古以五气、五色、五声，视人生死，盖即诚中形外之义，亦可见疾。虽伏而未发，其脏
腑已先受伤，故必现于形声动作，譬室有火患，初不及觉，驯至烟焰满中，则勃发而不可御矣。
然为曲突徙薪之计者，近医亦罕。《说部》载宋神宗精医理，有内侍病肿，太医言不治。帝
为诊之曰∶阴虽衰，阳未竭，犹可疗也。令食蒜煮团鱼而愈。熙宁初，京尹吕溱上殿进扎，
郎中周约随趋。帝问∶吕体中无恙否？吕以无对，顷之复问，且问周见吕如何？周对如吕。既
退
，吕引镜自照，顾周曰∶面有晦色否？周曰∶龙图无自疑，容彩安静。未几，溱果病，遂不
起。噫！如神宗者，可云望而知之矣。
切脉、辨证、立方，为医家三要，而脉尤重。盖脉既切明，自能辨证，而投药不难也
。今医
者，苦于脉理难凭，乃竟尽弃不究。惟学写医案，作门面语，论证则以活脱为能，用药惟以
和平为贵，自谓胜于偏执好奇孟浪自喜者。不知用药如用兵，贵乎神速，若迟疑不进，使邪
势蔓延，必至救援不及，致危殆而后已。夫偏执好奇，诚为医家所忌，然或因其立法乖异，
在病家尚不轻信；若和平之剂，人即知其未必效，亦取其无害而就之。岂知因循两字，误人
不浅，在寻常之症，弗药亦愈；若生死关头，其可须臾耽待乎？
余初读《灵》、《素》诸书，觉其经义渊深，脉理错杂，每若望洋意沮，继并心一志，
遍览
前贤注释，有所疑，则整日默坐苦思而力索之，乃渐通五运六气，阴阳应象之理。每调气度
脉浪，决人生死，亦时或有验。忆昔避兵乡里，对巷有吴某晨起方洒扫，忽仆地不语，移时
始醒。延余诊视，仍能起坐接谈，按脉则势急而锐，真有发如夺索者，盖肾气败也，危期当
不越宿。遽辞以出，人咸不之信，讵日未昃而气绝矣。又，布商周某，偶感微疾，就余诊视
。余曰∶今所患勿药可愈，惟按心脉独坚，湿痰阻气，气有余即是火，火郁不散当发痈。时
周脑后生细疮，累累若贯珠。余曰∶君以此无所苦，一旦勃发，为害非浅，亟宜慎之。彼终
不为意。及明春，果以脑后毒发而死。据此则凭脉决证，似乎如响斯应矣，岂知脉理微茫，
又有不可臆断者。余有戚某过余斋，形色困惫，询知患咳经月，行动气喘，故来求治。诊
其脉至而不定，如火薪然，窃讶其心精已夺，草枯当死。戚固寒士，余以不便明言，特赠二金
，惟令安养。时已秋半及霜，寒木落往探之，而病已痊。细思其故，得毋来诊时，日已西沉
，行急而咳亦甚，因之气塞脉乱，乃有此象欤？然惟于此而愈，不敢自信矣。脉理渊微，固
未易丝分缕析，而世之医家病家，咸以脉为首
务，岂知脉居四诊之末。上士欲求其备，原难舍脉以言病，而亦不能离病以就脉也。盖凡临
证，必先询其病之所在，与受之所由，察虚实，观气色，俟胸有成见，而后按脉以决其疑。
若脉不合症，必更求病之所以然，与脉之所以异，准此立方，或可无出入之虑。本不专以三
部九候为凭也。矧今世粗工，略知脉理，便强作解事，谓病之原，本按脉能知。在病家亦信
其造诣甚深，指下自能洞见。孰知古之宗工，亦无此本领乎？余为是言，非轻视夫脉也，正
以理甚渊微，未容伪托耳！
胎产非患，惟稽古杂志有异胎五则，称不救。而方书恰未之载，五者何？一曰束，胞带
紧束不解也；一曰冲，临产时，冲逆不下也；一曰挺者，横截腹中，手足不露；一曰捧心，子捧
母心，心随胎落；一曰，卷肠，肠断始脱。遇此五者，母子得存其一幸矣。至怀胎之迟速，
亦甚不同，有三四年而后生者，此胎气使然。静待固无所害，若见腹膨既久，误认为病，以药
攻之，必至胎损而堕，悔何及哉？更有七月五月而生者，考孕生五月，古名赅胎，以父母禀气
之旺，阳生而阴即长，故先期而产。此如向阳花木，得气在先，十月即华，不待三春始发耳
。俗子不明此理，妄有诽讪，至产母忿不欲生，良可痛恨。昔余家有坟丁赵德隆者，娶邻女
未六月而产一男，戚党咸窃笑，幸赵知妻素端方无疑问。子后渐长，声音笑貌，酷类德
隆，于是群疑始释。又有孕终不产者。《元人说部》所载∶南邑下砂四灶，盐丁顾寿五，妻王氏，
始笄适顾，子女已生其五，而于至大辛亥复有孕。及期，临蓐七日不娩，后仍如故。每嘱家
人死必焚我，勿待尽，须查看腹中物，以明何疾。继于至正庚寅十月，腹骤动，痛极而死。
越二日，家人遵遗言以火化之，取物视，则胞带缠束甚紧，剖之乃一男胎，其肋骨坚如铁石，
计怀胎四十年。其妇以甲戌生，死年七十有七。胎产常事，有怪异若此者，其故固不可解也
。
古云∶读书不明其义，不如不读。言恐反为书惑也。而在医为尤甚。盖古人方论，惟言
一症，不能随其传变，故可意会，而不可拘执。即如虚损一症，丹溪谓阳常有余，阴常不足，主
治在心肾。以心主血，肾主精，精竭血燥，火盛金衰，而成劳怯。故治以四物六味，补益真
阴，俾火自降，而肺金清肃。在东垣则又以脾胃为本，言土浓则金旺，而肾水亦足，故以补
中益气为主。后世咸宗李而以朱为误，谓造化生机，惟藉此春温之气，若专用沉阴清化之品
，则生生之气索然。是盖未知上损从阳，下损从阴之义矣。按《金匮》云∶脉大为劳。极虚
亦为劳。脉大指损及心脾，营血亏而气分泄越，宜归脾建中益气养营为要；极虚则言精血
内夺肝肾，阴不能自立，宜以四物八味，壮水化源。乃知前贤立方，本各有见；后人不分阴
阳，不察脉理，但言治损而茫不知其损之所
在也。嗟乎！药能治病，亦能致病。昔人有言∶不遇良医，不如不药。盖治病犹易，治药为
难耳。有友僻居乡曲，每言其处，苦无医士，无药肆。余谓∶果尔，亦未必非一乡之福也。
凡治病必察虚实，勿盛盛，勿虚虚，疏其血气，令其调达而致和平。此《素问》审治之
义也
。今之医士，每遇年老之人，辄投温补。而补之一字，又为人所乐闻。不知老人脾气既衰，
饮食入胃，输化不清，蒸变为痰，气机阻遏，气有余即是火。故治老人，略同幼稚，当以清
通为主，是即经旨六腑传化不藏，以通为用也。徐灵胎曰∶千年之木，往往自焚，盖阴尽火
炎，物理然也。余谓积秽沟渠，必多拥塞。人能味此，老人之疾，非纯以温补为法矣。昔金
坛王肯堂，年逾八旬，患脾泄，经年不愈。医投温补而转剧，延我邑李士材诊之，用巴豆霜
下痰涎数升而愈。此非李之明于辨证不能用，非王之知医，亦不敢服耳。张子和曰∶良工先
治实，后治虚；粗工或治实。或治虚；谬工则实实虚虚；惟庸工能补其虚，不敢治其实也。
昔有人乘舟遇风而患心疾，医者取多年船柁于手汗所积处，锉末饮之而愈。医以意用，
初似儿戏，往往巧发奇中，有未易致诘者。庐陵尝举此语坡公，公笑曰∶然。以才人之笔烧灰饮
学人，当疔昏惰。推之饮伯夷之盟水，即可救贪；食比干之饭，即可愈佞，舐樊哙之盾，亦
可治怯；臭西子之珥，亦可愈恶疾乎。庐陵亦大笑。余谓∶是固不可太泥。古人用药，每取
形质相类，性气相从，以达病所，亦有纯以意运，如弩牙速产，杵糠下噎，月季调经，扇能
止汗，蛇性上窜而引药，蝉膜外脱而退翳。所谓医者意也，殆即此类。本不当以常理格，亦
未可以必愈，其如或执而不通，适为坡老所笑耳。
今医士每见身热脉数，辄投柴葛，以为邪散则安。不知六淫感证，固非一端，见症虽略
相同，治法则自有别。盖温邪忌表，湿家忌汗，前贤固有明训。王晋三古方选注，集伤寒百十三
方，攻补温凉，无所不备，岂仅以解表为事哉？即足经纶，治表散亦不宜太过。盖病中大汗
，最能暗耗元阳，致病后每多损怯。尝《阅说》部所载，范云仕梁为治议时，武帝有九锡之
命，期在旦夕，而云适病疫，乃召徐文伯诊之，欲求速愈。文伯曰∶此甚易，但恐二年后不
复能治。云曰∶朝闻道夕死何妨？况二年乎。文伯乃以火 地，布桃柏叶于上，令云卧之，
汗大泄，翌日遂愈。后二年，云果暴卒。宣解之不宜过甚如此。治病不难用药，而难于辨证
，辨证既明，则中有所主，而用药自无疑畏。如明永乐中东宫妃张氏，经阻阅十月，疑有孕
。上命太医盛启东诊之，盛谓非孕，进方多破血品，东宫怒曰∶早晚望诞育，岂宜服此？即
屏退〉阅月病益剧，复召诊，仍疏前方，东宫禁盛于别室，而后服其方。盛家惶怖无地，事
恐不免，而盛洋洋若不经意。越三日，家人忽闻门外呼殿声甚喧，出视则盛已红棍前引，
获浓赏归矣。询之知妃服药后，下血数斗，疾渐平复。可见识病既真，下药终无疑畏，如盛者
于医，无愧为良矣。
《太素》之脉，析五运之微，穷造化之理，能决人富贵利达，贫贱寿夭，此无他，至于
理而止耳。盖人禀天地之气以生，故五行之气，隐于五脏，通于六腑，呼吸之间，阴阳开合，造
化玄微，靡不毕见。尝考《太素》诸书，首重心脉。心，主也，一身之动定系焉。凡人贵贱
，惟在轻清重浊，其词曰∶心脉分明紧秀洪，自然禄位至三公，清调三按俱无绝，福寿绵绵
紫诰隆。盖脉清则神清，脉浊则气俗，得先天气浓，故神旺气充，脉必明秀而无杂乱至贵也
。大抵男子以肝木巽位为主，女子以肺金兑位为先。清如玉之温润，应指分明，不沉不濡，
调调不绝；浊则粗燥无神，息数混杂，按之不显，如撒干砂，此贵贱之所由分也。然脉分六
部，变应万端，其间阴阳聚散，生克无穷，义奥同于易理，非有宿慧者，岂能参其机要哉？
藜藿之躯，不数服药，药故易于见功；膏粱之体，未病先药，既病而药难取效。常见富
人染病，一日数医，医者争奇，冀得偶中，方药乱投，致多误事。有挽显者诗曰∶堂深人不知何
病，身贵医争试一方。大抵富人病多误于乱药，贫人病多误于因循。
古人通过观察人的五气（风、暑、湿、燥、寒对应的生理表现）、五色、五声来判断人的生死，这大概体现了“内心真诚则外表显现”的道理，也可以借此看出疾病。即使病邪潜伏尚未发作，脏腑也已经先受了损伤，所以必然会表现在形体、声音和动作上。这就好比房子里有火灾隐患，起初人们察觉不到，等到烟雾火焰充满屋内时，火势猛烈爆发便无法控制了。然而，能够采取“曲突徙薪”（比喻消除隐患）这种预防措施的医生，现在也很少见。
《说部》记载，宋神宗精通医理。有一位内侍患了肿病，太医说治不好。皇帝亲自为他诊脉说：“阴气虽然衰弱，但阳气尚未竭尽，还可以治疗。”让他吃蒜煮团鱼，结果痊愈了。熙宁初年，京城长官吕溱上殿奏事，郎中周约跟随在旁。皇帝问：“吕溱身体还好吗？”吕溱没有回答。过了一会儿皇帝又问，并且问周约觉得吕溱怎么样？周约回答说像平时一样。退朝后，吕溱对着镜子照自己，问周约：“我脸色晦暗吗？”周约说：“吕大人不要多疑，面色神色很安详。”没过多久，吕溱果然生病了，最终没能治好。唉！像宋神宗这样的人，可以说是“望而知之”的高明境界了。
切脉、辨证、立方，是医生的三大要点，而脉诊尤其重要。因为脉象既然切得清楚明白，自然就能辨证，用药也就不难了。现在的医生，苦于脉理难以凭信，竟然完全抛弃不去研究。只学习写医案，做做表面文章，论证时以灵活脱套为能事，用药只求平和稳妥，自认为胜过那些偏执好奇、轻率自负的人。他们不知道用药如同用兵，贵在神速，如果迟疑不进，让邪气蔓延，必定会导致救援不及，直到出现危重情况才罢休。偏执好奇确实是医家所忌讳的，但如果立法怪异，病人尚且不敢轻信；如果是平和的药剂，人们虽然知道未必有效，但也因为无害而愿意接受。哪里知道“因循”这两个字，误人不浅，对于普通的病症，不吃药也能好；但在生死的关头，怎么可以片刻拖延呢？
我最初读《灵枢》、《素问》等书，觉得经文义理深奥，脉理错综复杂，常常感到像面对汪洋大海一样气馁。后来专心致志，遍览前贤的注释，有疑问就整天静坐苦思力索，于是逐渐通晓了五运六气、阴阳应象的道理。每当调息度脉，判断人的生死，有时也有应验。记得以前在乡里躲避战乱，对面巷子里有个姓吴的人早晨起来正在打扫，突然倒地不语，过了很久才醒过来。请我去诊治，他还能起坐交谈，按脉发现脉势急锐，真有如夺索般的感觉，这是肾气败绝的表现，危险期应该不会超过当晚。我急忙告辞出来，大家都不相信。谁知太阳还没偏西，他就气绝身亡了。
另外，有个布商周某，偶然得了点小病，来找我诊治。我说：“你现在的病不吃药也能好，只是心脉独坚，这是湿痰阻滞气机，气有余就是火，火郁结不散应当发痈疽。”当时周某脑后生了小疮，累累如串珠。我说：“你现在以此不觉得痛苦，一旦爆发，危害不小，务必谨慎。”他始终不在意。到了第二年春天，果然因为脑后毒发而死。据此来看，凭脉决断证候，似乎像回声一样应验，哪里知道脉理幽微渺茫，又有不能主观臆断的情况。
我的一个亲戚某人来我书房，形色困惫，询问得知他咳嗽已经一个月，行动气喘，所以来求治。诊其脉至而不定，像火烧柴薪一样急促，我心里惊讶他的心神精气已失，草木枯萎必死无疑。亲戚本是贫寒读书人，我不便明说，特意送了他二两银子，只让他安心调养。当时已是秋半霜降，寒木落叶，我去探望他，病却好了。仔细思考其中的缘故，莫非他来诊脉时，太阳已西沉，行走匆忙导致咳嗽加重，因此气塞脉乱，才呈现出那种凶象？然而只有这次痊愈，我不敢自信于自己的医术了。脉理渊深微妙，本来不容易丝丝缕缕地分析清楚，而世上的医生和病人都把脉诊当作首要任务，哪里知道脉诊在四诊（望、闻、问、切）中排在最后。高明的医生想要诊断完备，原本很难舍弃脉诊来说病，但也绝不能脱离病情去迎合脉象。凡是临证，必须先询问病在哪里，受病的缘由，察虚实，观气色，等到胸中有成竹，然后按脉来决断疑惑。如果脉象与症状不符，必须进一步探究病之所以然，以及脉象之所以不同，根据这些来立方，或许可以避免差错。本不是专门依靠三部九候来作为凭据的。况且现在的粗工，稍微懂点脉理，就强作解人，说病的根源，本来按脉就能知道。病人也相信他造诣很深，指下自然能洞见。哪里知道古代的宗师，也没有这种本领啊！我说这些话，并不是轻视脉诊，正是因为道理非常深奥，不容许虚伪托辞罢了！
胎产本身不是病患，只在古代杂记中有五种异常胎产称为“不救”。而方书中恰好没有记载，哪五种呢？一种是“束”，胞带紧束不解；一种是“冲”，临产时冲逆不下；一种是“挺”，横截腹中，手足不露；一种是“捧心”，胎儿捧着母亲的心，心随胎落；一种是“卷肠”，肠断始脱。遇到这五种情况，母子能保全其一算是幸运了。至于怀孕时间的迟速，也非常不同，有三四年后才生的，这是胎气使然。静静等待固然没有害处，如果看到肚子膨大很久，误认为是病，用药物攻伐，必定导致胎损流产，后悔莫及啊！更有七月或五月就生的，考证怀孕五月而生，古名叫“赅胎”，因为父母禀赋之气旺盛，阳生而阴即长，所以提前生产。这就像向阳的花木，得气在先，十月就开花，不需要等到春天才发芽。俗人不明这个道理，妄加诽谤，以至于产母愤怒不想活，实在令人痛恨。
过去我家有个坟丁叫赵德隆，娶邻家女子不到六个月就生了一个男孩，亲戚邻里都私下嘲笑，幸好赵德隆知道妻子一向端庄方正，没有怀疑。孩子后来渐渐长大，声音笑貌，极像赵德隆，于是众人的疑虑才消除。还有怀孕到足月却不生产的。《元人说部》记载：南邑下砂四灶，盐丁顾寿五的妻子王氏，刚出嫁时，子女已经生了五个，而在至大辛亥年又怀孕了。到了预产期，临盆七天不生，后来还是老样子。每次嘱咐家人死后一定要烧掉我，不要等到最后一刻，须查看腹中物体，以查明是什么病。接着在至正庚寅年十月，腹部突然剧烈跳动，疼痛至极而死。过了两天，家人遵照遗言用火化了她，取出东西看，原来是胞带缠束得很紧，剖开后是一个男胎，肋骨坚硬如铁石，计算怀胎四十年。那妇人出生于甲戌年，死时七十七岁。胎产是常事，竟有如此怪异的情况，其中的原因确实不可解释。
古人说：读书不明白其中的义理，不如不读。是说恐怕反而被书本迷惑。这在医学上尤其严重。因为古人的方论，只说一种症状，不能随着病情传变而变化，所以可以意会，而不能拘泥执着。就拿虚损这一症来说，朱丹溪认为阳常有余，阴常不足，主治在心肾。因为心主血，肾主精，精竭血燥，火盛金衰，而成劳怯。所以治疗用四物汤、六味地黄丸，补益真阴，使火自降，而肺金清肃。李东垣则认为以脾胃为本，说土厚则金旺，而肾水也足，所以以补中益气汤为主。后世都尊崇李东垣而认为朱丹溪错误，说造化的生机，全靠这春温之气，如果专用沉阴清化之品，那么生生之气就索然无味了。这大概是不知道上损从阳、下损从阴的道理啊。按《金匮要略》说：脉大为劳，极虚亦为劳。脉大指损伤及心脾，营血亏而气分泄越，宜用归脾汤、建中汤益气养营为要；极虚则说精血内夺肝肾，阴不能自立，宜用四物汤、八味丸，壮水化源。才知道前贤立方，本来各有见解；后人不分阴阳，不察脉理，只说治损而茫然不知损在哪里。唉！药能治病，也能致病。古人有话说：不遇到良医，不如不吃药。大概治病还容易，治药（处理药物副作用或误治）更难罢了。
有位朋友僻居乡间，常说当地苦无医生，无药店。我说：果真如此，也未必不是一乡的福气。凡治病必须察虚实，不要盛实更盛，不要虚者更虚，疏通气血，令其调达而达到和平。这是《素问》审治的道理。现在的医生，每遇到老年人，就投以温补。而“补”这个字，又被人乐于听到。不知道老人脾气既衰，饮食入胃，输化不清，蒸变为痰，气机阻遏，气有余就是火。所以治疗老人，略同于小孩，当以清通为主，这就是经旨所说的六腑传化不藏，以通为用。徐灵胎说：千年的木头，往往自焚，盖因阴尽火炎，这是物理规律。我认为积满污秽的沟渠，必然多拥塞。人能体味这一点，老人的疾病，就不是单纯用温补的方法了。
过去金坛王肯堂，年过八十，患脾泄，经年不愈。医生投以温补反而加重，请我县李士材诊治，用巴豆霜泻下痰涎数升而痊愈。这不是李士材善于辨证不能用，也不是王肯堂懂医，也不敢服用啊。张子和说：良工先治实，后治虚；粗工有的治实，有的治虚；谬工则实实虚虚（实证用补法使实更实，虚证用泻法使虚更虚）；只有庸工能补其虚，不敢治其实。
过去有人乘船遇风患心疾，医者取多年船舵上积存的手汗，锉成末饮服而愈。医生用心用药，起初似儿戏，往往巧发奇中，有难以责问的。庐陵曾将此话告诉苏东坡，苏公笑着说：对。以才人之笔烧灰给学人喝，能治昏惰。推而言之，喝伯夷盟誓的水，就能救贪；吃比干的饭，就能愈佞；舔樊哙的盾，也能治怯；闻西子的耳饰，也能愈恶疾吗？庐陵也大笑。我认为：这固然不可以太拘泥。古人用药，每取形质相类，性气相从，以达病所，也有纯以意运，如弩牙速产，杵糠下噎，月季调经，扇能止汗，蛇性上窜而引药，蝉膜外脱而退翳。所谓“医者意也”，大概就是这类。本不当以常理衡量，也不能保证一定痊愈，如果有人固执不通，正好被苏东坡老先生笑话罢了。
现在的医生每见身热脉数，就投以柴胡、葛根，以为邪散则安。不知道六淫感证，固非一端，见症虽略相同，治法则自有别。大概温邪忌表（发汗），湿家忌汗，前贤固有明训。王晋三《古方选注》，收集伤寒一百十三方，攻补温凉，无所不备，岂仅以解表为事哉？即使是足经病变，治表散也不宜太过。因为病中大汗，最能暗耗元阳，致病后每多损怯。曾阅《说部》所载，范云仕梁为治议时，武帝有九锡之命，期限在即，而范云适逢疫病，于是召徐文伯诊治，想求速愈。文伯说：这很容易，但恐怕两年后不能再治。范云说：朝闻道夕死何妨？何况两年呢。文伯于是用火熏地，铺桃柏叶在上面，让范云卧在上面，汗大泄，第二天就好了。两年后，范云果然暴卒。宣解之不宜过甚如此。治病不难用药，而难于辨证，辨证既明，则心中有所主，而用药自然无疑畏。
如明永乐年间，东宫妃张氏，经阻十月，怀疑有孕。皇上命太医盛启东诊治，盛说不是孕，进方多为破血药，东宫大怒说：早晚盼望生育，岂宜服此？即屏退盛启东。过了一个月病更重，再召诊治，仍开前方，东宫将盛启东禁闭于别室，而后服其方。盛家惶怖无地，事恐不免，而盛洋洋若不经意。过了三天，家人忽闻门外呼声甚喧，出视则盛已红棍前引，获浓赏归矣。询之知妃服药后，下血数斗，疾渐平复。可见识病既真，下药终无疑畏，像盛启东这样的医生，无愧为良医了。
《太素》的脉法，析五运之微，穷造化之理，能决人富贵利达，贫贱寿夭，这没有别的，至于理而止罢了。大概人禀天地之气以生，故五行之气，隐于五脏，通于六腑，呼吸之间，阴阳开合，造化玄微，无不毕见。曾考《太素》诸书，首重心脉。心，主也，一身之动定系焉。凡人贵贱，惟在轻清重浊，其词曰：心脉分明紧秀洪，自然禄位至三公，清调三按俱无绝，福寿绵绵紫诰隆。大概脉清则神清，脉浊则气俗，得先天气浓，故神旺气充，脉必明秀而无杂乱至贵也。大抵男子以肝木巽位为主，女子以肺金兑位为先。清如玉之温润，应指分明，不沉不濡，调调不绝；浊则粗燥无神，息数混杂，按之不显，如撒干砂，此贵贱之所由分也。然脉分六部，变应万端，其间阴阳聚散，生克无穷，义奥同于易理，非有宿慧者，岂能参其机要哉？
藜藿之躯（平民百姓），不数服药，药故易于见功；膏粱之体（富贵人家），未病先药，既病而药难取效。常见富人染病，一日数医，医者争奇，冀得偶中，方药乱投，致多误事。有挽显者诗曰：堂深人不知何病，身贵医争试一方。大抵富人病多误于乱药，贫人病多误于因循。
In ancient times, life and death were judged by observing a person's five qi (physiological manifestations corresponding to wind, summer heat, dampness, dryness, and cold), five colors, and five sounds. This essentially embodies the principle that "sincerity within manifests outwardly," and it also allows one to perceive diseases. Even when pathogenic factors are latent and not yet manifesting, the zang-fu organs have already been injured first; therefore, abnormalities must appear in the form, voice, and movements. It is like a house with a fire hazard: initially unnoticed, but once smoke and flames fill the room, the fire erupts violently and becomes uncontrollable. However, doctors who adopt preventive measures akin to "bending the chimney and moving the firewood" (metaphor for eliminating hazards) are rare nowadays.
The *Shuo Bu* records that Emperor Shenzong of Song was proficient in medical principles. An eunuch suffered from swelling, and the imperial physicians declared it incurable. The Emperor examined him himself and said, "Although yin qi is deficient, yang qi has not exhausted; it can still be treated." He prescribed garlic boiled with soft-shell turtle, which resulted in recovery. In the early Xining era, Lu Zhen, the prefect of the capital, entered the court to present memorials, followed by Zhou Yue, a Langzhong (mid-level official). The Emperor asked, "Is Lu Zhen healthy?" Lu Zhen did not answer. After a while, the Emperor asked again, inquiring how Zhou Yue perceived Lu Zhen's condition. Zhou replied that he seemed normal. Upon leaving the court, Lu Zhen looked in the mirror and asked Zhou, "Is my complexion dark?" Zhou said, "My Lord, do not doubt yourself; your countenance is calm and peaceful." Shortly thereafter, Lu Zhen fell ill and eventually died. Alas! One like Emperor Shenzong could be described as possessing the ability to "know through observation."
Pulse diagnosis, syndrome differentiation, and prescription formulation are the three essentials for physicians, with pulse diagnosis being particularly important. Once the pulse is clearly felt, syndrome differentiation naturally follows, making medication administration straightforward. Modern physicians, finding pulse theory difficult to rely upon, often abandon it entirely. They merely learn to write medical case records for show, valuing flexibility in argumentation and prioritizing mild medications, considering themselves superior to those who are dogmatic, curious, or reckless. They fail to realize that using medicine is like using troops; speed and agility are crucial. Hesitation allows pathogens to spread, leading to situations where rescue is impossible until critical danger ensues. While dogmatism is indeed taboo, if a prescription is unconventional, patients may hesitate to trust it; however, with mild prescriptions, although efficacy might be doubted, patients accept them because they are harmless. Ignoring this, the two characters "procrastination" cause significant harm. For ordinary ailments, abstaining from medicine may lead to recovery; but at the juncture of life and death, how can one delay even for an instant?
When I first read classics such as the *Ling Shu* and *Su Wen*, I found their meanings profound and pulse theories complex, often feeling discouraged as if facing an ocean. Later, focusing my mind, I extensively studied annotations by former sages. When doubts arose, I sat in silence all day, thinking hard and searching for answers, gradually comprehending the principles of the Five Movements and Six Qi, and Yin-Yang correspondences. Whenever I regulated breath and measured pulses to judge life and death, there were occasional instances of accuracy. Recalling my time hiding from war in the countryside, a Mr. Wu in the opposite alley suddenly collapsed while sweeping in the morning, remaining unconscious for some time before waking. I was summoned to examine him; he could sit up and talk. His pulse was rapid and sharp, resembling a pulling rope, indicating kidney qi exhaustion. The crisis would likely not last past nightfall. I hurriedly left, though others disbelieved me. Indeed, before noon, he passed away.
Another case involved a cloth merchant, Mr. Zhou, who sought treatment for a minor ailment. I stated, "Your current condition will resolve without medicine, but your heart pulse is uniquely firm, indicating damp-phlegm obstructing qi mechanism. Excess qi generates fire; if fire stagnates, carbuncles may develop." At that time, Mr. Zhou had small sores on the back of his neck, clustered like beads. I warned, "Though you feel no pain now, if these erupt, the harm will be severe; please be cautious." He ignored me. By the following spring, he indeed died from a toxic eruption on the back of his neck. Thus, judging syndromes via pulse seems as responsive as an echo. Yet, pulse theory is subtle and elusive, containing aspects that cannot be subjectively deduced.
A relative visited my study, appearing exhausted. Learning he had suffered from coughing for a month with shortness of breath upon exertion, I examined his pulse. It was erratic and rapid, like burning firewood. I internally suspected his heart spirit and essence were depleted, predicting death akin to withered grass. Being a poor scholar, I did not state this explicitly but gave him two taels of silver, advising rest. It was mid-autumn with frost; visiting him later after leaves had fallen, I found him recovered. Reflecting on this, perhaps during our consultation, the sun had set, and his hurried walking exacerbated his cough, causing qi stagnation and chaotic pulse presentation, creating that ominous image. Only in this instance did he recover, so I dare not claim confidence in my skills. Pulse theory is profound and subtle, difficult to analyze meticulously. Yet, modern physicians and patients prioritize pulse diagnosis, unaware that it ranks last among the Four Diagnostic Methods (Inspection, Auscultation/Olfaction, Inquiry, Palpation). A superior physician seeks completeness; while abandoning pulse to discuss disease is difficult, relying solely on pulse without considering disease is also impossible. In clinical practice, one must first inquire about the location and cause of the disease, observe deficiency/excess and complexion, forming a preliminary conclusion before palpating the pulse to resolve doubts. If the pulse contradicts symptoms, one must investigate the underlying causes of both the disease and the pulse discrepancy. Prescriptions based on this may avoid errors. It is not solely dependent on the Three Positions and Nine Pulses. Moreover, incompetent practitioners, knowing little of pulse theory, pretend to understand, claiming disease origins are known by pulse alone. Patients believe in their deep expertise, assuming clear insight under the fingers. Little do they know that ancient masters did not possess such infallible abilities either! My words are not to belittle pulse diagnosis but to emphasize its profundity, forbidding false pretenses.
Pregnancy and childbirth are not inherently pathological. Ancient miscellaneous records mention five types of abnormal deliveries deemed incurable, which are absent in medical formularies. What are they? First, "Binding": the umbilical cord tightly binds without release. Second, "Rushing": during labor, upward rushing prevents descent. Third, "Protruding": the fetus lies transversely in the abdomen, limbs hidden. Fourth, "Holding the Heart": the fetus presses against the mother's heart, causing the heart to descend with the fetus. Fifth, "Coiling Intestines": intestines rupture before delivery. Surviving any of these five scenarios, preserving either mother or child, is fortunate. Gestation periods vary greatly; some last three to four years due to fetal qi characteristics. Waiting quietly causes no harm. However, mistaking prolonged abdominal distension for illness and treating it with purgatives inevitably leads to fetal loss and abortion, bringing regret. Others deliver in the fifth or seventh month. Historically, delivery at five months was called "Gai Tai" (Complete Fetus), attributed to robust parental qi where yang generates and yin grows rapidly, leading to premature birth. Like plants facing the sun, receiving qi early, they bloom in ten months without waiting for spring. Laypeople misunderstanding this slander such cases, causing mothers despair, which is truly lamentable.
Previously, a grave keeper named Zhao Delong married a neighbor's daughter and fathered a son in less than six months. Relatives mocked him, but Zhao knew his wife was virtuous and harbored no suspicion. The child grew up resembling Zhao in voice and mannerisms, dispelling doubts. Another case involves prolonged pregnancy without delivery. The *Yuan Ren Shuo Bu* records Gu Shouwu, a salt worker in Nan Yi, whose wife Wang Shi had five children after marriage. In the Xin Hai year of Zhida, she became pregnant again. At term, labor lasted seven days without delivery. She instructed her family to cremate her immediately upon death, checking the abdomen to identify the anomaly. In October of the Geng Yin year of Zhengtong, her abdomen moved violently, and she died in extreme pain. Two days later, per her wishes, she was cremated. Inside, the umbilical cord was tightly bound. Cutting open revealed a male fetus with ribs hard as iron, calculated to have been gestated for forty years. The woman was born in Jia Xu and died at seventy-seven. Such anomalies in common events remain inexplicable.
Ancient saying: "Reading without understanding meaning is better than not reading at all," warning against being confused by texts. This applies especially to medicine. Ancient formulas addressed single symptoms without accounting for disease progression, allowing intuitive understanding but forbidding rigid adherence. Consider consumptive disorders. Zhu Danxi argued yang is often excessive and yin often deficient, focusing treatment on the Heart and Kidney. Since the Heart governs blood and the Kidney governs essence, essence depletion and blood dryness lead to hyperactive fire and declining metal (lung), resulting in consumption. Treatment used Si Wu Tang (Four Substance Decoction) and Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) to tonify true yin, suppressing fire and clearing lung metal. Li Dongyuan, conversely, emphasized the Spleen and Stomach as the root, stating thick earth strengthens metal and nourishes kidney water, advocating Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction). Later generations revered Li and dismissed Zhu, arguing that creative vitality relies on spring-warmth qi; using heavy, yin-cooling agents extinguishes generative energy. This reflects ignorance of the principle that upper damage follows yang and lower damage follows yin. According to the *Jin Gui Yao Lue*: "A large pulse indicates consumption; extreme emptiness also indicates consumption." A large pulse signifies damage to Heart and Spleen, with deficient nutritive blood and leaking qi, requiring Gui Pi Tang (Restore the Spleen Decoction) and Jian Zhong Tang (Establish the Middle Decoction) to tonify qi and nourish nutritive blood. Extreme emptiness indicates internal deprivation of essence and blood in Liver and Kidney, with yin unable to stand independently, requiring Si Wu Tang and Ba Wei Wan (Eight-Ingredient Pill) to strengthen water and transform sources. Thus, former sages had distinct insights; later practitioners, ignoring yin-yang and pulse theory, treat consumption blindly without locating the deficit. Alas! Medicine cures but also harms. As the saying goes, "Without a good doctor, better not to take medicine." Treating disease is easier; managing medicinal side effects is harder.
A friend living remotely complained of having no doctors or pharmacies nearby. I remarked this might be a blessing for the village. Treating disease requires assessing deficiency and excess; do not exacerbate excess or deplete deficiency. Unblock qi and blood, ensuring harmony. This is the therapeutic principle of the *Su Wen*. Modern physicians often prescribe warming tonics for the elderly. The word "tonic" is pleasing. However, elderly people have declining spleen qi; food intake fails to transform properly, steaming into phlegm, obstructing qi mechanism. Excess qi generates fire. Thus, treating the elderly resembles treating children: prioritize clearing and unblocking, aligning with the classic teaching that the fu organs transmit and transform without storing, functioning through unblocking. Xu Lingtai noted: "Millennium-old wood often burns itself due to yin exhaustion and fire flare-up, a natural law." Accumulated filth in ditches causes blockage. Understanding this, one sees that elderly diseases are not treated solely with warming tonics.
Wang Kentang of Jin Tan, over eighty, suffered from chronic spleen diarrhea. Warming tonics worsened his condition. Li Shicai of our county treated him with Ba Dou Shuang (Croton Seed Frost), purging several liters of phlegm-saliva, resulting in cure. This required Li's diagnostic skill and Wang's medical literacy to accept such treatment. Zhang Zihe stated: "Skilled practitioners treat excess first, then deficiency; mediocre ones treat either; erroneous ones make excess more excess and deficiency more deficient; only incompetent ones tonify deficiency and fear treating excess."
Once, someone contracted heart disease after a boat ride in the wind. The physician ground powder from hand-sweat accumulated on an old ship rudder and administered it, curing the patient. Using medicine by intuition seems playful but often hits the mark accurately, defying easy explanation. Lu Ling shared this with Su Dongpo, who laughed, "True. Burning a talented scholar's pen ash for a dull student to drink cures lethargy. Extending this, drinking water from Boyi's oath cures greed; eating Bi Gan's rice cures flattery; licking Fan Kuai's shield cures cowardice; smelling Xi Shi's earring cures severe disease?" Lu Ling laughed too. I argue this should not be taken too literally. Ancients often used herbs with similar forms or properties to reach the disease site, or relied purely on intuition, such as crossbow triggers accelerating birth, pestle chaff relieving dysphagia, rose monthly regulating menstruation, fans stopping sweat, snake venom guiding drugs upward, cicada slough removing corneal opacities. "Medicine is intention" fits this category. It shouldn't be judged by common sense, nor guaranteed to work. Those who are rigid invite ridicule from scholars like Dongpo.
Modern physicians seeing fever and rapid pulse often prescribe Chai Hu (Bupleuri Radix) and Ge Gen (Puerariae Lobatae Radix), believing dispersing pathogens ensures safety. They ignore that six exogenous pathogens manifest diversely; similar symptoms require different treatments. Warm pathogens contraindicate sweating; dampness contraindicates diaphoresis, as taught by ancients. Wang Jin San's *Gu Fang Xuan Zhu* compiles 113 Shang Han formulas, covering attacking, tonifying, warming, and cooling, not just releasing the exterior. Even for foot meridians, exterior-releasing methods should not be excessive. Profuse sweating during illness consumes primordial yang, leading to post-illness weakness. The *Shuo Bu* recounts Fan Yun serving Liang Dynasty Emperor Wu, awaiting investiture with Nine Bestowals. Falling ill with epidemic fever, he summoned Xu Wenbo for quick recovery. Wenbo warned recovery might prevent future treatment. Yun accepted, citing philosophical detachment. Wenbo heated the floor, laid peach and cypress leaves, and had Yun lie on them. Profuse sweating ensued, and Yun recovered next day. Two years later, Yun died suddenly. This illustrates the danger of excessive dispersion. Treating disease relies on medication, but differentiation is key. Clear differentiation brings confidence in prescribing.
During Yongle reign, Consort Zhang of the Eastern Palace missed her period for ten months, suspected pregnancy. Imperial Physician Sheng Qidong diagnosed non-pregnancy and prescribed blood-breaking herbs. The Crown Prince was angry, dismissing Sheng. A month later, illness worsened. Sheng was recalled, prescribed the same formula, but confined separately while the consort took it. Sheng's family feared execution, but Sheng remained calm. Three days later, loud cheers outside indicated Sheng received rich rewards. The consort expelled several dou of blood, and the illness resolved. True diagnostic insight removes hesitation in prescribing. Sheng Qidong was indeed a skilled physician.
The pulse theory in *Tai Su* analyzes the subtleties of Five Movements and the principles of creation, determining wealth, status, poverty, longevity, and mortality. This stems from understanding principles. Humans receive heaven-earth qi to live; five element qi hides in zang organs, connects to fu organs. In breathing, yin-yang opening/closing reveals creation's mysteries. Examining *Tai Su*, heart pulse is primary. The Heart is the master, governing bodily movement. Nobility/commonality depends on light/clear vs. heavy/turbid qi. Verses describe: "Clear, tight, elegant, surging heart pulse naturally leads to high office; smooth modulation without interruption brings lasting fortune and noble decrees." Clear pulse indicates clear spirit; turbid pulse indicates vulgar qi. Abundant prenatal qi yields vigorous spirit and full qi, resulting in clear, elegant, non-chaotic pulses indicative of nobility. Generally, men focus on Liver Wood (Xun position); women on Lung Metal (Dui position). Clear pulses are warm and moist like jade, distinct, neither sinking nor soggy, continuous. Turbid pulses are rough, spiritless, mixed rhythms, indistinct on pressure, like scattered dry sand, distinguishing status. Pulses divide into six positions with myriad variations, infinite yin-yang gathering/scattering and generation/restriction, profound as I Ching logic. Only those with innate wisdom can grasp their essentials.
Commoners rarely take medicine, so remedies show effect easily; elites take medicine preemptively, making treatment less effective when sick. Rich patients often see multiple doctors daily, competing for novelty, hoping for accidental success, leading to chaotic prescriptions and errors. A poem laments: "Deep halls hide unknown illnesses; noble bodies prompt doctors to try every prescription." Rich patients err from chaotic medicines; poor patients err from procrastination.