnosis is most accurate.

Su Dongpo said: The difficulty of understanding pulses is a concern since ancient times. Extreme deficiency may present with excess signs; extreme excess may present with deficient signs. Between these similarities and differences lies the distinction between life and death. Scholars often conceal their ailments to test physicians' competence. Whenever I sought medical treatment in my life, I would fully disclose my condition so the physician could clearly locate the disease. By determining deficiency/excess and cold/heat in mind first, then taking the pulse, ambiguous signs cannot confuse me. I seek only cure, not to hinder the physician!

In gynecology postpartum care, first inquire about the ease or difficulty of labor, amount of lochia, timing of diet, and survival of the infant. Since injury to form and blood differ, methods for tonifying Qi and Blood vary. Dietary irregularities require regulating the Middle Jiao; if the infant did not survive, one must also resolve depression/stagnation. Asking about desires reveals the disease: desire for heat indicates cold; desire for cold indicates heat; preference for stillness and aversion to movement indicates deficiency; restlessness indicates excess; aversion to food indicates food stagnation; aversion to wind indicates wind invasion; craving sweet taste indicates Spleen deficiency; craving pungent taste indicates Lung disease; craving sour taste indicates Liver deficiency; craving salty taste indicates Kidney weakness; craving bitter taste indicates Heart disease. These are compliant patterns and easy to treat. Conversely, if Heart disease craves salt, Lung injury craves bitter, Spleen weakness prefers sour, Liver disease likes spicy, and Kidney decline craves sweet, these are adverse signs. Mild illness becomes critical; critical illness leads to death. With correct treatment and preventive medication, life can be restored.

*Nan Jing · Chapter 51* states: Patients desiring cold and wanting to see others have disease in the Fu organs; patients desiring warmth and avoiding people have disease in the Zang organs.

Li Dongyuan's *Nei Wai Shang Bian* states: Regarding fever and aversion to cold, alternating chills and fever, steaming dry heat arising from between muscles indicates internal injury. Fever with simultaneous chills, fluttering heat arising from skin and hair indicates external contraction. Regarding loss of taste, inability to swallow, disharmony of hands and feet, and heat in both hypochondriac regions, these are internal injury syndromes.

Regarding normal taste perception, harmonious abdomen, normal urination and defecation, bone and tendon pain, immobility requiring support, these are external contraction syndromes.

Regarding aversion to wind, if residing outdoors in strong winds one feels no aversion, but only aversion to slight drafts from window cracks, this is internal injury.

Regarding clear nasal discharge, intermittent headache and spontaneous sweating, shortness of breath, insufficient respiration, timidity, and reluctance to speak, these are internal injury syndromes.

Regarding frequent urination without thirst, initially due to overwork and scanty diet; yellow-red urine, difficult defecation, or strangury-like sensations without actual dysentery, or loose yellow stools, or diarrhea, or constipation, all are internal injury syndromes.

Regarding epigastric stuffiness or chest obstruction feeling like knife-cutting pain, occurring alternately but not simultaneously; sometimes pain at the stomach region radiating to both hypochondria, limbs unable to move, weakness, lethargy, and drowsiness, all are internal injury syndromes.

Regarding the Qi of Minister Fire below the umbilicus rushing up to the chest uncontrollably, ceaseless Qi flow, even leading to severe panting, all are internal injuries.

Regarding persistent, uninterrupted headache, this is external contraction.

Regarding fixed accumulation pain, it is Blood pathology; wandering, non-fixed pain is Qi pathology.

Regarding pain location, relief upon pressure indicates deficiency; increased pain upon pressure indicates excess.

Wandering pain indicates Wind; spasms indicate Cold; vexation and thirst indicate Summerheat; heaviness and涩 (astringency/heaviness) indicate Dampness. Or predisposition to sexual indulgence, trauma from fright, dietary injury, or staying indoors and contracting summerheat, all are causes of disease, hence the importance of inquiry.

In the past, someone suffered throat pain and itching with no effect from various physicians. One physician asked about their usual diet and learned they loved eating turtledoves, which had eaten Pinellia corms and thus carried toxicity. Treatment with fresh Ginger cured them.

Similarly, Tang Ruzheng treated a child with wind-heat; the whole body recovered except the vertex. Upon inquiry, he found the wet nurse loved hot wine, realizing the toxicity was transmitted via milk. Doubling the dosage of Puerariae Radix (Ge Gen) and Coptidis Rhizoma (Huang Lian) in the formula led to recovery.