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Difficulty 61 states: The medical classics say, "Diagnosing through observation is called 'Shen' (Divine), diagnosing through hearing is called 'Sheng' (Sage), diagnosing through questioning is called 'Gong' (Skilled), and diagnosing through pulse palpation is called 'Qiao' (Skillful). What does this mean?"

Observation (Wang) refers to observing the colors of the Five Zang organs manifested on the patient's face. Each area of the face corresponds to specific organ divisions, allowing one to assess patterns of mutual generation and restriction (Xiang Sheng Xiang Ke). Hearing (Wen) refers to listening to the patient's voice to investigate the location of the disease. Questioning (Wen) refers to asking about the patient's complaints, as well as their preferences, aversions, joy, and anger, to seek the origin of the disease. Pulse palpation (Qie) refers to feeling the patient's pulse to determine which Zang or Fu organ is affected. "Shen" refers to a state of divine transformation that is unfathomable. "Sheng" refers to reaching the utmost perfection. "Gong" refers to specialized expertise. "Qiao" refers to mental agility and flexibility. This differs slightly from the statement in *Ling Shu: Pathogenic Factors, Zang-Fu Organs, and Disease Manifestations Chapter*; perhaps the classic has a different source.

However, "diagnosing through observation" means knowing the disease by observing the five complexions.
To diagnose through observation is to perceive the Shen Qi (Spiritual Energy) within the patient's constitution and complexion luster. This is what *Ling Shu* refers to when it says, "Crude physicians guard the form; superior physicians guard the Shen." Human Shen Qi reveals itself most authentically between intention and non-intention. The physician must clear the mind and concentrate spirit, perceiving it immediately upon contact. One should not be overly rigid; rigidity introduces subjective bias, causing the physician's and patient's Shen Qi to mix, leading to ambiguity and difficulty in grasping the true nature of the condition. This illustrates the subtle principle of comprehending Shen with Shen. What is Shen Qi? It consists of Guang (Light/Luster) and Ti (Body/Substance). Guang refers to external brightness; Ti refers to internal moistness/luster. Guang is formless and governs Yang and Qi; Ti has form and governs Yin and Blood. When Qi and Blood are harmonious and Yin and Yang do not conflict, both Guang and Ti are naturally present. *Su Wen: Generation of Colors of the Five Zang Chapter* states: "The Qi of the Five Zang organs manifests in color. If the color appears like dead grass (greenish-black), death ensues; if like orange peel (dull yellow), death ensues; if like dried bone (pale white), death ensues; if like congealed blood (dark red/black), death ensues; if like leaking roof water (dull black), death ensues. These are the signs of death in the five colors." Dry and withered colors indicate the exhaustion of both Qi and Blood, lacking both Guang and Ti, meaning Shen Qi has departed, hence indicating death. Conversely, green like a kingfisher feather indicates life; red like a rooster comb indicates life; yellow like a crab's belly indicates life; white like pig fat indicates life; black like a crow's feather indicates life. These are signs of life in the five colors. This is because Qi and Blood are undamaged, possessing both Guang and Ti, neither overly internalized nor excessively exposed. Thus, although ill, life is preserved. Furthermore, the healthy appearance of the Heart is like cinnabar wrapped in silk; the Lung is like red wrapped in silk; the Liver is like cyan-purple wrapped in silk; the Spleen is like a trichosanthes fruit wrapped in silk; the Kidney is like purple wrapped in silk. These are the external manifestations of the Five Zang organs. In a healthy person, with harmonious Zang organs, the complexion derives from Stomach Qi and emerges between the skin and hair. Stomach Qi yields a yellow hue, while skin/hair yields a white hue. Essence and Qi are contained internally, and precious luster radiates externally, neither floating/exposed nor muddy/obscure. Hence, it is described as "wrapped in silk." Observing the discussion on colors in *Nei Jing*, it divides into three grades: death, illness, and normalcy. Although "Shen Qi" is not explicitly stated, it is implied within. However, while the five colors correspond internally to the five Zang organs as a norm, diseases involve variations, and sometimes colors do not correspond to the Zang organs, representing variation within variation. If one can observe Shen Qi, using the norm to identify variations, then one grasps the essentials of color diagnosis.

"Diagnosing through hearing" means distinguishing disease by listening to the five tones.
To diagnose through hearing is to listen to the voice, distinguish between clear and turbid sounds, and thereby investigate the disease. Earth corresponds to the number five, and five corresponds to tone. Thus, sound originates from the Spleen-Earth and resonates in the Lung-Metal. The Heart governs speech; the Heart opens into the tongue, which is the mechanism of sound production. The Liver governs language; the Liver meridian circulates along the throat and enters the Ying-Sang (the upper part of the pharynx behind the soft palate). The throat is the pathway for Qi to ascend and descend. The Ying-Sang is where Qi is distributed. When Liver and Heart Qi are harmonious, speech becomes clear and bright. However, sound also emanates from the Moving Qi (Dong Qi) in the Kidneys. Therefore, if Kidney Qi is short, Upper Qi cannot connect with Lower Qi. Vocalization and singing arise from the Five Spirits and Five Emotions of the Zang organs, producing sound. Unclear speech should be attributed to the Heart and Liver; the ability to speak without sound should be attributed to the Spleen and Lungs; the ability to speak with sound but with disconnected breath should be attributed to the two Kidneys. This is the origin and course of sound. If one follows the classic method of matching the five tones to the five Zang organs: Liver corresponds to Jue (Wood), its sound is shouting; Heart corresponds to Zhi (Fire), its sound is laughing; Spleen corresponds to Gong (Earth), its sound is singing; Lung corresponds to Shang (Metal), its sound is weeping; Kidney corresponds to Yu (Water), its sound is groaning. If one understands the origin, distinguishes clarity from turbidity, separates Yin from Yang, and examines deficiency and excess, one can investigate the disease condition. In the method of hearing sounds, one would then be close to mastery.

"Diagnosing through questioning" means asking about desires for the five flavors (sour, bitter, sweet, pungent, salty) to know where the disease originated and is located.
To diagnose through questioning is to inquire and investigate the origin and details. A skilled questioner does not merely ask about symptoms but seeks the etiology based on those symptoms. Conditions such as Tuoying (Depletion of Camp Qi) and Shijing (Loss of Essence) can be understood by asking about the patient's social status (noble/poor) and wealth. One must ask systematically: Does the patient have chronic diseases? Have they experienced anger, worry, or sorrow? Do they prefer light or heavy tastes? Do they prefer dry or moist foods? Are they addicted to tea or alcohol? Further, ask the cause of the initial onset, previous symptoms, and subsequent changes. Which is heavier, aversion to cold or aversion to heat? Is there sweat or no sweat? Is the sweat profuse or slight? Where does the sweat start and stop? Regarding headache or body pain, when does it occur and where is the location? Is the taste bland or bitter? Is there thirst or no thirst? Do they desire to drink or not? Do they drink much or little? Do they prefer hot or cold drinks? Do they desire food or not? Can they eat or not? Do they eat much or little? Is digestion fast or slow? Is there distension or pain in the chest, heart, hypochondrium, or abdomen? Is urination and defecation unobstructed or obstructed? Is stool dry or loose? Is urine clear or turbid? Is the color yellow or pale? For women, ask about pregnancy and childbirth, whether menstruation occurs early or late, presence of distension/pain, presence of leukorrhea (Daixia), whether it is red or white, and the volume. Through such detailed inquiry, correlating observed symptoms with etiology, one achieves the principle of treating the disease by seeking its root.

"Diagnosing through pulse palpation" means examining the Cun-Kou (Radial) pulse, observing deficiency and excess, to know which Zang-Fu organ is diseased.
To diagnose through palpation is to examine the Cun-Kou pulse to identify the disease, which is not the comprehensive pulse diagnosis method of all arteries found in *Nei Jing*. Some may ask: *Nei Jing* lists only eight pulse types for comprehensive diagnosis: Floating (Fu), Deep (Chen), Slow (Huan), Urgent (Ji), Large (Da), Small (Xiao), Slippery (Hua), and Choppy (Se). It emphasizes comparing their intensity and extremes, marking differences of three degrees, making the variations precise. Why did later generations complicate this into twenty-nine pulses, becoming more obscure in pursuit of precision? Is this due to the error of taking only the Cun-Kou pulse? The answer is: No. Zhang [Zhongjing] said: Later generations find identifying pulses difficult, but they do not realize that ancient physicians found examining pulses even more difficult. "Identifying" the pulse means knowing: Floating is not Deep; Deep is not Floating; Slow is not rapid (not reaching); Rapid is excessive; Deficient is not Excess; Excess is not Deficient; Slippery is not Choppy; Choppy is not Slippery; Long is not Short; Short is not Long; Large is not Small; Small is not Large; Slow (Huan) is not deficient (not reaching strength); Weak is not vigorous; Hidden (Fu) is not visible; Soft is without strength; Minute (Wei) is not manifest; Scattered (San) is not gathered; Surging (Hong) is large and expansive; Fine (Xi) is minute and thin; Intermittent (Dai) involves replacement/interruption; Firm (Lao) is solid and fixed; Moving (Dong) is slippery and larger above the Guan position; Wiry (Xian) feels like a bowstring, firm under pressure; Tight (Jin) feels like a twisting rope; Hollow (Kou) is floating and large but empty upon pressure; Leathery (Ge) is empty inside and hard outside; Knotted (Jie) is slow with interruptions; Rapid-Cessation (Cu) is rapid with interruptions. Using comparative methods, these are relatively easy to distinguish under the fingers. "Examining" the pulse requires recognizing the cause of the felt pulse and the syndrome it governs, confirming it with the mind. Zhongjing's *Ping Mai Pian* states: Floating indicates exterior; Deep indicates interior; Rapid indicates Fu organs; Slow indicates Zang organs. It also states: Floating indicates Wind, Heat, Qi excess, Qi deficiency, lack of Blood, or Deficiency. Is it an external contraction or internal injury? Is it a Qi disorder or Blood disorder? Is it Excess or Deficiency? One must examine the symptoms for exterior/interior, Yin/Yang, Cold/Heat, Deficiency/Excess, and the duration of the disease (old vs. new), as well as the strength of the pulse (strong vs. weak), and make a judgment based on reasoning. Then, refer to Observation, Hearing, and Questioning. Only when all four diagnostic methods are complete can one ensure safety and accuracy. Thus, it is said that examining the pulse is even more difficult. How can one not be cautious?

The classics state: Knowing from external signs is called 'Sheng'; knowing from internal mechanisms is called 'Shen'. This is what is meant.
Observing color and hearing sound constitutes knowing from the exterior, hence called 'Sheng'. Asking for causes and palpating the pulse constitutes knowing from the interior, hence called 'Shen'. This summarizes the meaning of the Four Diagnostic Methods discussed above.
Above, Volume IV, Difficulties 48 to 61, discuss diseases.