治病之要。在临症时。先察内外脏腑经络新久虚实食痰气血。才以脉合之。（脉经一书。拳拳
以诊法示人。而开卷便云观色察形。彼此参伍。以决死生。可见望闻问切。诊家不可忽一。难经以切位四诊之末。则知
望闻问
之间。其于病情之大段已得。不过再诊其脉。看病应与不应耳。乃近来迎医服药者。不惟不先言其所苦。甚至再三询叩。
终于默默而隐疾以困医者。讵知医而果可为人所困者。则其病亦未有不为医所困者也。不亦愚昧之甚耶。）如症与脉合。
或正治或从治可也。
有症与脉不合者。则当审其轻重。辨其真假。舍症从脉。或舍脉从症以治之。（轻者从症。十唯一二
。重者从脉。十当八九。景岳从舍辨。言之最详。）复有症与时不合者。舍症从时。或舍时从症以治
之。（此则从症者多于从时。）脉症时三者。须时时互相参考。（诊家大要。）
（谦按。内经难经。皆有色诊之文。孙真人亦有未诊先问。最不误事之训。诚哉斯言。四诊不可缺一。）
何谓内。言七情也。喜怒忧思悲恐惊是也。七情之病起于脏。七情过极。必生拂郁之病。此
拂郁从内起。拂郁之脉。大抵多弦涩凝滞。其来也必不能缓。其去也必不肯迟。先有一种似数非
数躁动之象。细体认之。是无焰之火也。是无韵之音也。是往来不圆滑也。此为郁脉。法当疏之
发之。（郁火脉极难看。缘火不透发。则经脉俱为所遏。故多沉伏不出耳。）
如火在下而以湿草盖之。则闷而不舒。必至烧干而自尽。故疏之发之。使火气透。则及此可以自存。
（所以忌用寒凉。必先升散之故。得此一喻。倍见省豁。）何也。郁是气抑。抑则气不透。不
透则热。热则为火也。古方疏发以越鞠丸为主。严用和以逍遥散代之。如单得郁脉。上二方是也。
（东庄云。越鞠之芎 。即逍遥之归芍也越鞠之苍术。即逍遥之白术也。越鞠之神曲。
即逍遥之陈皮也。越鞠之香附。即逍遥之柴胡也。越鞠之栀子。即逍遥之加味也。然越鞠峻而逍遥则和矣。越鞠燥而逍
遥则润矣。）如郁
而血为火迫。变成燥症。（如热甚而痛。及手足头面似觉肿起。或两颌拥肿。臂膊磊块。烦躁作渴。四肢痉搐。两目直
视。
角弓反张。小便短赤
。大便秘结。之类。皆属燥症。其脉必浮数无序。
疏肝益肾汤。从水生木可也。（熟地可加至一二两）左归饮重加归芍。（再加柴胡则与疏肝意更合）
或不清。及加丹皮芩栀。以清肝胆二经。（滋肾生肝。饮有神效。）所谓肝肾并治也。
何谓外。言六淫也。风寒暑湿燥火是也。（虽是六淫并举。然下文只就风寒而言。于暑湿燥
火未概也。须类推之。）六淫之邪。或从皮毛而传络。从络传经。从经传腑，从腑传脏是也。（感
邪由表入里。一层深一层。其间次第。此处分晰最清。）亦有竟感于络。竟感于经者。六淫所
感。必生拂郁之病。此拂郁从外入。故必皮毛先闭。外束其所感之邪。而蒸蒸发热也。法当疏之
发之是也。大抵脉或浮或洪或大或紧而必数者也。是燎原之火也。是击撞之声也。是往来不肯沉
静而出于皮肤之外也。亦谓之郁脉。是外郁也。疏之发之。不愈则霜雪以压之。古方麻黄桂枝白
虎承气等剂是也。些真外感也。易之以羌活冲和者。亦真外感也。（近日医家一见发热。无论内
伤外感。一味羌活冲和。混行表散。每致津枯液涸而成败症者。盖羌防辛芷之属。原与麻桂并
烈也。用者审之。）有内伤似外感者。此火不可发散也。发散则亡阴。不可霜雪以压之。压之是
灭火也。（以发散寒凉为长技者。亟当以此等论药之。）初起小
柴胡汤加减调之可也。逍遥散加生地。合生脉加黄芩之类。以滋肾生肝。生金滋水可也。重则
六味饮加归芍。合生脉（以滋水清火。）可也。盖非水无以救火也。非有根之水。无以救离根
之火也。（补北方即所以泻南方。一定之理。却是不易之法。）何谓脏腑。有从腑迁脏者。有从
脏迁腑者。如阳明伤食。则气阻而脾不能化。则其病迁于脾。初起法当先消食。食消则气通而
脾运矣。久之则脾病亦深。必先救脾。何也。腑尚可病。脏不堪久病也。腑主气。气无形。无形
治之以无形。易也。脏主血。血有形。有形者。亦须假无形以治之而后有形。故难也。传曰。无
形之气易补有形之血难偿。此之谓也。消食者。保和枳术等类是也。然不可过于消也。经曰。大
积大聚。皆可犯也。衰其半而已。如过于消。则气衰矣。消之不得其法。或不及。则食积而生热
。热则脾病。当用参术。如五味异功散六君子汤。或加枳桔。以开提健运。再佐以芩连。以消其
积热。（此条当并入后论食一条同看）此脏腑相救缓急之法也。各脏腑可以类推之。何谓经络。
经者。如江河之经芒。其筋脉生于肉中。络者如藤之络石。其筋脉生于皮里肉外。经筋属五脏。
络筋属六腑。属五脏者。以血药补之。以行经药通之。补之者。归芍熟地是也。通之者。川芎秦
艽没药乳香是也。属六腑者。以气药补之。以走络药通之。补之者。人参白术黄 是也。通之者。
柴胡羌活葛根是也。然又要看其病之浅深。而彼此相通。不可执一也。
何谓新久。有内伤之新。有外感之新。有内伤之久。有外感之久。内伤之新。补之当蚤。外感之
新。散之戒重。如补之迟。迁延成弱矣。散之重。变成他症矣。内伤之久。补之当峻当速。外感
之久。散之不可峻不可久不可猛不可速。何也。人之元气有限。病久必伤元气。若再攻之。元气
竭矣。真阴亡矣。经云。邪之所凑。其气必虚。又曰。粗工汹汹。以为可攻。此之谓也。
何谓虚实。有阴虚。有阳虚。有先天之阴阳虚。何谓阴虚。血虚也。何谓阳虚。气虚也。血
虚者。补其血。四物汤之类是也。气虚者。补其气。补中益气汤之类是也。先天之阴虚。六味左
归之类是也。先天之阳虚。八味右归之类是也。有攻伐太过之阳虚。如用寒凉而致阳遏不升。当以
参术黄 温之。甚者姜桂以助之。又甚者八味右归。从其原以救之。有攻伐太过之阴虚。如用发
散而致津液干枯。当以归芍熟地滋之。枸杞龟鹿两胶粘腻之物以填之是也。（邯郸赵氏云。读仲
景书而不读东垣书。则内伤不明。而杀人多矣。读东垣书而不读丹溪书。则阴虚不明。而杀人又多矣。
读丹溪书而不读薛氏书。则真阴真阳不明。而杀人又多矣。四明合张李朱薛四大
家以立言。而于真阴真阳之外。又发攻伐太过之阴虚阳虚两种。以补前贤之所未发。而救败之法乃备。然则读
四家书而不读高氏书。则攻伐太过之阴虚阳虚不明。而杀人又多矣。
何谓食。膏粱爆炙。酒酪 乳。能生火而伤胃之阴。伤阴者。救之四物以养血。（欲养胃阴。
须去川芎加甘草。）佐之芩连栀柏以清火。（左归饮去茯苓加花粉。尤为稳当。）浮瓜沉李。冷
水寒冰。能灭火而伤胃之阳。伤阳者。救之理中以养气。佐之桂附豆蔻以生火。（虚而不寒。则
一理中足矣。）至于饥饱失时。则中气受伤。当补而兼运。六君子汤加枳实桔梗之类。运而
提之。
何谓痰。有食积之痰。有中虚之痰。有水泛水沸所为之痰。食积之痰。消其食则痰自除。保
和大安枳术之类。虚者六君子之类。中虚之痰。或脾虚不运。或胃虚不容。脾虚不运则积。六君
子加白豆蔻神曲是也。胃虚不容则聚。六君子加砂仁神曲是也。水泛为痰。土虚不能摄水也。其
痰浓而白。补中益气加半夏木香白豆蔻是也。亦有命门火衰。不能配水。而水泛为痰者。仲景云。
气虚痰泛当以八味丸补而逐之。吴茭山亦云。（八味丸治痰之本也。）水沸为痰。其痰白如沫。吐出
如蟹沫。少顷变为稠粘之水。此肾水不足。不能制火。火紧而沸也。六味丸主之。（此症间有火
不归原。格阳上焰者。其痰亦白如沫。其脉必浮洪数大。而重按则空。或右尺沉细无力。治当引火归原。八味饮主之。
王节斋。痰
之本水也。原于肾。痰之动湿也。主于脾。二语深透痰症之根。四明诸法。皆治痰之本。不治痰之标。独扼其要。稍似
水泛水沸两条中。遗却火
不配水。格阳上焰两症耳。今僭补入庶无剩义）。
何谓血。凡六淫七情之病。皆有因死血薄积于脏腑而成者。其症见于外。或似外感。或似内
伤。医家以见症治之。鲜不谬矣。大凡死血在内。其脉必涩滞。其出于皮肤也必不满。其入于筋
骨也必不完。其形大抵如线涂生漆。不能充润之状。（线涂生漆。形容涩滞之脉。犹文章之化境
也。非天资颖悟。精于脉理者。不能道此。）凡医者遇病。多于痰食求之。死血多不之察。故备言之（四明于症之最
难审者。审得独精。脉之最难认者。认得倍细。而于郁火郁血两症。其形容脉象处。尤为精尽。
诊家主此。则无难审之症难认之脉。而病亦无可遁之情矣。）
何谓症与脉合。与脉不合。有外感之症脉。有内伤之症脉。外感者。蒸蒸发热。其脉必洪大
浮数。是症与脉
合也。如发热而脉不洪大浮数。是症与脉不合也。传曰。阳症得阴脉者死。此句是论伤寒。若别
症不可便断为死。此必是火遏也。或胃阴不能充拓也。或肾水不能化其荣血也。则舍症从脉可也。
火遏者。逍遥散加生地薄荷以发之。或加丹皮山栀。屈曲下行以通之可也。胃阴不能充拓者。四
物汤（亦须去川芎加甘草。方合阳明。）重加熟地枸杞人参麦冬五味以滋之可也。（左归饮去茯
苓加归芍合生脉甚验。）肾水不能化其荣血者。六味左归以补之可也。如内伤而外不发热。其脉
当静。而反浮躁洪大而数。是症与脉不合也。传曰。阴症得阳脉者生。此句亦论伤寒。若别症又
不可便许为生。此必是阴亡也。或阳明有食与火也。或肾虚不能纳气也。或过服乌附而下焦津液
枯竭也。又有一种重按有力。却不弦。从肌肉渗开。脉与肉无界限。此近于浮洪豁大也。总是阴
之象也。阴亡也。（此阴字当作精字血字津液字看。治宜温养濡润填补。一用苦寒沉降之阴药。
败阳灭火。祸不旋踵矣。）如阴亡。分先后天以救其阴。（先天者。肾中之阴也。后天者。胃中之阴也。缘
救阴之法。则上文已详。兹故不另立耳。）有食与火者。健运兼清凉也。（宜从养阴
治。使阴气外溢则得汗而火自清。阴血下润。则便通而食自下。不可妄用芩连以清火。
枳朴以消食也。）肾虚不能纳气者。六味都气。（都气尤捷）过服乌附者。六味兼黄柏知母是也。（知
柏两味。性味苦寒。大戕脾胃。非有中焦实火下焦湿火不宜妄用。今因乌附过剂。以致下焦津液枯竭。则黄柏之燥。尤
非所
宜。且六味纯阴润下。但壮水之主。自足以制阳光矣。何必更加知
柏哉。）脉与肉无界限者。六味加归身枸杞子枣仁白芍合生脉也。凡症皆有合不合。举此可以引
伸触类矣。
何谓症与时不合。譬如夏月恶热而燥。不当用辛热矣。然却是无根之火。狂越于外。（须知
此火不可水灭。不可湿伏。折以寒凉。无
不立毙。故当舍时从症耳。）非人参桂附八味。无以返飞越之孤阳。（须浸冷服。乃合伏其所
主。先其所因。其始则同。其终则异之义。否则恐其拒格耳。）传曰桂附清蒸热是也。此舍时从症
之谓也。又如冬月畏寒怕冷。必当辛热矣。然却是火郁于中。火热生风。冲突元气。气从火散。
故凛凛畏寒。（即疟疾之战。亦非真寒也。此等若认作真寒。而以热药治之。则误矣。）或辛甘
以发之。（逍遥散加生地薄荷。或加山栀丹皮。）或芩连承气以通之。则火透而寒除矣。传曰硝
黄解寒战是也。此亦舍时从症之谓也。（夏月用凉药。冬月用热药。互看。）
治病的关键，在于临证时，首先要考察内外、脏腑、经络的新久虚实以及食积、痰饮、气滞、血瘀等情况，然后才用脉诊来印证。（《脉经》一书，恳切地以诊法示人，但开篇便说观察面色、察验形体，彼此参伍对照，以此决断生死。可见望、闻、问、切四诊，医生不可忽略其中任何一项。《难经》将切脉列为四诊之末，由此可知在望、闻、问之间，病情的大致情况已经获得，不过再诊其脉，看病是否与症状相应罢了。然而近来求医服药的人，不仅不先说出自己的痛苦，甚至反复询问叩击，最终却沉默不语，隐瞒隐疾而困扰医生。岂不知如果医生果然被病人所困，那么他的病也必然没有被医生治好的道理。这不是很愚昧吗。）如果症状与脉象相符，可以采用正治法或从治法进行治疗。
如果有症状与脉象不符的情况，就应当审察病情的轻重，辨别真假，采取舍症从脉，或舍脉从症的方法治疗。（轻症多从症，十例中仅有一二例；重症多从脉，十例中当有八九例。张景岳关于“从舍”的辨析，论述最为详尽。）又有症状与季节时令不符的情况，采取舍症从时，或舍时从症的方法治疗。（这种情况中，从症的多于从时的。）脉、症、时三者，必须时时互相参考。（这是诊病家的关键要点。）
（谦按：《内经》、《难经》都有色诊的文章，孙思邈也有未诊先问、最不误事的训诫。这话确实正确。四诊不可缺一。）
什么叫“内”？指七情。喜、怒、忧、思、悲、恐、惊就是七情。七情致病起于内脏。七情过极，必然产生拂郁之病。这种拂郁从内部发生。拂郁的脉象，大抵多表现为弦、涩、凝滞。其来势必然不能舒缓，其去势必然不肯迟缓，先有一种似数非数、躁动不安的象。仔细体认它，就像没有火焰的火，没有韵律的声音，往来不圆滑。这就是郁脉，治法应当疏解发散。（郁火脉极难辨认，因为火气不透发，经脉都被阻滞，所以多沉伏不出。）
就像火在下面，用湿草盖住，就会闷而不舒，必定烧干而自尽。所以疏解发散，使火气透发，这样才能自我保全。（所以忌讳使用寒凉药，必须先升散的原因。得到这个比喻，更加明白透彻。）为什么呢？郁是气机抑制，抑制则气不通畅，不通畅则生热，热盛则为火。古方疏发以越鞠丸为主，严用和以逍遥散替代。如果单得郁脉，上述两个方剂即可。（东庄说：越鞠丸中的川芎，即逍遥散中的当归、白芍；越鞠丸中的苍术，即逍遥散中的白术；越鞠丸中的神曲，即逍遥散中的陈皮；越鞠丸中的香附，即逍遥散中的柴胡；越鞠丸中的栀子，即逍遥散的加味部分。然而越鞠丸峻烈，逍遥散则平和；越鞠丸燥烈，逍遥散则滋润。）如果郁结导致血液被火逼迫，变成燥症。（如热甚而痛，手足头面似乎肿起，或两颊肿胀，臂膊有硬块，烦躁口渴，四肢痉挛抽搐，两眼直视，角弓反张，小便短赤，大便秘结等，都属于燥症。其脉必浮数无序。可用疏肝益肾汤，从水生木的角度治疗。（熟地可加至一二两）左归饮重加当归、白芍。（再加柴胡则与疏肝之意更合）或者不清爽，加上丹皮、黄芩、栀子，以清肝胆二经。（滋肾生肝，饮之神效。）这就是所谓肝肾并治。
什么叫“外”？指六淫。风、寒、暑、湿、燥、火就是六淫。（虽然六淫并举，但下文只就风寒而言，对于暑、湿、燥、火并未全面涉及。须类推之。）六淫之邪，有的从皮毛传入络脉，从络脉传入经脉，从经脉传入腑，从腑传入脏。（感邪由表入里，一层深一层，其间次第，此处分析最清晰。）也有直接感受于络，直接感受于经的。六淫所感，必然产生拂郁之病。这种拂郁从外部侵入，所以必定皮毛先闭，外束其所感之邪，从而蒸蒸发热。治法应当疏解发散。大抵脉象或浮、或洪、或大、或紧，且必然数。这是燎原之火，是撞击之声，是往来不肯沉静而出于皮肤之外。这也称为郁脉，是外郁。疏解发散，如果不愈，就用霜雪以压制它。古方麻黄汤、桂枝汤、白虎汤、承气汤等剂就是这类。如果是真正的外感，改用羌活冲和汤，也是真正的外感。（近日医家一见发热，无论内伤外感，一味使用羌活冲和汤，混行表散，往往导致津枯液涸而成败症。大概羌活、防风、辛夷、白芷之类，原本与麻黄、桂枝同样猛烈。使用者需谨慎。）有内伤类似外感的，这种火不可发散。发散则亡阴，不可用霜雪压制。压制就是灭火。（以发散寒凉为长技的医生，亟当以此类理论审视药物。）初起用小柴胡汤加减调治即可。逍遥散加生地，合生脉散加黄芩之类，以滋肾生肝，生金滋水即可。重则六味地黄丸加当归、白芍，合生脉散（以滋水清火）即可。盖非水无以救火也，非有根之水，无以救离根之火也。（补北方即所以泻南方，一定之理，却是不易之法。）
什么叫脏腑？有从腑迁延到脏的，有从脏迁延到腑的。如阳明伤食，则气阻而脾不能运化，则病迁于脾。初起法当先消食，食消则气通而脾运了。久了则脾病也深，必先救脾。为什么呢？腑尚可病，脏不堪久病。腑主气，气无形，无形治之以无形，容易。脏主血，血有形，有形者，也必须假借无形以治之而后有形，所以难。传曰：无形之气易补，有形之血难偿，说的就是这个意思。消食药，保和丸、枳术丸等类就是。然而不可过于消导。经曰：大积大聚，皆可犯也，衰其半而已。如果过于消导，则气衰了。消导不得法，或不及，则食积而生热，热则脾病，当用人参、白术。如五味异功散、六君子汤，或加枳壳、桔梗，以开提健运。再佐以黄芩、黄连，以消其积热。（此条应当并入后论食一条同看）这是脏腑相救缓急的方法。各脏腑可以类推。
什么叫经络？经，如同江河的主干，其筋脉生于肉中。络，如同藤蔓缠绕石头，其筋脉生于皮里肉外。经筋属五脏，络筋属六腑。属五脏的，以血药补之，以行经药通之。补之者，当归、白芍、熟地是。通之者，川芎、秦艽、没药、乳香是。属六腑的，以气药补之，以走络药通之。补之者，人参、白术、黄芪是。通之者，柴胡、羌活、葛根是。然而又要看其病的浅深，而彼此相通，不可执一。
什么叫新久？有内伤之新，有外感之新，有内伤之久，有外感之久。内伤之新，补之当早。外感之新，散之戒重。如果补之迟，迁延成弱矣。散之重，变成他症矣。内伤之久，补之当峻当速。外感之久，散之不可峻、不可久、不可猛、不可速。为什么呢？人之元气有限，病久必伤元气。如果再攻之，元气竭矣，真阴亡矣。经云：邪之所凑，其气必虚。又曰：粗工汹汹，以为可攻。说的就是这个意思。
什么叫虚实？有阴虚，有阳虚，有先天之阴阳虚。什么叫阴虚？血虚也。什么叫阳虚？气虚也。血虚者，补其血，四物汤之类是。气虚者，补其气，补中益气汤之类是。先天之阴虚，六味地黄丸、左归丸之类是。先天之阳虚，八味地黄丸、右归丸之类是。有攻伐太过之阳虚，如用寒凉而致阳遏不升，当以人参、白术、黄芪温之。甚者姜、桂以助之。又甚者八味地黄丸，从其原以救之。有攻伐太过之阴虚，如用发散而致津液干枯，当以当归、白芍、熟地滋之。枸杞、龟鹿胶等粘腻之物以填之是。（邯郸赵氏说：读仲景书而不读东垣书，则内伤不明，而杀人多矣。读东垣书而不读丹溪书，则阴虚不明，而杀人又多矣。读丹溪书而不读薛氏书，则真阴真阳不明，而杀人又多矣。四明合并张元素、李杲、朱震亨、薛己四大名家以立言，而于真阴真阳之外，又发攻伐太过之阴虚阳虚两种，以补前贤之所未发，而救败之法乃备。然而读四家书而不读高氏书，则攻伐太过之阴虚阳虚不明，而杀人又多矣。）
什么叫食？膏粱爆炙，酒酪乳制品，能生火而伤胃之阴。伤阴者，救之四物汤以养血。（欲养胃阴，须去川芎加甘草。）佐之黄芩、黄连、栀子、黄柏以清火。（左归饮去茯苓加花粉，尤为稳当。）浮瓜沉李，冷水寒冰，能灭火而伤胃之阳。伤阳者，救之理中汤以养气。佐之肉桂、附子、豆蔻以生火。（虚而不寒，则一理中汤足矣。）至于饥饱失时，则中气受伤，当补而兼运。六君子汤加枳实、桔梗之类，运而提之。
什么叫痰？有食积之痰，有中虚之痰，有水泛水沸所为之痰。食积之痰，消其食则痰自除。保和丸、大安丸、枳术丸之类。虚者六君子汤之类。中虚之痰，或脾虚不运，或胃虚不容。脾虚不运则积，六君子汤加白豆蔻、神曲是。胃虚不容则聚，六君子汤加砂仁、神曲是。水泛为痰，土虚不能摄水也。其痰浓而白，补中益气汤加半夏、木香、白豆蔻是。亦有命门火衰，不能配水，而水泛为痰者，张仲景说：气虚痰泛当以八味地黄丸补而逐之。吴茭山也说。（八味地黄丸治痰之本也。）水沸为痰，其痰白如沫，吐出如蟹沫，少顷变为稠粘之水。此肾水不足，不能制火，火紧而沸也。六味地黄丸主之。（此症间有火不归原，格阳上焰者，其痰亦白如沫，其脉必浮洪数大，而重按则空。或右尺沉细无力，治当引火归原，八味地黄饮主之。王节斋说：痰之本水也，原于肾。痰之动湿也，主于脾。这两句话深透痰症之根。四明诸法，皆治痰之本，不治痰之标。独扼其要，稍似水泛水沸两条中，遗却火不配水，格阳上焰两症耳。今僭补入庶无剩义）。
什么叫血？凡六淫七情之病，皆有因死血薄积于脏腑而成者。其症见于外，或似外感，或似内伤。医家以见症治之，鲜不谬矣。大凡死血在内，其脉必涩滞。其出于皮肤也必不满。其入于筋骨也必不完。其形大抵如线涂生漆，不能充润之状。（线涂生漆，形容涩滞之脉，犹文章之化境也。非天资颖悟，精于脉理者，不能道此。）凡医者遇病，多于痰食求之，死血多不之察。故备言之。（四明对于症之最难审者，审得独精，脉之最难认者，认得倍细。而于郁火郁血两症，其形容脉象处，尤为精尽。诊家主此，则无难审之症难认之脉，而病亦无可遁之情矣。）
什么叫症与脉合，与脉不合？有外感之症脉，有内伤之症脉。外感者，蒸蒸发热，其脉必洪大浮数，是症与脉合也。如发热而脉不洪大浮数，是症与脉不合也。传曰：阳症得阴脉者死。此句是论伤寒。若别症不可便断为死。此必是火遏也。或胃阴不能充拓也。或肾水不能化其荣血也。则舍症从脉可也。火遏者，逍遥散加生地、薄荷以发之。或加丹皮、山栀，屈曲下行以通之可也。胃阴不能充拓者，四物汤（亦须去川芎加甘草，方合阳明。）重加熟地、枸杞、人参、麦冬、五味子以滋之可也。（左归饮去茯苓加归芍合生脉甚验。）肾水不能化其荣血者，六味地黄丸、左归丸以补之可也。如内伤而外不发热，其脉当静，而反浮躁洪大而数，是症与脉不合也。传曰：阴症得阳脉者生。此句亦论伤寒。若别症又不可便许为生。此必是阴亡也。或阳明有食与火也。或肾虚不能纳气也。或过服乌头、附子而下焦津液枯竭也。又有一种重按有力，却不弦，从肌肉渗开，脉与肉无界限，此近于浮洪豁大也。总是阴之象也。阴亡也。（此阴字当作精字、血字、津液字看。治宜温养濡润填补。一用苦寒沉降之阴药，败阳灭火，祸不旋踵矣。）如阴亡，分先后天以救其阴。（先天者，肾中之阴也。后天者，胃中之阴也。缘救阴之法，则上文已详，兹故不另立耳。）有食与火者，健运兼清凉也。（宜从养阴治，使阴气外溢则得汗而火自清，阴血下润，则便通而食自下，不可妄用黄芩、黄连以清火，枳实、厚朴以消食也。）肾虚不能纳气者，六味都气丸。（都气丸尤捷）过服乌头、附子者，六味地黄丸兼黄柏、知母是也。（知母、黄柏两味，性味苦寒，大戕脾胃，非有中焦实火下焦湿火不宜妄用。今因乌头、附子过剂，以致下焦津液枯竭，则黄柏之燥，尤非所宜。且六味地黄丸纯阴润下，但壮水之主，自足以制阳光矣，何必更加知母、黄柏哉？）脉与肉无界限者，六味地黄丸加当归身、枸杞子、枣仁、白芍合生脉散也。凡症皆有合不合，举此可以引申触类矣。
什么叫症与时不合？譬如夏月恶热而燥，不当用辛热矣。然却是无根之火，狂越于外。（须知此火不可水灭，不可湿伏，折以寒凉，无不立毙。故当舍时从症耳。）非人参、肉桂、附子、八味地黄丸，无以返飞越之孤阳。（须浸冷服，乃合伏其所主，先其所因，其始则同，其终则异之义。否则恐其拒格耳。）传曰：桂附清蒸热是也。此舍时从症之谓也。又如冬月畏寒怕冷，必当辛热矣。然却是火郁于中，火热生风，冲突元气，气从火散，故凛凛畏寒。（即疟疾之战，亦非真寒也。此等若认作真寒，而以热药治之，则误矣。）或辛甘以发之。（逍遥散加生地、薄荷，或加山栀、丹皮。）或黄芩、黄连、承气汤以通之，则火透而寒除矣。传曰：硝石、大黄解寒战是也。此亦舍时从症之谓也。（夏月用凉药，冬月用热药，互看。）
The key to treating disease lies in, when attending to a case, first examining the interior and exterior, zang-fu organs, meridians and collaterals, as well as the newness or chronicity, deficiency or excess, food retention, phlegm-fluids, qi stagnation, and blood stasis. Only then should one use pulse diagnosis to verify. (*Mai Jing* [Classic of Pulse Diagnosis], earnestly demonstrates diagnostic methods, yet opens by stating to observe complexion and examine form, cross-referencing these to determine life and death. This shows that inspection, auscultation-olfaction, inquiry, and palpation—the four diagnostic methods—must not be neglected by physicians. *Nan Jing* [Classic of Difficult Issues] lists palpation as the last of the four, indicating that through inspection, auscultation-olfaction, and inquiry, the general picture of the illness is already grasped; the pulse is merely checked to see if it corresponds with the symptoms. However, modern patients seeking medical treatment often fail to state their suffering initially, and even after repeated questioning, remain silent, hiding hidden ailments and confounding the physician. If a physician can indeed be confounded by a patient, then surely the disease cannot be cured by the physician either. Is this not extremely foolish?) If symptoms and pulse correspond, one may employ direct treatment (Zheng Zhi) or following treatment (Cong Zhi).
If symptoms and pulse do not correspond, one must assess the severity, distinguish truth from falsehood, and adopt treatment based on pulse while discarding symptoms, or vice versa. (For mild cases, follow symptoms in 1-2 out of 10 instances; for severe cases, follow pulse in 8-9 out of 10 instances. Zhang Jingyue’s discussion on “following and discarding” is most detailed.) There are also cases where symptoms do not correspond with the season/time; here, one may discard symptoms to follow the season, or discard the season to follow symptoms. (In such cases, following symptoms is more common than following the season.) The pulse, symptoms, and time must always be cross-referenced. (This is the essential principle of diagnosis.)
(Qian notes: Both *Nei Jing* [Inner Canon] and *Nan Jing* contain texts on color diagnosis. Sun Simiao also instructed that asking questions before diagnosing prevents errors. These words are truly correct. The four diagnostic methods cannot lack any one.)
What is meant by "Interior"? It refers to the Seven Emotions: joy, anger, worry, thought, grief, fear, and fright. Diseases arising from the seven emotions originate in the Zang organs. Extreme emotional excess inevitably leads to Qi constraint (Fu Yu) pathology. This constraint originates internally. The pulse of constraint generally appears wiry (Xian), choppy (Se), or stagnant. Its arrival is never slow, its departure never lingering; there is initially a restless quality resembling rapidity but not quite so. Careful contemplation reveals it as fire without flame, sound without rhythm, and movement lacking smoothness. This is the pulse of constraint; the method is to disperse and vent it. (The pulse of constrained fire is extremely difficult to identify because the fire fails to emerge, obstructing the meridians, thus appearing deep and hidden.)
It is like fire beneath covered with wet grass: it becomes stifled and uncomfortable, eventually burning dry and extinguishing itself. Therefore, dispersing and venting allows the fire energy to emerge, enabling self-preservation. (Hence, cold-cooling herbs are contraindicated; ascending and dispersing methods must be used first. This analogy clarifies the point significantly.) Why? Constraint is Qi inhibition. Inhibition prevents Qi flow; lack of flow generates heat; heat becomes fire. Ancient formulas for dispersing and venting prioritize Yueju Wan. Yan Yonghe substituted Xiaoyao San. If only the pulse of constraint is found, either formula suffices. (Dongzhuang stated: The Chuanxiong in Yueju Wan corresponds to Danggui and Baishao in Xiaoyao San; Cangzhu corresponds to Baizhu; Shenqu corresponds to Chenpi; Xiangfu corresponds to Chaihu; Zhizi corresponds to the added ingredients in Xiaoyao San. However, Yueju Wan is harsh, while Xiaoyao San is mild; Yueju Wan is drying, while Xiaoyao San is moistening.) If constraint forces blood, transforming into dryness pathology (such as severe heat pain, swelling of limbs/head/face, swollen cheeks, lumps in arms, irritability, thirst, limb spasms, staring eyes, opisthotonos, scanty dark urine, constipation—all belonging to dryness pathology), the pulse will be floating, rapid, and disordered. One may use Shugan Yishen Tang, treating via Water generating Wood (Shudi can be increased to 30-60g). Zuogui Yin with heavy Danggui and Baishao (adding Chaihu aligns better with liver-soothing intent). Or add Mudanpi, Huangqin, Zhizi to clear Liver and Gallbladder channels (Nourishing Kidney to generate Liver yields divine effects). This is treating Liver and Kidney together.
What is meant by "Exterior"? It refers to the Six Evils: wind, cold, summerheat, dampness, dryness, and fire. (Although all six are listed, the text focuses on wind and cold; summerheat, dampness, dryness, and fire must be inferred.) Pathogens of the Six Evils may transmit from skin/hair to collaterals, from collaterals to meridians, from meridians to Fu organs, and from Fu organs to Zang organs. (Pathogens enter from exterior to interior, layer by layer; the sequence is clearly analyzed here.) Some directly affect collaterals or meridians. Infection by the Six Evils inevitably causes constraint pathology entering from outside. Thus, skin pores close first, binding the pathogen externally, causing steaming fever. The method is to disperse and vent. The pulse is typically floating, surging, large, or tight, and invariably rapid. This is like a prairie fire, a striking sound, moving outward beyond the skin. This is also called the pulse of constraint, specifically external constraint. Dispersing and venting is the method; if ineffective, use "frost and snow" to suppress it. Ancient formulas include Mahuang Tang, Guizhi Tang, Baihu Tang, and Chengqi Tang. For true exterior contraction, Qianghuo Chonghe Tang is also appropriate. (Recent physicians, seeing fever regardless of interior injury or exterior contraction, indiscriminately use Qianghuo Chonghe Tang for surface dispersion, often leading to fluid exhaustion and failure. Qianghuo, Fangfeng, Xin Yi, Bai Zhi are as potent as Mahuang and Guizhi. Users must be cautious.) Interior injuries mimicking exterior contraction involve fire that must not be dispersed. Dispersion consumes Yin; suppression extinguishes fire. (Physicians skilled in dispersion and cooling must scrutinize drugs using this theory.) Early stage may be treated with modified Xiao Chai Hu Tang. Xiaoyao San plus Shengdi, combined with Shengmai San plus Huangqin, nourishes Kidney to generate Liver and Lung to nourish Water. Severe cases use Liuwei Dihuang Wan plus Danggui and Baishao, combined with Shengmai San (nourishing Water to clear Fire). Water is needed to save Fire; rooted Water is needed to save rootless Fire. (Tonifying North extinguishes South; this is an immutable principle.)
What about Zang-Fu organs? Disease may transfer from Fu to Zang, or Zang to Fu. For example, Yangming food retention blocks Qi, impairing Spleen transformation; disease transfers to Spleen. Initially, resolve food; once resolved, Qi flows and Spleen functions. Prolonged illness deepens Spleen pathology; rescue Spleen first. Why? Fu organs tolerate disease longer; Zang organs do not. Fu governs Qi (formless); treating formless with formless is easy. Zang governs Blood (formed); treating formed requires formless mediation, making it difficult. As stated: Formless Qi is easy to tonify; formed Blood is hard to replenish. Food-resolving formulas include Baohe Wan and Zhizhu Wan. Do not over-disperse. Classics say: For major accumulations, attack moderately, stopping at half strength. Over-dispersion depletes Qi. Improper dispersion leads to heat from food retention, damaging Spleen. Use Renshen and Baizhu. Formulas like Wuwei Yigong San or Liujunzi Tang, plus Zhike and Jiegeng, promote transport. Add Huangqin and Huanglian to clear accumulated heat. (See this alongside the section on food.) This is the method of mutual rescue between Zang and Fu. Apply by analogy to other organs.
What about Meridians and Collaterals? Meridians are like river main channels, veins within muscle. Collaterals are like vines on rocks, vessels between skin and muscle. Meridian sinews belong to Zang organs; collateral sinews belong to Fu organs. Zang-related conditions are tonified with blood herbs and unblocked with meridian-moving herbs. Tonics: Danggui, Baishao, Shudi. Unblockers: Chuanxiong, Qinjiao, Moyao, Ruxiang. Fu-related conditions are tonified with Qi herbs and unblocked with collateral-penetrating herbs. Tonics: Renshen, Baizhu, Huangqi. Unblockers: Chaihu, Qianghuo, Gegen. Assess depth of disease; connections vary; do not adhere rigidly.
What about New vs. Chronic? New interior injury requires early tonification. New exterior contraction requires caution against heavy dispersion. Delayed tonification leads to weakness; heavy dispersion creates other syndromes. Chronic interior injury requires vigorous and rapid tonification. Chronic exterior contraction requires gentle, prolonged, non-violent, non-rapid dispersion. Why? Vital Qi is limited; chronic illness damages it. Further attacking depletes Qi and destroys True Yin. Classics: Where evil gathers, Qi is deficient. Fumbling doctors rashly assume attackability. This applies here.
What about Deficiency and Excess? There is Yin deficiency, Yang deficiency, and congenital Yin/Yang deficiency. Yin deficiency is Blood deficiency; treat with Siwu Tang. Yang deficiency is Qi deficiency; treat with Buzhong Yiqi Tang. Congenital Yin deficiency uses Liuwei Dihuang Wan or Zuogui Wan. Congenital Yang deficiency uses Bawei Dihuang Wan or Yougui Wan. Over-treatment causing Yang deficiency (cold herbs suppressing Yang) requires Renshen, Baizhu, Huangqi warming, or Ginger/Cinnamon, or Bawei Dihuang Wan. Over-treatment causing Yin deficiency (dispersing herbs drying fluids) requires Danggui, Baishao, Shudi nourishment, plus Gouqi, Gui/Lu Jiao filling. (Zhao Handan noted: Reading Zhang Zhongjing without Li Dongyuan leaves interior injury unclear, killing many. Reading Li without Zhu Danxi leaves Yin deficiency unclear, killing more. Reading Zhu without Xue Ji leaves True Yin/Yang unclear, killing even more. Gaogufeng synthesizes these four masters, adding insights on over-treatment-induced Yin/Yang deficiency, completing rescue methods. Yet reading these four without Gaogufeng leaves over-treatment deficiencies unclear, killing more.)
What about Food? Rich, fried, roasted foods, alcohol, dairy generate fire and damage Stomach Yin. Rescue with Siwu Tang to nourish Blood (remove Chuanxiong, add Gancao to nourish Stomach Yin). Add Huangqin, Huanglian, Zhizi, Huangbai to clear fire. Zuogui Yin minus Fuling plus Huafen is stable. Cold fruits, ice water extinguish fire and damage Stomach Yang. Rescue with Lizhong Tang to nourish Qi. Add Rongui, Fuzi, Doukou to generate fire. (If deficient but not cold, Lizhong Tang alone suffices.) Irregular eating damages Middle Qi; tonify while promoting transport. Liujunzi Tang plus Zhishi, Jiegeng promotes lifting.
What about Phlegm? Phlegm from food retention resolves with food resolution: Baohe Wan, Da'an Wan, Zhizhu Wan. Phlegm from Middle deficiency uses Liujunzi Tang. Spleen deficiency accumulation: Liujunzi Tang plus Doukou, Shenqu. Stomach deficiency gathering: Liujunzi Tang plus Sharen, Shenqu. Water flooding phlegm (Earth deficiency failing to control Water): thick white phlegm; Buyzhong Yiqi Tang plus Banxia, Muxiang, Doukou. Mingmen fire decline failing to coordinate Water causes flooding phlegm: Zhang Zhongjing recommends Bawei Dihuang Wan to tonify and expel. Wu Jiaoshan agrees (Bawei Dihuang treats the root of phlegm). Boiling water phlegm (white foam, crab-spume-like, turning viscous): Kidney Water insufficiency failing to control Fire. Treat with Liuwei Dihuang Wan. (Sometimes Fire fails to return to origin, Floating Yang flares: white foam phlegm, floating/surging/rapid/large pulse, empty on deep pressure, or weak Right Chi pulse. Guide Fire back to origin with Bawei Dihuang Yin. Wang Jiezhai said: Phlegm root is Water from Kidney; Phlegm movement is Dampness governed by Spleen. Gaogufeng’s methods treat the root, not the branch, grasping the essence. I supplement the missing Fire/Water imbalance and Floating Yang cases.)
What about Blood? All Six Evils and Seven Emotions diseases may involve dead blood accumulating in Zang-Fu. Symptoms appear externally, mimicking exterior or interior patterns. Treating only visible symptoms leads to error. Dead blood inside presents with choppy/stagnant pulse, incomplete skin manifestation, incomplete bone/tendon involvement. Shape resembles raw lacquer lines, lacking moisture. (Metaphorically brilliant; only those gifted in pulse analysis understand.) Physicians often seek phlegm/food, neglecting blood. (Gaogufeng analyzes difficult symptoms precisely and pulses finely. Mastering this eliminates diagnostic difficulty.)
Symptom-Pulse Correspondence: Exterior contraction with steaming fever and surging/floating/rapid pulse corresponds. Fever without such pulse does not correspond. Classics: Yang syndrome with Yin pulse indicates death (specific to Shanghan). Other cases imply Fire constraint, Stomach Yin insufficiency, or Kidney Water failing to transform Ying Blood. Discard symptoms, follow pulse. Fire constraint: Xiaoyao San plus Shengdi, Bohe to vent; or add Mudanpi, Zhizi to guide downward. Stomach Yin insufficiency: Siwu Tang (remove Chuanxiong, add Gancao for Yangming) with heavy Shudi, Gouqi, Renshen, Maidong, Wuweizi. Zuogui Yin minus Fuling plus Danggui/Baishao + Shengmai San is effective. Kidney Water insufficiency: Liuwei/Zuogui Wan tonifies.
Interior injury without fever should have quiet pulse; floating/surging/rapid pulse does not correspond. Classics: Yin syndrome with Yang pulse indicates survival (specific to Shanghan). Other cases imply Yin collapse, Yangming food/fire, Kidney failing to grasp Qi, or excessive Wutou/Fuzi depleting Lower Jiao fluids. Pulse strong on deep pressure but not wiry, merging with flesh, boundary-less, resembling floating/surging/vast: Yin image, Yin collapse. (Interpret "Yin" as Essence, Blood, Fluids. Treat with warm/nourishing/filling methods. Using bitter-cold sinking Yin drugs destroys Yang and extinguishes fire, bringing disaster.) Rescue Yin by distinguishing Pre-Heaven (Kidney) and Post-Heaven (Stomach). Food/Fire: Promote transport and cool (nourish Yin to induce sweat/clear fire, moisten intestines/pass stool; avoid Huangqin/Huanglian/Zhishi/Houpo). Kidney failing to grasp Qi: Liujunzi Duqi Wan. Excessive Wutou/Fuzi: Liuwei Dihuang Wan plus Huangbai, Zhimu. (Huangbai/Zhimu are bitter-cold, damaging Spleen/Stomach; unsuitable unless real Fire/Damp-Heat exists. Here, Lower Jiao fluid depletion makes Huangbai’s dryness inappropriate. Liuwei’s pure Yin moistening sufficiently controls Yang; no need for Huangbai/Zhimu.) Boundary-less pulse: Liuwei Dihuang Wan plus Dangshen, Gouqi, Suanzaoren, Baishao + Shengmai San. Examples illustrate extension to other cases.
Symptom-Time Non-correspondence: Summer heat/dryness suggests avoiding acrid-hot herbs. However, rootless Fire may flare externally. (Do not extinguish with water or suppress with dampness/cold; immediate death results. Discard time, follow symptoms.) Only Renshen, Rougui, Fuzi, Bawei Dihuang Wan can restore wandering solitary Yang. (Serve cold to match "subdue the dominant, address the cause, start same end different" principle, preventing rejection.) Classics: Cinnamon/Aconite clears steaming heat. This is discarding time for symptoms. Winter cold suggests acrid-hot. However, Fire may constrain internally, generating Wind, conflicting with Yuan Qi, scattering Qi, causing shivering. (Malaria chills are not true cold. Treating as true cold with hot herbs is error.) Use acrid-sweet to vent (Xiaoyao San + Shengdi/Bohe or Zhizi/Mudanpi) or Huangqin/Huanglian/Chengqi Tong to penetrate Fire and remove cold. Classics: Shi-Huang resolves chills. Also discarding time for symptoms. (Summer cold/winter hot herbs viewed mutually.)