病之有形者，可望而知，有声者，可闻而知。至无形无声处，须问而知，更切而知，此治病所以赖有四诊也。然而四诊中，有正象，有反象，有真象，有假象，往往诸诊无可凭。偶得一诊以为确据者，固恃临诊时，有神明之用耳。癸巳春，余客都门，有孙姓女公子患咽痛症，前医以其胸满闷溺短赤，任用破气导湿之剂，症益剧。来延余诊，切其脉，数甚，左尺独微，知是春温邪盛，水液受耗，非滋清不可，用白虎汤，冬地汤法，加减治之而愈。愈后，旬有余日，前症复作。余诊之，身热汗出，烦躁口干，脉来滑数，舌中苔厚而黄，谂是饮食不节，温邪复聚为患，又用白虎承气汤法治之。两剂，病不减。至再诊时，望见被褥太厚，始知病所以不减故，令去其半，告以症宜凉不宜温。投剂始效，十数服而病豁然。此望而知之一证也。丙戌秋八月，余同邑城南，陆家溏陆大兴，患胸痛半年，请诊于余。面色唇舌俱赤，鼻息亦粗，脉象尤数，大致似有火郁。及问病状，渠答曰；稍感外寒，痛势连绵，必饮热烧酒，始能止痛。因知症系虚寒，一切面舌之赤，鼻息之粗，脉象之数，是饮热烧酒所致。用四逆汤理中汤等方，加减治之，其痛即平。此间而知之一证也。癸巳秋，余入都，至某太史处，闻人笑语云：你太快活，故生病矣。阅时，即有某舆夫来求诊。余切其脉，细而涩，因知所闻快活生病，殆此人也。遂用十全大补汤法补之。或以其形貌壮伟，且系劳力粗人，疑药不合。余曰；此盖色劳，其外虽强，其中实馁，非补不治。服药数剂，果大效，后询诸人，渠果香巢遍筑，如狡兔有三窟然。此闻而知之一证也。庚寅春季，余客天津，适同乡余君秋田病剧，速余往诊。上吐下泻，神识支离，不惟饮食不思，并碧霞膏亦不能吸，症象颇危。然余切其脉，虚细中尚有和缓之致，外象虽险，真气未漓。与以附子理中汤加味，吐泻即止。继进十全大补汤法，随时减增，共调治月余而愈。此切而知之一证也。比而论之，可凭者在此，即不可凭昔在彼，总恃临证时，于无可凭中，求其着实可凭处，奉为定凭而已。至于治病之法，寒者温之，热者清有之，实者泻之，虚者补之。有一病即有一法，药味无可乱投，即制方有大小，用药有轻重，亦皆各行其是，未可混施。然而有时寒热虚实，病情错出，治法亦不能不变通者，是又恃临治之人，善为权度焉。丁酉春仲，余往吴桥，为王君检予治中风时，渠夫人亦病剧，日夕惊恐，合目尤甚，畏寒不已，头裹重绵，犹觉冷风袭入骨髓，身热有汗，胸脘时觉火烧，溺赤便溏，舌苔灰腻，脉时虚缓，时滑数，时左盛，时右盛。余先用加味八珍汤法补之，继用郁芩五苓散法泻之，更间用理中汤、三黄汤法以温之清之，终以参斛汤法加味调治之，居然逐次奏功，月余丽症悉愈。或间治病如行路，一病止一路，今之路何其多?余曰：路何尝多哉，不过盘旋往复，多费周折耳。此症气血极虚，中有湿热凝聚为患，故见症错杂如此。以其气虚有湿，而用补气燥湿之剂，必至血耗：以其血虚有火，而用养血清火之剂，必至气馁。合用之不能，专任焉不得。于是或补或泻或清或温，随时以策应之，譬诸路，有直捷处，亦有曲折处，遇曲折处，仍直捷行之，必室碍而难通，惟循途曲赴焉。斯曲折之路，与直捷之路，势虽不同，及其到也则一。尝闻人传述一种怪病云，其病已延数医，每易一医，初剂必较，再剂即不效，主人束手无策，坐以待毙。噫，此殆曲折之路，误为直捷之路。故有行辄阻，天下岂真有怪病哉。所虑者，主人苦于不知，多方畏葸，旁人不知而貌为知，妄虞殷勤。此中贻误正多。放愚谓前症情形极重，竟能转危为安者，实渠子元常侍奉之力，元常于余相交有年，每谈医理，吻合无间。故余得曲折如志，与为诊治，设遇逆旅主人，虽神明如扁鹊，亦莫可如何耳。只得诿之曰；敷为之也，有命存焉而已。
Diseases that have visible forms can be known through observation (Wang), and those with audible sounds can be known through listening and smelling (Wen). As for those without form or sound, one must know them through inquiry (Wen) and further through palpation (Qie); this is why treating diseases relies on the Four Diagnostic Methods (Si Zhen: Observation, Listening/Smelling, Inquiry, Palpation). However, among these four methods, there are correct manifestations (Zheng Xiang) and reverse manifestations (Fan Xiang), true manifestations (Zhen Xiang) and false manifestations (Jia Xiang). Often, all diagnostic methods fail to provide a reliable basis. Occasionally, relying on just one method as definitive evidence indeed depends on the physician's divine perceptiveness during clinical practice.
In the spring of the Guisi year, while residing in the capital, I treated a young lady surnamed Sun who suffered from throat pain. Previous physicians, noting her chest fullness and scanty dark urine, had arbitrarily administered formulas to break Qi stagnation and guide out dampness, causing her condition to worsen. Upon my examination, her pulse was rapid (Shu), but the left Chi position was particularly weak. I deduced that this was due to flourishing Spring-Warmth pathogenic factors consuming body fluids, requiring nourishment and clearing heat. I treated her using the principles of Baihu Tang (White Tiger Decoction) and Dongdi Tang (Winter Earth Decoction), with modifications, resulting in recovery. More than ten days after recovery, the original symptoms recurred. Upon re-examination, she presented with fever, sweating, irritability, dry mouth, a slippery-rapid pulse, and a thick yellow coating on the center of the tongue. I realized this was caused by irregular diet leading to the re-accumulation of Warmth pathogens. I again treated her using the method of Baichengqi Tang (White Tiger and Da Chengqi Decoction combined). After two doses, the illness did not subside. During the second follow-up, observing that her bedding was too thick, I understood the reason for the lack of improvement. I instructed her to remove half of it and advised that her condition required cooling rather than warming. Only then did the medication take effect, and after more than ten doses, her illness cleared up completely. This is a case of "knowing through observation."
In the eighth month of autumn in the Bingxu year, Lu Daxing, a fellow townsman living at Lujia Tang south of the city, suffered from chest pain for half a year and requested my consultation. His complexion, lips, and tongue were all red, his nasal breathing was coarse, and his pulse was particularly rapid, generally resembling a Fire Stagnation pattern. However, upon inquiry, he replied that slight exposure to external cold caused continuous pain, which could only be relieved by drinking hot distilled liquor. Thus, I determined the syndrome was Deficiency-Cold. The previously mentioned redness of the face and tongue, coarse breathing, and rapid pulse were all induced by the consumption of hot liquor. I treated him with modifications of Sini Tang (Frigid Extremities Decoction) and Lizhong Tang (Regulate the Middle Decoction), after which the pain subsided immediately. This is a case of "knowing through inquiry."
In the autumn of the Guisi year, upon entering the capital, I visited the residence of a certain Grand Secretary. I heard someone say jokingly, "You are too happy, hence you became ill." Shortly after, a sedan-chair bearer came to seek treatment. Palpating his pulse, I found it fine and choppy (Se), and thus inferred that the person referred to by the comment about "becoming ill from excessive joy" was likely this individual. I treated him using the method of Shiquan Dabu Tang (Comprehensive Great Tonic Decoction) to tonify. Some doubted the prescription because of his robust physique and status as a laborer. I stated, "This is exhaustion from sexual activity (Se Lao). Although his exterior appears strong, his interior is actually deficient; it cannot be cured without tonification." After several doses, the effect was significant. Later inquiries revealed he indeed indulged excessively in sexual activities, like a cunning rabbit having three burrows. This is a case of "knowing through hearing."
In the spring of the Gengyin year, while staying in Tianjin, my fellow townsman Yu Qiutian fell severely ill, and I was urgently summoned. He experienced vomiting and diarrhea, disordered consciousness, loss of appetite for food, and even an inability to tolerate the scent of Bixia Gao (a specific medicinal paste/powder). The symptoms appeared critical. However, palpating his pulse, I detected a sense of harmony and moderation within the deficiency and fineness. Although the external signs were dangerous, the True Qi had not yet been depleted. I administered modified Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction), and the vomiting and diarrhea ceased immediately. Subsequently, I used the method of Shiquan Dabu Tang, adjusting ingredients as needed, and after over a month of treatment, he recovered. This is a case of "knowing through palpation."
Comparatively speaking, what is reliable lies here, and what is unreliable lies there. It always depends on the physician, during clinical practice, to find the truly reliable aspects amidst the seemingly unreliable ones, taking them as the definitive basis. Regarding therapeutic methods, Cold is treated with Warmth, Heat with Clearing, Excess with Purging, and Deficiency with Tonifying. For every disease, there is a corresponding method; herbs should not be thrown together randomly. Whether the formula is large or small, or whether the dosage is heavy or light, each follows its own logic and should not be mixed indiscriminately. However, when Cold, Heat, Excess, and Deficiency present in a mixed manner, therapeutic methods must also be flexible. This again relies on the practitioner's ability to weigh and adapt appropriately.
In mid-spring of the Dingyou year, while traveling to Wuqiao to treat Wang Jianyu for Wind-Stroke, his wife was also critically ill. She suffered from day-and-night panic, fear of closing her eyes, extreme aversion to cold, and despite wrapping her head in heavy cotton, still felt cold wind penetrating to the bone marrow. She had fever with sweating, a burning sensation in the chest and epigastrium, dark urine, loose stools, a grayish-greasy tongue coating, and a pulse that was sometimes deficient and slow, sometimes slippery and rapid, sometimes dominant on the left, and sometimes on the right. I first treated her with modified Bazhen Tang (Eight Treasures Decoction) to tonify, followed by Yuxin Wuling San (Yu Jin, Huang Qin, and Five-Ingredient Powder with Poria) to drain damp-heat. Intermittently, I used Lizhong Tang and Sanhuang Tang (Three-Yellow Decoction) to warm and clear, finally concluding with modified Shenhu Tang (Ginseng and Dendrobium Decoction) for regulation. Gradually, the treatment took effect, and after more than a month, all symptoms resolved. Someone asked, "Treating disease is like walking; one disease corresponds to one path. Why are there so many paths now?" I replied, "Where are there many paths? It is merely winding back and forth, involving more detours. This patient had extreme Qi and Blood deficiency, compounded by the accumulation of Damp-Heat. Hence the symptoms were so complex. If one uses only Qi-tonifying and Damp-drying herbs for Qi-deficiency with Dampness, it will inevitably consume Blood. If one uses only Blood-nourishing and Fire-clearing herbs for Blood-deficiency with Fire, it will inevitably damage Qi. Neither combined use nor exclusive reliance on one method works. Therefore, one must alternate between tonifying, draining, clearing, and warming, responding flexibly. This is like walking: there are direct routes and winding routes. If one forces a direct route through a winding section, it leads to obstruction. One must follow the winding path. Though the winding path and direct path differ in shape, they lead to the same destination."
I once heard of a strange disease where multiple physicians had been consulted. Each time a new physician was engaged, the first dose showed some effect, but the second dose failed. The family was helpless, waiting for death. Alas, this is mistaking a winding path for a direct one. Thus, progress is blocked at every turn. Are there truly strange diseases in the world? What is worrying is that the family, ignorant of medicine, acts with hesitation, while bystanders pretend to understand and offer presumptuous advice, causing much delay. I believe that the previous case, though critical, turned from danger to safety largely due to the diligent care of the patient's son, Yuan Chang. Having studied medicine with me for years, Yuan Chang understood medical principles perfectly. This allowed me to proceed with the necessary complex treatment without interference. Had an interfering layperson been present, even a physician as skilled as Bian Que would have been powerless. We would have had to resign ourselves, saying, "It is fate; destiny prevails."