这一条路就是“临证察机，使药要和”。这个“机”是什么呢？这个“机”就是病机。临证的时候，首先是要察明病机，然后再根据这个病机来处方，使方药与病机相契合，这样一个看病的路子就是上工的路子。“临证察机，使药要和者，似迂而反捷”，这样的方法迂不迂呀？确实好像有点迂。病人来了，还要察什么机。心梗的病人一来我就用益气养阴、活血化瘀的协定方，这个很快呀，还察什么机。但，最后的结果呢？恐怕你那个益气养阴、活血化瘀的结果赶不上。这就是“似迂而反捷”啊。见一个咽痛，你就清热利咽，玄参、麦冬、桔梗、甘草，行不行呢？这样看起来快，看起来不“迂”，可实际的效果怎么样呢？相信大家都会有经历。前些天看一个病人，咽喉痛、声音嘶哑，要用笔来代口，浑身没力气，开什么方呢？光有这些还开不出方。你要是急着开什么山豆根、牛蒡子，你就成下工了，因为你“对病欲愈，执方欲加”嘛。你还要“临证察机”，不要急着用山豆根。当时，我为病人摸脉，发现两尺浮紧，紧属寒，浮是表，浮紧就是表寒，一个典型的太阳伤寒证。太阳伤寒用什么方？用麻黄汤。再看看舌象，舌苔白腻，苔腻是湿，所以病人浑身困倦乏力。于是我给她开了两剂麻黄汤加苍术。病人是晚上来诊的，诊前已经输过几天抗生素，但丝毫未见效果。开药以后，当晚煎服。第二天上午给我电话，咽痛十去七八，声音已经无碍，两剂尽后，诸证释然。大家想一想这个病例，明明是咽喉肿痛，用压舌板一看，咽部充血几个“+”，扁桃体肿大，应该清热，应该利咽，应该消肿，可你为什么偏偏不用这些，反而去“火上加油”呢？就是因为这个舌脉显示出病机是表寒，所以，要用温散表寒的麻黄汤。温散药一下去，寒解了，咽喉果然就不痛。这就是“临证察机，使药要和”。临床诊病就是这么一个过程。古人讲“必伏其所主而先其所因”，就是这个意思。前段时间还看过一个女学生，也是咽喉肿痛。她的咽喉肿痛到什么程度呢？三天两头要去吊针，要去打青霉素。人家油炸东西，她从那儿经过，咽喉就要肿痛，就要化脓，更别说吃了。现在好啦，不但闻到没问题，吃下去也没问题了。咽喉肿痛只是一个症状，不是诊断，没有理由就去用山豆根，就去用桔梗。你要获得一个诊断，你的治疗是对诊断负责，而不是对病人说的某个症状负责。炎症好像两个火，如果真的有火，那就应该清，用玄麦甘桔肯定好。火的表现是很明确的，你打开火看一看，明明显显的，看得见是红的，摸起来烫手。人身的火证也是这样，它有它的指征。而我看的这位学生，脸色青青的，唇淡、舌也淡，手冰冷，脉沉细。哪有一点火热的征象？根据这个舌脉，根据这个四诊的材料，这个人根本不可能有火。可是你看看前面医生开的，全是牛黄解毒、玄麦甘桔，都在清热利咽。看过这个病人，你就会明白，中医为什么没有疗效？这个病人我始终都在用扶阳的方法，开始用归芪建中汤，后来用附子理中汤。现在，不但咽喉不肿痛，体质也得到全面的改善。这个例子再一次告诉我们上工与下工的路子，它的区别在哪里。“临证察机”这个路子看起来迂回了，走了弯路，可是最后的结果却快捷得多，这正是“贤者之所得，愚者之所失也”。直接清热利咽，或者查查药典，看哪味药治咽痛，哪味药有抗菌消炎作用，这样看起来似乎直接一些，快一些，可实际呢？她按照这个路子搞了几年都没有搞好，从中学一直到大学还在吊针，还在吃牛黄解毒。而在这里仅仅服药一个月，什么都解决了，至少基本解决了，哪一个更快呢？所以，这是“贤者之所得，愚者之所失”。贤者之所以成为贤者，就是他按照这个方法去做了；而愚者之所以成为愚者，是因为他没有按照这个方法去做，是因为他失去了“临证察机”这个窍诀。我想大家从现在开始就应该希望做个贤者，不要做个愚者。而做个贤者的办法就是“临证察机”。今后对每一个病人都要临证察机，开始察不对这没关系，但，一定要履行这个手续，一定要朝着这个方向走。开始的准确性比较小，也许只有百分之十，但，慢慢地就会增加到百分之二十、三十，到了八十、九十，十愈八九了，我们就成了上工。大家应该具备这个信心，方法对了，只是时间问题。
二、临证察机
《皇汉医学》讲的“临证察机，使药要和”，可简称为“察机药和”。察机实际上就是求本，“察机药和”就是治病求本。机是病机，病是疾病，那么机呢？这个问题我们前面已经讨论过，机就是导致事物发生的关键要素。现在政要所在的地方为什么又称机关呢？当地要发展，看什么呢？就看那栋楼！因为它是党政机关所在。所以病机就是导致疾病发生的那个最关键的因素。这与病理变化这个面显然有很大的区别。原子弹的威力大不大？当然很大。可是这个启动按钮没必要搞得那么大，一点就行了。病机实际上就是这么一回事。
1.何以察机
病机的概念出自《素问》的“至真要大论”里。至，是至高无上；真，不是假的；要，重要。最真实不虚的，最重要的论述就在这一篇里。我们从病机放在这一篇，而不放在其他篇，就可以看出它确实是一个关键的因素。“至真要大论”在具体讲述病机前，有黄帝的一段引子：“夫百病之生也，皆生于风寒暑湿燥火，以之化之变也。经言盛者泻之，虚者补之，余锡以方士，而方士用之尚未能十全，余欲令要道必行，桴鼓相应，犹拔刺雪污，工巧神圣，可得闻乎？”黄帝在这段引子中讲到了百病产生的原因都离不开风寒暑湿燥火，然后在这个原因的基础上再产生其他的变化。虽然，我们看病的时候，也许看到的是这个变化后的疾病，好像它没有风寒暑湿，好像它没有“外感”，但是，这个最根本的原因大家不能忘记，不能含糊。所以，黄帝在这里说得很肯定。接下来黄帝又说，经典里明明说了，“盛者泻之，虚者补之”，可是我把这个方法告诉医生，医生在临床上用起来效果并不十分满意，疗效还达不到百分之百。我想把这样一个最真实不虚，最最重要的医道真正地流传下去，使医生能很快地把握它，用它来治病就好像拔刺雪污一样。临床治病究竟能不能像拔刺一样，像雪污一样，立竿见影，手到病除呢？是不是真有这样的方法？岐伯回答说：有！有这个方法，“审察病机，勿失气宜，此之谓也”。就这么一句话，你看病机多重要。审察好了，把握好了，治起疾病来就会像拔刺一样，就会像雪污一样，就这么简单。可是如果没有把握好，治起疾病来就没有办法做到这一点，临床就没有办法达到百分之百的疗效。那么，怎么样才能审察好病机呢？审察病机很关键的一点就是“勿失气宜”，要抓住“气宜”。这个提法在“至真要大论”里有两处，另一处说“谨候气宜，勿失病机”。可见两句话是互相关联的。实在地说，病机就是气宜，气宜就是病机，这两者讲的是一回事。那气宜是什么呢？就是前面讲的“风寒湿暑燥火”，就是六气，就是与六气相关的这些因素。审察病机，要勿失气宜，那么这个气宜怎么求呢？比如现在天阴了，要下雨了，这个气宜我们知道不知道？知道！这是湿来了。我们可以直接感受这个气宜的变化，在这个时候产生的疾病，不管它是什么病，都与这个气宜有关，抓住了这一点，不失去这一点，那你就抓住了病机。如果天气突然转冷，北风来了，这就是寒的气宜。上面这个气宜，我们可以很明显地感受到，这个气宜叫做外气宜，或者叫做显气宜。那么，还有另外一些我们不容易觉察出来的，那当然就叫做内气宜。或者叫隐气宜。这个气宜可以通过舌脉来体察。除此之外，是不是还有一个更加便于我们了解气宜的方法呢？实际上，整个《素问》的七篇大论就是讲的这个问题，这就要涉及运气这门专门的学问。在《素问》的第九篇“六节藏象论”里，有这样一段话：“不知年之所加，气之盛衰，虚实之所起，不可以为工。”这句话讲得非常严重。不可以为工是什么呢？就是不可以当医生。现在大家可以问问自己，你知道年之所加吗？不知道！可是不知道你还是在当医生，你还是要为工，这就是当今中医界的现状。年之所加，气之盛衰，虚实之所起，这就要谈到运气的问题。今年是庚辰年，那今年的年之所加是什么呢？庚本属金，而运气的干支讲化合，乙庚化金，所以，今年的年运是金运。年运确定以后，还要根据地支定出年气，今岁地支为辰，辰为太阳寒水司天，太阴湿土在泉。一个金运太过，一个寒水司天，一个湿土在泉，这就是今岁气宜的大框架。再详细一些的气宜，就要看主客加临，气有气的主客加临，运有运的主客加临。气分六步，运分五步，这就是五运六气的大体情况。我们临证求气宜，很大的一个方面就是要从这里面求。比如现在，现在已步入小雪节，是六气里面最后的一个气，也是五运里面最后的一个运。这时的主气是太阳寒水，客气是太阴湿土。凡是在这个区间患的病，不管你是什么病，都与以上这些气宜的综合作用相关。审察病机要考虑这些因素，治疗疾病也要考虑这些因素。这些因素不但会导致外感病，也会影响内伤病。因此，气宜不但外感病要求，内伤病也要求。懂得了气宜，懂得了上述气宜的综合作用，你就懂得了“年之所加，气之盛衰，虚实之所起”，你就可以为工。就是因为这一步，做医生的路就变得海阔天空，所以，运气这门学问很重要。南宁有一位名医叫曾邕生，也是我的一位师父，他就是整天研究这个“年之所加，虚实之所起”。早些年他自己开门诊，每天都要看一二百病人，多的时候看到三百多。单号看农村的，双号看城里的。一个人怎么能看这么多的病人？就是因为他知道这个“年之所加，气之盛衰，虚实之所起”。气宜清楚了，再一对照病人，病机就容易带出来，病机一出来，方药也就跟着出来。所以，病既看得快，也看得好。所以，病机的关键是气宜，而要抓住气宜，就要知道年之所加。
2.十九病机
这一条诊疗路径就是“临证察机，使药要和”。这个“机”是什么呢？这个“机”就是病机（疾病发生、发展与变化的关键机制）。在临床诊疗时，首先要查明病机，然后根据这个病机来处方，使方药与病机相契合，这样一个看病的路子就是高明医生（上工）的路子。“临证察机，使药要和者，似迂而反捷”，这样的方法迂回吗？确实好像有点迂回。病人来了，还要去探查什么病机。比如心肌梗死（心梗）的病人一来，我就直接用益气养阴、活血化瘀的协定方，这很快呀，还探查什么病机。但是，最后的结果呢？恐怕你那个益气养阴、活血化瘀的效果赶不上（通过辨证论治得出的效果）。这就是所谓的“看似迂回实则快捷”。见到一个咽喉痛，你就清热利咽，用玄参、麦冬、桔梗、甘草，行不行呢？这样看起来快，看起来不“迂”，可实际的效果怎么样呢？相信大家都有过经历。前些天我看一个病人，咽喉痛、声音嘶哑，需要用笔写字代替说话，浑身没力气，开什么方呢？光有这些症状还开不出方子。你要是急着开山豆根、牛蒡子，你就成了低水平医生（下工）了，因为你“对病欲愈，执方欲加”（为了治愈某种病名而固执地套用固定方药）。你还要“临证察机”，不要急着用山豆根。当时，我为病人摸脉，发现两尺脉浮紧，紧脉主寒，浮脉主表，浮紧就是表寒，这是一个典型的太阳伤寒证（外感风寒邪气侵袭体表所致的病证）。太阳伤寒用什么方？用麻黄汤（发汗解表，宣肺平喘的方剂）。再看看舌象，舌苔白腻，苔腻是湿，所以病人浑身困倦乏力。于是我给她开了两剂麻黄汤加苍术（燥湿健脾的药）。病人是晚上来就诊的，诊前已经输过几天抗生素，但丝毫未见效果。开药以后，当晚煎服。第二天上午给我电话，咽痛十去七八，声音已经无碍，两剂药吃完后，各种症状都消除了。大家想一想这个病例，明明是咽喉肿痛，用压舌板一看，咽部充血几个“+”，扁桃体肿大，应该清热，应该利咽，应该消肿，可你为什么偏偏不用这些，反而去“火上加油”呢？就是因为这个舌脉显示出病机是表寒，所以，要用温散表寒的麻黄汤。温散药一下去，寒邪解除了，咽喉果然就不痛了。这就是“临证察机，使药要和”。临床诊病就是这么一个过程。古人讲“必伏其所主而先其所因”，就是这个意思。前段时间还看过一个女学生，也是咽喉肿痛。她的咽喉肿痛到什么程度呢？三天两头要去吊针，要去打青霉素。人家油炸东西，她从那儿经过，咽喉就要肿痛，就要化脓，更别说吃了。现在好啦，不但闻到没问题，吃下去也没问题了。咽喉肿痛只是一个症状，不是诊断，没有理由就去用山豆根，就去用桔梗。你要获得一个诊断，你的治疗是对诊断负责，而不是对病人说的某个症状负责。炎症好像两个火，如果真的有火，那就应该清，用玄麦甘桔肯定好。火的表现是很明确的，你打开火看一看，明明显显的，看得见是红的，摸起来烫手。人身的火证也是这样，它有它的指征。而我看的这位学生，脸色青青的，唇淡、舌也淡，手冰冷，脉沉细。哪有一点火热的征象？根据这个舌脉，根据这个四诊（望、闻、问、切）的材料，这个人根本不可能有火。可是你看看前面医生开的，全是牛黄解毒、玄麦甘桔，都在清热利咽。看过这个病人，你就会明白，中医为什么没有疗效？这个病人我始终都在用扶阳的方法，开始用归芪建中汤（补气养血、温中补虚的方剂），后来用附子理中汤（温中祛寒、补气健脾的方剂）。现在，不但咽喉不肿痛，体质也得到全面的改善。这个例子再一次告诉我们上工与下工的路子，它的区别在哪里。“临证察机”这个路子看起来迂回了，走了弯路，可是最后的结果却快捷得多，这正是“贤者之所得，愚者之所失也”。直接清热利咽，或者查查药典，看哪味药治咽痛，哪味药有抗菌消炎作用，这样看起来似乎直接一些，快一些，可实际呢？她按照这个路子搞了几年都没有搞好，从中学一直到大学还在吊针，还在吃牛黄解毒。而在这里仅仅服药一个月，什么都解决了，至少基本解决了，哪一个更快呢？所以，这是“贤者之所得，愚者之所失”。贤者之所以成为贤者，就是他按照这个方法去做了；而愚者之所以成为愚者，是因为他没有按照这个方法去做，是因为他失去了“临证察机”这个窍诀。我想大家从现在开始就应该希望做个贤者，不要做个愚者。而做个贤者的办法就是“临证察机”。今后对每一个病人都要临证察机，开始察不对这没关系，但，一定要履行这个手续，一定要朝着这个方向走。开始的准确性比较小，也许只有百分之十，但，慢慢地就会增加到百分之二十、三十，到了八十、九十，十愈八九了，我们就成了上工。大家应该具备这个信心，方法对了，只是时间问题。
二、临证察机
《皇汉医学》讲的“临证察机，使药要和”，可简称为“察机药和”。察机实际上就是求本，“察机药和”就是治病求本（寻找疾病的根本原因并加以治疗）。机是病机，病是疾病，那么机呢？这个问题我们前面已经讨论过，机就是导致事物发生的关键要素。现在政要所在的地方为什么又称机关呢？当地要发展，看什么呢？就看那栋楼！因为它是党政机关所在。所以病机就是导致疾病发生的那个最关键的因素。这与病理变化这个面显然有很大的区别。原子弹的威力大不大？当然很大。可是这个启动按钮没必要搞得那么大，一点就行了。病机实际上就是这么一回事。
1.何以察机
病机的概念出自《素问》的“至真要大论”篇。至，是至高无上；真，不是假的；要，重要。最真实不虚的，最重要的论述就在这一篇里。我们从病机放在这一篇，而不放在其他篇，就可以看出它确实是一个关键的因素。“至真要大论”在具体讲述病机前，有黄帝的一段引子：“夫百病之生也，皆生于风寒暑湿燥火，以之化之变也。经言盛者泻之，虚者补之，余锡以方士，而方士用之尚未能十全，余欲令要道必行，桴鼓相应，犹拔刺雪污，工巧神圣，可得闻乎？”黄帝在这段引子中讲到了百病产生的原因都离不开风寒暑湿燥火，然后在这个原因的基础上再产生其他的变化。虽然，我们看病的时候，也许看到的是这个变化后的疾病，好像它没有风寒暑湿，好像它没有“外感”（外邪侵袭），但是，这个最根本的原因大家不能忘记，不能含糊。所以，黄帝在这里说得很肯定。接下来黄帝又说，经典里明明说了，“盛者泻之，虚者补之”，可是我把这个方法告诉医生，医生在临床上用起来效果并不十分满意，疗效还达不到百分之百。我想把这样一个最真实不虚，最最重要的医道真正地流传下去，使医生能很快地把握它，用它来治病就好像拔刺雪污一样。临床治病究竟能不能像拔刺一样，像雪污一样，立竿见影，手到病除呢？是不是真有这样的方法？岐伯回答说：有！有这个方法，“审察病机，勿失气宜，此之谓也”。就这么一句话，你看病机多重要。审察好了，把握好了，治起疾病来就会像拔刺一样，就会像雪污一样，就这么简单。可是如果没有把握好，治起疾病来就没有办法做到这一点，临床就没有办法达到百分之百的疗效。那么，怎么样才能审察好病机呢？审察病机很关键的一点就是“勿失气宜”，要抓住“气宜”（六气的适宜规律）。这个提法在“至真要大论”里有两处，另一处说“谨候气宜，勿失病机”。可见两句话是互相关联的。实在地说，病机就是气宜，气宜就是病机，这两者讲的是一回事。那气宜是什么呢？就是前面讲的“风寒湿暑燥火”，就是六气，就是与六气相关的这些因素。审察病机，要勿失气宜，那么这个气宜怎么求呢？比如现在天阴了，要下雨了，这个气宜我们知道不知道？知道！这是湿来了。我们可以直接感受这个气宜的变化，在这个时候产生的疾病，不管它是什么病，都与这个气宜有关，抓住了这一点，不失去这一点，那你就抓住了病机。如果天气突然转冷，北风来了，这就是寒的气宜。上面这个气宜，我们可以很明显地感受到，这个气宜叫做外气宜，或者叫做显气宜。那么，还有另外一些我们不容易觉察出来的，那当然就叫做内气宜。或者叫隐气宜。这个气宜可以通过舌脉来体察。除此之外，是不是还有一个更加便于我们了解气宜的方法呢？实际上，整个《素问》的七篇大论就是讲的这个问题，这就要涉及运气（五运六气学说）这门专门的学问。在《素问》的第九篇“六节藏象论”里，有这样一段话：“不知年之所加，气之盛衰，虚实之所起，不可以为工。”这句话讲得非常严重。不可以为工是什么呢？就是不可以当医生。现在大家可以问问自己，你知道年之所加吗？不知道！可是不知道你还是在当医生，你还是要为工，这就是当今中医界的现状。年之所加，气之盛衰，虚实之所起，这就要谈到运气的问题。今年是庚辰年，那今年的年之所加是什么呢？庚本属金，而运气的干支讲化合，乙庚化金，所以，今年的年运是金运。年运确定以后，还要根据地支定出年气，今岁地支为辰，辰为太阳寒水司天，太阴湿土在泉。一个金运太过，一个寒水司天，一个湿土在泉，这就是今岁气宜的大框架。再详细一些的气宜，就要看主客加临，气有气的主客加临，运有运的主客加临。气分六步，运分五步，这就是五运六气的大体情况。我们临证求气宜，很大的一个方面就是要从这里面求。比如现在，现在已步入小雪节气，是六气里面最后的一个气，也是五运里面最后的一个运。这时的主气是太阳寒水，客气是太阴湿土。凡是在这个区间患的病，不管你是什么病，都与以上这些气宜的综合作用相关。审察病机要考虑这些因素，治疗疾病也要考虑这些因素。这些因素不但会导致外感病，也会影响内伤病。因此，气宜不但外感病要求，内伤病也要求。懂得了气宜，懂得了上述气宜的综合作用，你就懂得了“年之所加，气之盛衰，虚实之所起”，你就可以为工。就是因为这一步，做医生的路就变得海阔天空，所以，运气这门学问很重要。南宁有一位名医叫曾邕生，也是我的一位师父，他就是整天研究这个“年之所加，虚实之所起”。早些年他自己开门诊，每天都要看一二百病人，多的时候看到三百多。单号看农村的，双号看城里的。一个人怎么能看这么多的病人？就是因为他知道这个“年之所加，气之盛衰，虚实之所起”。气宜清楚了，再一对照病人，病机就容易带出来，病机一出来，方药也就跟着出来。所以，病既看得快，也看得好。所以，病机的关键是气宜，而要抓住气宜，就要知道年之所加。
2.十九病机
This therapeutic path is "observe the pathogenesis during clinical practice, and ensure harmony between medicine and pathology." What is this "pathogenesis" (Ji, the key mechanism of disease occurrence)? This "pathogenesis" refers to the pathogenesis (the key mechanism governing the occurrence, development, and transformation of diseases). During clinical diagnosis and treatment, one must first ascertain the pathogenesis, and then prescribe based on this pathogenesis, ensuring that the herbal formula aligns with the pathogenesis. Such an approach to treating patients is the method of a superior physician (Shang Gong). "Observing the pathogenesis during clinical practice and ensuring harmony between medicine and pathology seems circuitous but is actually expedient." Is this method circuitous? Indeed, it may seem somewhat so. When a patient arrives, why bother investigating the pathogenesis? For instance, when a patient with myocardial infarction (Xin Geng) arrives, I directly use a consensus prescription for replenishing Qi and nourishing Yin, and promoting blood circulation to remove stasis; this is fast, so why investigate the pathogenesis? However, what is the final outcome? Probably, the results of merely using prescriptions for replenishing Qi and nourishing Yin, and promoting blood circulation to remove stasis, will not match those achieved through syndrome differentiation. This is what is meant by "seemingly circuitous yet actually expedient." Upon seeing a case of sore throat, if you simply clear heat and benefit the throat using Xuanshen (Scrophulariae Radix), Maidong (Ophiopogonis Radix), Jiegeng (Platycodonis Radix), and Gancao (Glycyrrhizae Radix et Rhizoma), would that work? It appears fast and not "circuitous," but how is the actual effect? I believe everyone has experience with this. A few days ago, I treated a patient with sore throat and hoarseness who had to write instead of speak due to inability to vocalize, accompanied by general weakness. What prescription should be used? One cannot prescribe based solely on these symptoms. If you rush to prescribe Shandougen (Sophorae Tonkinensis Radix) or Niubangzi (Arctii Fructus), you become an inferior physician (Xia Gong), because you are "seeking cure for a specific disease name and rigidly adding fixed formulas." You must "observe the pathogenesis during clinical practice" and not rush to use Shandougen. At that time, while palpating the patient's pulse, I found both Chi (Cun-Kuan-Chi) positions floating and tight. A tight pulse indicates Cold, and a floating pulse indicates Exterior; thus, floating and tight signifies Exterior Cold, which is a typical Taiyang Shanghan syndrome (a disease pattern caused by exogenous Wind-Cold invading the exterior). What formula is used for Taiyang Shanghan? Mahuang Tang (Ephedra Decoction). Looking at the tongue coating, it was white and greasy; greasiness indicates Dampness, explaining the patient's general fatigue and heaviness. Therefore, I prescribed two doses of Mahuang Tang plus Cangzhu (Atractylodis Rhizoma). The patient visited in the evening and had received intravenous antibiotics for several days prior, with no effect whatsoever. After taking the decoction that night, she called me the next morning: her sore throat had improved by 70-80%, her voice was normal, and after finishing the two doses, all symptoms resolved. Consider this case: clearly, there was sore throat and swelling; upon examination with a tongue depressor, pharyngeal congestion was marked (+), and tonsils were enlarged. One might think clearing heat, benefiting the throat, and reducing swelling is necessary. Why did we not do that, but instead seemingly "add fuel to the fire"? Because the tongue and pulse indicated the pathogenesis was Exterior Cold, so we used Mahuang Tang to warm and disperse Exterior Cold. Once the warming and dispersing herbs took effect, the Cold was resolved, and indeed, the sore throat disappeared. This illustrates "observing the pathogenesis during clinical practice and ensuring harmony between medicine and pathology." Clinical diagnosis follows this process. As the ancients said, "One must subdue the dominant factor and address the root cause first," which means exactly this. Recently, I also treated a female student with sore throat. Her condition was so severe that she needed IV drips and penicillin injections every few days. Merely passing by places where food was being fried would trigger sore throat, swelling, and even suppuration, let alone eating such food. Now, fortunately, she has no problem smelling or eating them. Sore throat is merely a symptom, not a diagnosis. There is no reason to blindly use Shandougen or Jiegeng. Your treatment must be responsible for the diagnosis, not just for a symptom reported by the patient. Inflammation resembles fire; if there is true Fire, it should be cleared, and Xuanmai Ganjie Tang would certainly be effective. The manifestations of Fire are explicit: open the fire, and it is visibly red and hot to the touch. Similarly, Fire patterns in the human body have their specific indicators. However, the student I examined had a bluish complexion, pale lips and tongue, cold hands, and a deep, fine pulse. Where was any sign of Heat or Fire? Based on the tongue and pulse, and the four diagnostic methods (inspection, auscultation/olfaction, inquiry, and palpation), this person definitely did not have Fire. Yet, look at the prescriptions from previous doctors: they all used Niuhuang Jiedu Pian (Calculus Bovis and Rhubarb Detoxification Tablets) and Xuanmai Ganjie Tang, all aimed at clearing heat and benefiting the throat. After seeing this patient, you will understand why some TCM treatments lack efficacy. For this patient, I consistently used methods to support Yang. Initially, I used Guiqi Jianzhong Tang (Angelica and Astragalus Middle-Jian Replenishing Decoction), and later Fuzi Lizhong Tang (Aconite and Ginger Middle-Warming Decoction). Now, not only has the sore throat subsided, but her constitution has also comprehensively improved. This example again reveals the difference between the paths of superior and inferior physicians. The path of "observing the pathogenesis" may seem circuitous and indirect, but the final result is much more expedient. This is precisely "what the wise attain, and what the foolish lose." Directly clearing heat and benefiting the throat, or consulting pharmacopoeias to find herbs for sore throat or antibacterial/anti-inflammatory properties, seems direct and fast. But practically? She followed this path for years without success, still receiving IV drips and taking Niuhuang Jiedu from middle school through university. Here, within just one month of herbal medication, everything was resolved, or at least basically resolved. Which is faster? Thus, this is "what the wise attain, and what the foolish lose." The wise become wise because they follow this method; the foolish remain foolish because they do not, losing the key secret of "observing the pathogenesis during clinical practice." I hope everyone starts now to aspire to be wise rather than foolish. The way to be wise is "observing the pathogenesis during clinical practice." From now on, for every patient, one must observe the pathogenesis. Even if initial observations are incorrect, one must perform this procedure and move in this direction. Initial accuracy may be low, perhaps only 10%, but gradually it will increase to 20%, 30%, and eventually 80% or 90%. When eight or nine out of ten cases are cured successfully, we become superior physicians. Everyone should have confidence; with the correct method, it is merely a matter of time.
II. Observing Pathogenesis During Clinical Practice
"Huang Han Yi Xue" (Imperial Han Medicine) states "observe the pathogenesis during clinical practice, and ensure harmony between medicine and pathology," which can be abbreviated as "observe pathogenesis and harmonize medicine." Observing pathogenesis is essentially seeking the root ("Qiu Ben"), and "observing pathogenesis and harmonizing medicine" means treating diseases by addressing their root causes. Ji refers to pathogenesis, Bing refers to disease. So, what is Ji? We discussed this earlier: Ji is the key element leading to the occurrence of things. Why are government offices called "Ji Guan" (organs/agencies)? To develop locally, what do people look at? That building! Because it houses the party and government organs. Therefore, pathogenesis is the most critical factor leading to the occurrence of disease. This differs significantly from the broad aspect of pathological changes. Is the power of an atomic bomb great? Certainly. But the start button doesn't need to be large; a simple press suffices. Pathogenesis is essentially like this.
1. How to Observe Pathogenesis
The concept of pathogenesis originates from the chapter "Zhi Zhen Yao Da Lun" (Discourse on the Most Essential and Truest Principles) in Su Wen (Basic Questions). "Zhi" means supreme; "Zhen" means true (not false); "Yao" means important. The most authentic and crucial discussions are found in this chapter. The placement of pathogenesis in this chapter, rather than others, shows it is indeed a key factor. Before detailing pathogenesis in "Zhi Zhen Yao Da Lun," there is an introduction by Yellow Emperor: "The generation of hundreds of diseases all arises from Wind, Cold, Summer-Heat, Dampness, Dryness, and Fire, transforming and changing from them. The classics state: 'Excess is drained, deficiency is tonified.' I have bestowed this upon medical practitioners, yet their application is not yet perfect. I wish for this essential Dao to be practiced effectively, responding like drum and stick, removing spines and washing away filth, achieving divine skill. May I hear how?" In this introduction, Yellow Emperor explained that the causes of all diseases stem from Wind, Cold, Summer-Heat, Dampness, Dryness, and Fire, generating further changes from these causes. Although, in clinical practice, we may see diseases that have transformed, appearing devoid of Wind, Cold, etc., or seemingly lacking "exogenous pathogens," we must not forget or blur this fundamental cause. Thus, Yellow Emperor spoke definitively. He continued, stating that although classics say "Excess is drained, deficiency is tonified," when he taught this to doctors, clinical results were unsatisfactory, failing to reach 100% efficacy. He wished to pass down this most authentic and vital medical Dao so doctors could grasp it quickly, treating diseases as easily as removing spines or washing filth. Can clinical treatment truly be as immediate as removing spines or washing filth, curing diseases instantly upon hand contact? Is there such a method? Qibo answered: Yes! There is this method: "Examine and observe the pathogenesis, do not miss the suitability of Qi (Six Qi), this is it." Just this one sentence shows how important pathogenesis is. If examined and grasped well, treating diseases becomes as easy as removing spines or washing filth. However, if not grasped well, treatment cannot achieve this, and clinical efficacy cannot reach 100%. So, how to examine pathogenesis well? A key point in examining pathogenesis is "do not miss the suitability of Qi," meaning to grasp the "Qi Yi" (appropriateness/pattern of Six Qi). This phrase appears twice in "Zhi Zhen Yao Da Lun"; another instance says "Carefully await the suitability of Qi, do not miss the pathogenesis." These two statements are interrelated. Essentially, pathogenesis is Qi Yi, and Qi Yi is pathogenesis; they refer to the same thing. What is Qi Yi? It refers to the previously mentioned "Wind, Cold, Dampness, Summer-Heat, Dryness, and Fire," i.e., the Six Qi and related factors. To examine pathogenesis and not miss Qi Yi, how does one seek this Qi Yi? For example, if the sky is cloudy and rain is coming, do we know this Qi Yi? Yes! Dampness is arriving. We can directly perceive changes in Qi Yi. Diseases arising at this time, regardless of type, relate to this Qi Yi. Grasping and holding onto this point means grasping the pathogenesis. If the weather suddenly turns cold and north wind blows, this is the Qi Yi of Cold. The aforementioned Qi Yi is obvious and perceivable, called External Qi Yi or Manifest Qi Yi. Then, there are other less perceptible ones, called Internal Qi Yi or Hidden Qi Yi. This Qi Yi can be perceived through tongue and pulse. Besides, is there a more convenient method to understand Qi Yi? Actually, the Seven Great Discourses of Su Wen discuss this, involving the specialized study of Yun Qi (Five Movements and Six Qi). In the ninth chapter of Su Wen, "Liu Jie Zang Xiang Lun" (Discourse on the Six Sections and Viscera Manifestations), there is a passage: "Not knowing what is added by the year, the flourishing and declining of Qi, and the origin of excess and deficiency, one cannot serve as a physician." This statement is very serious. "Cannot serve as a physician" means one is unfit to be a doctor. Ask yourselves now: Do you know "what is added by the year"? No! Yet, not knowing, you still serve as doctors, which reflects the current status of the TCM field. "What is added by the year, the flourishing and declining of Qi, and the origin of excess and deficiency" relates to Yun Qi. This year is Geng Chen. What is "added by the year" this year? Geng belongs to Metal. In Yun Qi theory, Heavenly Stems combine: Yi and Geng transform into Metal. Thus, the annual movement (Yun) is Metal Movement. After determining annual Yun, Earthly Branches determine annual Qi. This year's branch is Chen. Chen corresponds to Solar Cold Water ruling the Heaven (Si Tian), and Taiyin Damp Earth ruling the Earth (Zai Quan). An excessive Metal Movement, Cold Water ruling Heaven, and Damp Earth ruling Earth form the framework of this year's Qi Yi. More detailed Qi Yi requires observing the superposition of Host and Guest. Qi has its Host-Guest superposition, and Yun has its own. Qi divides into six steps, Yun into five steps. This is the general situation of Five Movements and Six Qi. Seeking Qi Yi clinically largely involves understanding this. For example, we have entered the Xiaoxue (Minor Snow) solar term, the last of the Six Qi and the last of the Five Yun. The Host Qi here is Solar Cold Water, and the Guest Qi is Taiyin Damp Earth. Any illness occurring in this interval, regardless of type, relates to the combined effect of these Qi Yis. Examining pathogenesis must consider these factors, and treating diseases must also consider them. These factors not only cause exogenous diseases but also affect endogenous diseases. Therefore, Qi Yi applies to both exogenous and endogenous diseases. Understanding Qi Yi and its combined effects means understanding "what is added by the year, the flourishing and declining of Qi, and the origin of excess and deficiency," enabling one to serve as a physician. This step makes the physician's path vast and open, so Yun Qi studies are crucial. Zeng Yongsheng, a famous physician in Nanning and my master, spent his days studying "what is added by the year, and the origin of excess and deficiency." In early years, he ran a clinic, seeing 100-200 patients daily, up to 300. Odd-numbered days for rural patients, even-numbered days for urban patients. How could one person see so many? Because he knew "what is added by the year, the flourishing and declining of Qi, and the origin of excess and deficiency." With clear Qi Yi, comparing it with the patient brings out the pathogenesis easily. Once pathogenesis emerges, the formula follows. Thus, diseases are treated quickly and well. Therefore, the key to pathogenesis is Qi Yi, and grasping Qi Yi requires knowing "what is added by the year."
2. Nineteen Pathogeneses