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Ask what medicines the patient has taken. Which medicine showed slight efficacy and which did not, to clarify whether there were medication errors, so as to verify the previous causes of disease, deliberate on one's own insights, and secretly take measures for rescue. There is no need to nitpick or speak recklessly, which would harm medical ethics and elegance. If the condition is already critical and beyond rescue, one must not be greedy for merit or show off skills, nor prescribe arbitrarily against common opinion, thereby inviting slander ("many mouths can melt metal"). This is a habitual practice among doctors in Shaoxing: failing to investigate the coldness, heat, deficiency, or excess of the disease, as well as its root and branch, yin and yang; instead, patients specialize in discussing medications to question doctors, while doctors specialize in discussing prescriptions to harm colleagues, fostering a bad custom of discussing drugs rather than diseases. This is why Yu Jiayan (courtesy name Xichang) formulated the "Formula for Discussing Diseases," proposing the famous theory of "discussing the disease first, then the medication."

[Note by Rongzhai] The role of "checking old prescriptions" has other important significance. Past treatments can affect current symptoms and signs. If a typhoid fever patient has taken antipyretics, their normal fever pattern (continued fever) will change. If a patient with pain has taken analgesics, their pain sensation will temporarily alleviate. We must understand which symptoms are aggravated or alleviated due to treatment or medication. Therefore, we must thoroughly understand the relationship between symptoms and past treatments.

Newly acquired diseases are easy to treat; chronic diseases are difficult to cure. It is widely known that acute diseases do not involve deficiency, and chronic diseases do not involve excess. However, sudden onset diseases such as wind-stroke, cold-stroke, summerheat-stroke, dampness-stroke, evil-stroke, poisoning, as well as phlegm syncope, deficiency syncope, food syncope, and sexual syncope, are by no means easy to treat, nor are they devoid of deficiency syndromes. Chronic diseases such as stubborn phlegm, retained fluids, qi stagnation, blood stasis, and the "three chronicities and six depressions" often present as excess syndromes mimicking deficiency. If symptoms are carefully examined and clearly differentiated, and medication is administered decisively, the disease trend will naturally gradually subside, showing daily improvement, and it may not necessarily be difficult to cure. Asking about the duration of the disease aims to observe whether it is an external contraction, internal injury, external contraction complicated by internal injury, internal injury complicated by external contraction, excess or deficiency, excess complicated by deficiency, or deficiency complicated by excess, thereby determining the accurate target of treatment. In summary, it lies in the physician being knowledgeable through extensive experience, understanding the disease, mastering pulse diagnosis through frequent examination, proficient in using effective medicines, possessing true learning, taking responsibility, while the patient trusts completely and maintains good self-care. When both conditions are met, achieving perfection, how could there be sighs about the lack of good physicians and untreatable diseases? As for the method of pulse diagnosis, the six meridian pulse images and essentials of pulse diagnosis have been recorded previously, so they are not repeated here.

[Note by Xiu] Yu's diagnostic methods are concise yet essential, serving as a model for future learners. Yu Xichang's formula for discussing diseases is detailed yet appropriate, also serving as a model for future learners. Let us describe its format: Year, month, place, person, age. What is the body type (fat/thin, long/short)? What is the complexion (black/white, dry/moist)? What is the voice (clear/turbid, long/short)? What is the physical and mental state (suffering/joy)? On which day did the disease start? What was the initial medication? What was taken subsequently? Which medicine showed slight efficacy, and which did not? Which time of day (day/night) shows heavier symptoms? Is cold or heat more prevalent? What are the dietary preferences and quantities? Are bowel movements and urination smooth or obstructed? Regarding the three positions and nine inspections of the pulse, which inspection is uniquely abnormal? Among the twenty-four pulse types, which pulse appears alone? Which pulses appear concurrently? Are the symptoms internal injury, external contraction, both internal and external, or neither? Based on the classics, what disease is diagnosed? Where are the root and branch, and what is the sequence? How should sweating, vomiting, purging, harmonizing, cooling, warming, tonifying, and draining be applied? Which of the Seven Formulas is suitable? Which of the Ten Categories? Which of the Five Qi? Which of the Five Flavors? With which decoction name should modifications and combinations be made? When is the efficacy expected? All details must be clear and precise, ensuring accuracy without error, gaining public trust, truly serving as a model for the medical profession, without need for rhetorical embellishment. Its self-interpretation states: "Year" refers to the Heavenly Stems and Earthly Branches, indicating that treating disease requires first understanding the Six Qi and Six Climatic Factors. "Month" indicates understanding the Four Seasons. "Place" involves distinguishing high/low and dry/damp, noting different适宜 (suitability) of the five directions. "Age, body type, voice, qi" are used in conjunction with pulse diagnosis to ensure safety. "Physical and mental state" verifies the seven emotions and labor/rest. "Start date" examines the duration and transmission changes. "Asking about past medications and efficacy" aids in deliberating one's own views. "Day/night cold/heat" distinguishes qi vs. blood levels. "Diet and excretion" inspects gastrointestinal harmony. "Which inspection is uniquely abnormal" deduces the location of disease in the twelve meridians. "Which pulse appears" examines yin/yang and exterior/interior for errors. "Diagnosing based on classics" ensures correct naming leads to smooth speech and lawful success. "Root and branch sequence" identifies severity and order. "Application of sweating, vomiting, purging, etc." seeks a definitive method for non-healing cases. "Seven Formulas" (Great, Small, Slow, Urgent, Odd, Even, Compound) prevent arbitrary drug preparation. "Ten Categories" (Dispersing, Unblocking, Tonifying, Draining, Light, Heavy, Slippery, Astringent, Dry, Damp) prevent indiscriminate drug use. "Five Qi and Five Flavors" represent the highest method of medication, combining Cold, Heat, Warm, Cool, Neutral with Sour, Pungent, Sweet, Bitter, Salty. "Decoction names for modification" follows ancient traditions. "Expected efficacy time" allows precise differentiation and determines recovery period based on disease duration. Thus, medical records depend on the individual; skill varies. Accumulating decades of experience treating thousands without error is possible.

[Note by Lian] Zhang Shiwan, an elder physician from the early Qing Dynasty, made many innovations in diagnostic methods. I hereby summarize his theories to supplement Yu's shortcomings. (1) Differentiating Form: Carefully observe the slipperiness or roughness of the skin to infer the abundance or decline of body fluids; the density or sparseness of texture to infer the strength or weakness of Ying and Wei; the firmness or softness of flesh to infer the deficiency or excess of Stomach Qi; the thickness or thinness of tendons to infer the fullness or emptiness of Liver Blood; the size of bones to infer the courage or timidity of Kidney Qi; the hardness or flexibility of nails to infer the purity or turbidity of Gallbladder fluid; the fatness or thinness of fingers to infer the prosperity or withering of Meridian Qi; the thickness or thinness of palms to infer the abundance or scarcity of Zang Qi; the coldness or heat of the Chi position (forearm) to infer the yin or yang of interior and exterior. For women in secluded quarters who often hide behind screens, preventing visual inspection of the face, inspecting the color, pallor, fatness, or leanness of the wrist veins suffices to gain insight. Furthermore, observing skin texture, muscle firmness, tendon thickness, bone size, nail flexibility, finger shape, palm thickness, and forearm temperature, combined with movement stability, breath intensity, pulse, and symptoms, makes the deficiency or excess of qi and blood, the rigidity or gentleness of temperament, the劳逸 (work/rest) of the body, the refinement or coarseness of diet, and the favorable or unfavorable nature of the illness clear in mind. (2) Differentiating Color: Complexion should be bright and moist, not dull or lifeless. Colors from sudden external pathogens may be cloudy or turbid; colors from chronic qi deficiency should be emaciated and clear. If pathogenic factors are sharp but the complexion is pale and spiritless, or if the patient is chronically weak yet looks charming and glossy, these are not normal colors. Among the five colors, dark blue/black indicates depressed Yang qi regardless of disease duration. Yellow appearing on the face without dryness indicates recovery. Dark circles under eyes like soot indicate cold phlegm; dark eyes with red cheeks indicate hot phlegm; dark eyes with difficulty walking and groaning indicate phlegm-fluid entering bones; dark eyes with earthy complexion, flaccid limbs, and stiff joints indicate wind-phlegm. Yellow luster indicates Stomach Qi presence and survival; dry yellow indicates fluid exhaustion and poor prognosis. Yellow sclera indicates jaundice or epistaxis; severe irritability with yellow eyes indicates worsening disease. Black qi arising from mouth, nose, ears, or eyes in healthy people indicates danger. Red on cheekbones and black at Shenting point indicate fire entering Heart and Kidney, a sign of sudden death. Yellow belongs to Spleen/Stomach: fat yellow indicates phlegm-dampness; dry yellow indicates stomach fire; pale yellow indicates original Spleen Qi deficiency; dark yellow indicates prolonged fluid consumption. Yellow is the central color; its deficiency/excess and cold/heat mechanisms are judged by diet and excretion. White belongs to Lung: moist white indicates Lung/Stomach fullness; fat white and soft to touch indicates qi deficiency with phlegm; thin white with bright red nails indicates qi deficiency with fire; dull white with pale nails indicates Lung/Stomach deficiency-cold; slightly blue-white or prominent blue arm veins indicates qi deficiency failing to control blood; if nails are also blue, it indicates yin-cold. White represents qi deficiency; even with bleeding or fever, it is deficient fire, never excess heat. Blue-black belongs to Liver/Kidney: coarse texture indicates musculoskeletal strain; dry/withered indicates depletion of Ying blood; fat/moist black indicates marrow fullness; thin/emaciated black indicates internal damage by yin fire. Blue-black indicates strong Lower Jiao qi; even if attacked by external cold, it transforms into pathogenic heat, never deficiency-cold. Red belongs to Heart and governs Sanjiao: deep red and firm indicates innate fire tendency; red with firm popliteal fossa indicates Ying blood fullness; slightly red and fresh indicates qi deficiency with fire; red and dry/shiny indicates blood deficiency with hyperactive fire. Red is the color of flaming fire; worry only about fluid exhaustion and blood depletion, not deficiency-cold. Fire-type individuals are rarely fat with dampness; even with phlegm-cough, it is dry qi. These are the essentials of observation. (3) Differentiating Voice: Although voice originates from the Lung, it actually stems from the Dantian. Its clarity or turbidity depends on constitution, but remaining consistent with one's usual voice is auspicious. Clear voice despite illness indicates body sick but qi healthy. Turbid voice at onset indicates pathogen invading clear pathways. Weak voice continuing shortly after onset indicates original Middle Jiao deficiency. Groaning indicates pain. Slow speech indicates wind. Excessive talking indicates fire activity. Muffled voice as if speaking from a room indicates dampness in Middle Jiao. Faint voice, speaking only once a day, indicates loss of upright qi. Disheveled clothes, inappropriate speech, ignoring social boundaries indicates disorder of Shen (Spirit). Lazy/cowardly speech, heavy then light, indicates internal injury to Yuan Qi. Loud/aggressive speech, light then heavy, indicates external pathogenic invasion. Furrowed brows and groaning indicate headache. Belching while holding the heart area indicates Zhongwan pain. Groaning unable to turn over, sitting with one leg down indicates lower back pain. Shaking head while touching cheek indicates tooth/jaw pain. Moaning unable to walk indicates waist/foot pain. Sighing during examination indicates qi stagnation. Shaking head while speaking indicates interior pain. Emaciated body with hoarse voice indicates consumption (Lao Zhai) or lung ulcers. Sudden aphonia indicates latent wind-phlegm/fire or caused by shouting/crying. Slurred speech indicates wind-phlegm. Talking alone/disconnectedly indicates mental injury from overthinking. Typhoid complication with hoarse voice and oral ulcers indicates Huo Huo (Erosive ulcerative disease). Healthy person without chills/fever but short of breath indicates phlegm-fire. These are the essentials of listening. Mr. Shi Feinan (Qing Dynasty, Xiantong era) was concise in inquiry. I summarize his views to supplement Yu's omissions. Disease hides internally; symptoms manifest externally. Skilled inquirers do not just ask about symptoms but seek causes through them. First, ask about past habits: history of phlegm, anger/worry, dietary preferences (light/heavy, dry/moist), tea/alcohol habits, stool consistency. For women, ask about pregnancy/birth, menstrual cycle (early/late), distension/pain. Then ask about current disease: cause, initial symptoms, progression, severity of chills/fever, sweating status (amount, origin, cessation), taste (bland/bitter), thirst, drinking preference (hot/cold - note: preference for hot drinks does not always mean cold syndrome, sometimes due to obstruction relieved by heat). Appetite, digestion speed, chest/flank/abdominal pain, bowel/bladder status (dry/loose stool, clear/turbid urine, yellow/light color - excretion is crucial as it reflects external manifestation). Detailed questioning based on symptoms to determine causes aligns with Xuanyuan/Qibo's principle of seeking the root. These are the essentials of inquiry. Kou Zongshi said: Inquiry before diagnosis is most accurate. For women, menstruation must be asked first. Zhang Zihe said: Ask about pregnancy for female patients; avoid blood-moving drugs if pregnancy is uncertain. Peng Yongguang said: For postpartum women, ask about lochia amount and abdominal masses. He Xichi said: For women with missed periods of 4-5 months, check if nipples/root are dark and breasts elevated; if pregnant, menstruation continues monthly, so ask about flow and fetal movement. These are essential gynecological inquiries. Jingyue's Ten Questions Song covers chills/fever, sweat, head/body, excretion, diet, chest, deafness/thirst, past illness, causes, and medication response. For women, menstruation and lochia are key. This is a brief overview of inquiry methods. Elder doctor Zhao Qingchu stated that while detailed inquiry is necessary, it must be combined with color and pulse analysis; do not be misled by patient statements.

[Note by Rongzhai] The methods for diagnosing typhoid fever discussed by Yu and reproduced from Yu Xichang and eight other families in this chapter align well with modern requirements for "medical history investigation." The section on "observing new vs. old" refers to collecting "current medical history" and "past medical history." This not only provides diagnostic evidence but can serve as the basis for diagnosis under certain special conditions; this constitutes the "Inquiry" aspect of our "Four Diagnostic Methods." I believe that besides the items mentioned in this chapter, the scope of medical history collection should also pay attention to: (1) Time and circumstances of onset—accuracy is better. Use various timing methods, e.g., specific date/time, morning/noon/evening/midnight, before/after meals, etc. Onset can be sudden (e.g., lobar pneumonia, malaria), gradual (e.g., typhoid), or insidious (e.g., chronic diseases). (2) Relationship between symptoms and time—symptoms have temporal patterns. Ignoring temporality loses diagnostic value. E.g., malaria fever occurs every other day or every third day, lasting minutes to hours. Typhoid presents with continuous high fever, while tuberculosis shows low-grade afternoon fever. Thus, timing is crucial. (3) Relationship between symptoms—symptoms are interconnected. E.g., malaria typically starts with chills, then fever, then sweating; this sequence is a diagnostic marker. Fever and headache relation: in acute febrile diseases, higher fever correlates with worse headache; as fever drops, headache alleviates. This relationship indicates the headache is caused by fever, not other reasons. Therefore, when asking about symptoms, note their interrelationships rather than isolating them, to avoid diagnostic errors. Other factors like impact on physiological functions, symptom analysis, system-specific details, and potential triggers should also be considered. Regarding "past medical history," it should vary based on current history; if a specific system dominates current symptoms, inquire deeply into that system historically. "New disease triggering old disease," such as complications in Chapter 9 (typhoid with phlegm, blood, hernia, consumption), obtaining these histories early is significant for diagnosis and future treatment.