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The difficulty in distinguishing diseases lies not in identifying true conditions, but in differentiating between similar (suspected) conditions. The difficulty in treating diseases lies not in handling direct (Zheng) and reverse (Ni) patterns, but in responding to "reverse treatment" (Fan Zhi) and "following treatment" (Cong Zhi).

When pathogenic factors accumulate within, it is an Excess condition. In severe cases, it may present with silence, reluctance to speak, unwillingness to move the limbs, dizziness, blurred vision, or frequent diarrhea. These are all signs of a great Excess presenting with Deficient appearances. This is like overeating, which leads to fatigue and a desire to lie down.

When the Spleen and Stomach are damaged, it is a Deficiency condition. In severe cases, it may present with abdominal distension and fullness, inability to ingest food, stagnation of Qi, and obstruction of bowel and bladder movements. These are all signs of extreme Deficiency presenting with Excessive appearances. This is like prolonged hunger, which leads to a loss of appetite.

Spleen-Stomach Deficiency-Cold is a True Yin pattern. When Yin Cold reaches its extreme, it often causes "Yin repelling Yang" (Ge Yang), manifesting as red face, red eyes, mouth and tongue ulcers, restless tossing of hands and feet, and confused speech, which superficially resembles a Yang pattern. This is like the severe cold of winter where water freezes into hard ice; hardness is an image of Yang-Gang.

Unresolved pathogenic heat is a True Yang pattern. When Yang Heat reaches its extreme, it often causes Jue (syncope/cold extremities due to heat blockage). During Jue, there is no breath at the mouth and nose, and the hands and feet are cold, which superficially resembles a Yin pattern. This is like the scorching heat of midsummer where trees weep sap; sap is an image of Yin-Soft.

Therefore, predecessors said: When Excess presents with Deficient appearances, and Deficiency presents with Excessive appearances, error lies in mistaken tonification or purgation. When Yin patterns resemble Yang, and Yang patterns resemble Yin, error lies in mistaken warming or cooling. Can one fail to distinguish them?

In fact, this is easy to understand. For example, True Cold manifests as cold extremities, vomiting, abdominal pain, diarrhea, clear and frequent urination. Even if fever occurs, the patient desires clothing. The pulse is deep, small, slow, or soggy; eye discomfort improves with warmth. True Heat manifests as restlessness, panting, thirst, loud voice, constipation, dark and scanty urine, fever with a desire to throw off covers. The pulse is slippery, rapid, large, or forceful; eyes hurt and fear light and heat. False Cold manifests as a cool body but aversion to clothing, hot and difficult stool, irritability, desire for drinks, foul-smelling exhaled air. The pulse is slow but forceful, or deep and surging. False Heat manifests as a red face and hot body, but without removing covers and with calm spirit; speech may be delirious but breath is faint; or false mania with sudden rising and falling that stops when restrained; or skin spots like mosquito bites, pale red and fine; or preference for cold water but drinking little; or constipation with frequent urination. The pulse may be rapid but soggy, or floating, large, rootless, knotted, wiry, or intermittent. True Deficiency manifests as pale complexion, exhausted form, depleted essence, timid Qi, spontaneous sweating, incontinence of bowels and bladder, weak and spiritless pulse. True Excess manifests as internal organ knotting, external meridian closure, Qi stagnation, blood stasis causing harm, and pulses that are all robust. False Deficiency appears emaciated but the pulse is pathological and strong. False Excess appears vigorous but the healthy Qi is greatly depleted.

Treating True Deficiency requires tonification; Treating True Excess requires attack/purgation; Treating True Cold requires warming; Treating True Heat requires cooling. This is called Direct (Zheng) and Reverse (Ni) treatment. Treating False Cold requires clearing internal heat; once internal heat is cleared, floating Yin retreats. Treating False Heat requires warming True Yang; once the middle warms, deficient fire returns to its source. Treating False Deficiency, since healthy Qi is damaged, one should directly eliminate the pathogen; once the pathogen is gone, the body is safe. Treating False Excess, although pathogens are abundant, one should simultaneously tonify healthy Qi; once healthy Qi is preserved, major disaster is avoided.

Moreover, tonification inherently contains the intent to purge. There is no case where healthy Qi recovers while pathogens remain, nor where healthy Qi exhausts while life is preserved. If absolutely necessary, one should proceed lightly and slowly, embedding attack within defense. This is called Reverse (Fan) and Following (Cong) treatment.

In summary, those who can withstand attack therapies are indeed Excess patterns. Excess patterns are mostly Heat; even if drugs are cold, there is no worry. Those who cannot withstand attack therapies are Deficiency patterns. Deficiency patterns are mostly Cold; if drugs are not warm/hot, changes may occur rapidly during breathing, making response too late. Therefore, for suspected symptoms, facial expression and spirit are insufficient evidence; one must refer to pulse theory. If pulse theory is also insufficient, one must observe constitution, preference for warm/cool, phlegm, sweat, stool, urine, aversion to cold/heat, duration of disease, and whether previous medication was erroneous. Then administer decoctions. Even if not perfectly accurate, it will not be far off.

Regarding methods such as "Tonifying to treat obstruction" (Se Yin Se Yong), "Purging to treat discharge" (Tong Yin Tong Yong), "Warming to treat heat" (Re Yin Re Yong), "Cooling to treat cold" (Han Yin Han Yong), "Using heat avoiding heat seasons" (Yong Re Yuan Re), and "Using cold avoiding cold seasons" (Yong Han Yuan Han): For instance, Spleen Deficiency causing distension is treated with Ginseng (Renshen) and Atractylodes (Baizhu); the Spleen is tonified and distension消 (disappears). Kidney Deficiency causing rebellious Qi is treated with Schisandra (Wuweizi); the Kidney is tonified and Qi returns to the source, rebellious fullness calms. This is Tonifying to treat obstruction. Typhoid with heat-induced diarrhea, or dry feces inside, is treated with Tiao Wei Cheng Qi Tang to purge and bring peace. Dysentery with obstruction is treated with Shaoyao Tang to promote flow and cure. This is Purging to treat discharge. Drugs that are inherently cold are counter-assisted with hot drugs; drugs that are inherently hot are counter-assisted with cold drugs, to avoid rejection. As the Classic says: One must first address the primary cause and subdue the underlying reason; they differ at the start but converge at the end. This is Warming to treat heat, Cooling to treat cold. Cold diseases suit hot drugs; heat diseases suit cold drugs. Use only enough to hit the target; do not overuse, lest drug damage occur. As the Classic states: Long-term use increases Qi energy, which is the norm of transformation. Increased Qi over time leads to premature death. This is Using heat avoiding heat seasons, Using cold avoiding cold seasons. The above methods are general principles of Following Treatment. Expanding upon them depends on the wise physician's ability to infer by analogy. Thus it is said: Diseases have no fixed shape; physicians have no fixed formulas; drugs have no fixed categories. Compliance, opposition, advance, and retreat depend on timing. Sovereign, minister, assistant, and courier roles depend on application. Sage-like skill depends on the person. Those who rigidly apply standard opposites to true/reverse patterns may not err greatly when facing true diseases. But once facing suspected diseases, where treatment requires reverse/following approaches, it is like crossing a vast sea without knowing the shore. Between subtle nuances, life and death hang in the balance. Moreover, False Deficiency is rare, while False Excess is common. Errors in False Cold are understandable, but errors in False Heat are incurable; one dose enters, and the five viscera burst. Humans are not wood or stone; such words chill the heart. Yet there are cases where following treatment opposes the truth, turning false illness into true illness. All these harms stem from suspicion/similarity. White-haired scholars exhausting classics still make mistakes. How sad! Therefore, I carefully compile these most difficult aspects of distinguishing and treating diseases to inform future generations. Those who take benevolence as their responsibility should surely share this sentiment.