成氏注以沉浮分阴阳为太阳少阴俱有紧脉但浮而紧者太阳也沉而紧者少阴也又论文但言寸口则不得以关前为阳关
后为阴故不得不以浮沉分之然古人所云寸口多兼关尺而言如难经及后章所云水下二刻一周循环当复寸口虚实见焉皆谓
手太阴之经渠穴也知此则不必曲为疏解而无诊下焦于寸部之谬矣此所言邪似是湿邪盖有天之湿雾露雨是也天本乎气故
中上中表中经络有地之湿水泥是也地本乎形故中下中里中筋骨今既明言清邪为雾露之气矣则所谓浊邪者非地之湿气而
河内经曰风者上先受之湿者下先受之又云清湿地气之中人也必从足始若浊邪是寒邪则足太阳当先受之不应独中下焦而
见足膝逆冷便溺妄出之证也或曰审尔则与湿痹脉证不同何也曰湿痹重而此轻惟重则湿气内流而趋下故其脉沉细其证关
节疼痛而烦身色如熏黄惟轻则所伤者阴冷之气而已故其脉紧其证头痛项强腰痛与伤寒同也惟浊邪中下焦则与伤寒异以
其径犯脏腑筋骨肌肉而不止于经络故耳内栗者身不战而但心惕惕然栗也难经论五邪以中湿为肾邪其病足胫寒而逆则此
云足膝逆冷为肾中湿邪明甚其便溺妄出者则河间所谓邪客于肾部手足厥阴之经廷孔郁结极甚而气血不能宣通则痿痹神
无所用故津液渗入膀胱而旋溺遗失不能收禁也然则治之奈何曰治天之湿当同司天法湿上甚而热者平以苦温佐以甘辛以
汗为效而止当于伤寒法中选用治地之湿当因在泉法湿淫于内治以苦热佐以酸淡以苦燥之以淡泄之如四逆白通之类亦可
也三焦者原气之别使主通行上中下之三气经历于五脏六腑也通行三气即纪氏所谓下焦禀真元之气即元气也上达至于中
焦中焦受水谷精悍之气化为荣卫荣卫之气与真元之气通行达于上焦也三焦通则上下内外左右皆通也今表气微虚里气微
急三焦相溷则内外不通矣上焦病则郁热内发而为口糜蚀龈中焦焦病则脾不能化胃之所纳而胃中为之浊胃中浊则无水谷
之精气以为荣无水谷之悍气以为卫而荣卫何由通也荣卫不通则血凝冱而不流矣夫人之所以生者荣卫耳荣卫不通而可以
久乎荣行脉中卫行脉外不能一时而通必有先后欲知荣与卫之孰为先通则于何而验之若卫气先通者必先小便赤黄而后发
痈脓若荣气先通者必先嚏 咽塞而后下血如豚肝也内经谓三焦者决渎之官水道通焉膀胱者州都之官津液藏焉气化则能
出矣夫岂独从下焦膀胱之气化而已肺主通调水道下输膀胱而脾病者九窍不通小便不利是小便亦从上中二焦之气化者也
故卫气通则小便赤黄也内经论嚏或因寒气下临心气上从或因热气下临肺气上从李明之云阳气不得出者曰塞阴气不得下
降者曰噎又曰塞者五脏之所主阴也血也噎者六腑之所主阳也气也二者皆由阴中伏阳而作也由此观之则嚏塞皆阴阳寒热
相搏之候耳故曰寒厥相逐为热所拥血凝自下状如豚肝卫气者温分肉充皮肤肥腠理司开阖故其通也以溃脓荣气者其津液
注之于脉化以为血以荣四末注五脏六腑故其通也以下血也若荣卫之气毕竟不通则阴阳俱厥脾气孤弱不能散精上归于肺
通调水道故五脏之液注下下焦不阖数至圊而难无气以出之故也脐中如筑拘急而痛肾间动气将绝故也故曰命将难全
脉阴阳俱紧者口中气出唇口干燥蜷卧足冷鼻中涕出舌上苔滑勿妄治也到七日以来其人微发热手足温者此为欲解或
到八日以上反大发热者此为难治其恶寒者必欲呕也腹内痛者必欲利也此脉此证表里阴阳混淆未的疑似之间慎勿妄投药
饵徐而俟之若七日之外当解之候微热手足温则为邪气解而自愈矣若八日以上当解不解反发大热此为逆证不可治也
脉阴阳俱紧至于吐利其脉独不解紧去人始能安此为欲解若脉迟至六七日不欲食此为晚发水停故也为未解食自可者
为欲解
成 脉阴阳俱紧为寒气甚于上下至于吐利之后紧脉不罢者为其脉独不解紧去则人安为欲解若脉迟至六七日不欲
食
者为吐利后脾胃大虚内经曰饮入于胃游溢精气上输于脾脾气散精上归于肺通调水道下输膀胱水精四布五经并行脾胃气
强则能输散水饮之气若脾胃气虚则水饮内停也所谓晚发者后来之疾也若至六七日而欲食者则脾胃已和寒邪已散故云欲
解○紧病脉当作三节看
病六七日手足三部脉皆至大烦而口噤不能言其人躁扰者必欲解也
成 烦热也传经之时病患身大烦口噤不能言内作躁扰则阴阳争胜若手足三部脉皆至为正气胜邪气微阳气复寒气
散
必欲解也
若脉和其人大烦目重睑内际黄者此为欲解也
成 脉经曰病患两目 中有黄色起者其病方愈病以脉为主若目黄大烦脉不和者邪胜也其病为进目黄大烦而脉和
者
为正气已和故云欲解
脉浮而数浮为风数为虚风为热虚为寒风虚相搏则洒淅恶寒也
成 内经曰有者为实无者为虚气并则无血血并则无气风则伤卫数则无血浮数之脉风邪并于卫卫胜则荣虚也卫为
阳
风搏于卫所以为热荣为阴荣气虚所以为寒风并于卫者发热恶寒之证具矣
张 古今皆以数脉为热今仲景以数脉为虚寒何也数则为虚乃阴阳偏负之理非专寒而专热也浮为阳浮数为阳虚沉
为
阴沉数为阴虚阳虚者则恶寒药用温热抑阴扶阳阴虚者则发热药用寒凉抑阳扶阴使二气平其病自愈且如病在表脉浮而数
乃阴盛阳虚汗之则愈下之则死病在里脉沉而数乃阳盛阴虚下之则愈汗之则死经论昭然非有差别
脉浮而滑浮为阳滑为实阳实相搏其脉数疾卫气失度浮滑之脉数疾发热汗出者此为不治
成 浮为邪气并于卫而卫气胜滑为邪气并于荣而荣气实邪气胜实拥于荣卫则荣卫行速故脉数疾一息六至曰数平
人
脉一息四至卫气行六寸今一息六至则卫气行九寸计过平人之半是脉数疾知卫气失其常度也浮滑数疾之脉发热汗出而当
解若不解者精气脱也必不可治经曰脉阴阳俱盛大汗出不解者死
伤寒咳逆上气其脉散者死谓其形损故也
成 千金方以喘嗽为咳逆上气者肺病散者心脉是心火刑于肺金也内经曰心之肺谓之死阴死阴之属不过三日而死
以
形见其损伤故也此内伤也
问曰脉有三部阴阳相乘荣卫血气在人体躬呼吸出入上下于中因息游布津液流通随时动作效象形容春弦秋浮冬沉夏
洪察色观脉大小不同一时之间变无常经尺寸参差或短或长上下乖错或存或亡病辄改易进退低昂心迷意惑动失纪纲愿为
具陈令得分明师曰子之所问道之根源脉有三部尺寸及关
成 寸为上部关为中部尺为下部按此下后人以为出王叔和今按脉经载张仲景论脉止此一条则知非叔和自撰也
荣卫流行不失衡铨
成 衡铨者称也可以称量轻重内经曰春应中规夏应中矩秋应中衡冬应中权荣行脉中卫行脉外荣卫与脉相随上下
应
四时不失其常度也
肾沉心洪肺浮肝弦此自经常不失铢分
成 肾北方水旺于冬而脉沉心南方火旺于夏而脉洪肺西方金旺于秋而脉浮肝东方木旺于春而脉弦此为经常铢分
之
不差也
出入升降漏刻周旋水下二刻一周循环
成 人身之脉计长一十六丈二尺一呼脉行三寸一吸脉行三寸一呼一吸为一息脉行六寸一日一夜漏水下百刻人一
万
三千五百息脉行八百一十丈五十度周于身则一刻之中人一百三十五息脉行八丈一尺水水下二刻人二百七十息脉行一十
六丈二尺一周于身也脉经之行终而复始若循环之无端也
当复寸口虚实见焉
成 经脉之始从中焦注于手太阴寸口二百七十息脉行一周身复还至于寸口寸口为脉之经始故以诊视虚实焉经曰
虚
实死生之要皆见于寸口之中
变化相乘阴阳相干风则浮虚寒则牢坚沉潜水蓄支饮急弦动则为痛数则热烦
成 风伤阳故脉浮虚寒伤阴故脉牢坚搐积于内者谓之水蓄故脉沉潜支散于外者谓之支饮故脉急弦动则阴阳相搏
相
搏则痛生焉数为阳邪气胜阳胜则热烦焉
设有不应知变所缘三部不同病各异端
成 脉与病不相应者必缘传变之所致三部以候五脏之气随部察其虚实焉
太过可怪不及亦然邪不空见中必有奸审察表里三焦别焉知其所舍消息诊看料度脏腑独见若神为子条记传与贤人
成 太过不及之脉皆有邪气干于正气审察在表在里入腑入脏随其所舍而治之
师曰呼吸者脉之头也
成 难经曰一呼脉行三寸一吸脉行三寸以脉随呼吸而行故言脉之头也此乃胗脉入门之要法
初持脉来疾去迟此出疾入迟名曰内实外虚也
成 外为阳内为阴内经曰来者为阳去者为阴是出以候外入以候内疾为有余有余则实迟为不足不足则虚来疾去迟
者
阳有余而阴不足故曰内虚外实来迟去疾者阳不足而阴有余故曰内实外虚
问曰上工望而知之中工问而知之下工脉而知之愿闻其说师曰病家人请云病患苦发热身体疼病患自卧师到诊其脉沉
而迟者知其瘥也何以知之表有病者脉当浮大今脉反沉迟故知愈也
成 望以观其形证问以知其病所苦脉以别其表里病苦发热身疼邪在表也当卧不安而脉浮数今病患自卧而脉沉迟
者
表邪缓也是有里脉而无表证则知表邪当愈也
假令病患云腹内卒痛病患自坐师到脉之浮而大者知其瘥也何以知之若里有病者脉当沉而细今脉浮大故知愈也
成 腹痛者里寒也痛甚则不能起而脉沉细今病患自坐而脉浮大者里寒散也是有表脉而无里证也则知里邪当愈是
望
证问病切脉三者相参而得之可为十全之医针经曰知一为上知二为神知三神且明矣
师曰病家人来请云病患发热烦极明日师到病患向壁卧此热已去也其脉已和故言已愈
发热烦极则不能静卧今向壁静卧知热已去
设令向壁卧闻师到不惊起而盼视若三言三止脉之咽唾者此诈病也设令脉自和处言汝病大重当须服吐下药针灸数十
百处乃愈
成 诈病者非善人以言恐之使其畏惧则愈医者意也此其是欤此非治法设为诈病规模彼以诈病此以诈治
师持脉病患欠者无病也
成 针经曰阳引而上阴引而下阴阳相引故欠阴阳不相引则病阴阳相引则和是欠者无病也
脉之呻者病也
成 呻呻吟之声身有所苦则然也
言迟者风也
成 风客于中则经络急舌强难运用也
摇头言者里痛也
成 里有病欲言则头为之战摇
行迟者表强也
成 表强者由筋络引急而行步不利也
坐而伏者短气也
成 短气里不和也故坐而喜伏
坐而下一脚者腰痛也
成 内经曰腰者身之大关节也腰痛为大关节不利故坐不能正下一脚以缓腰中之痛也
里实护腹如怀卵物者心痛也
成 心痛则不能伸仰护腹以按其痛
师曰伏气之病以意候之今月之内欲有伏气假令旧有伏气当须脉之若脉微弱者当喉中痛似伤非喉痹也病患云实咽中
痛今复欲下利
成 冬时感寒伏藏于经中不即发者谓之伏气至春分之时伏寒欲发故云今月之内欲有伏气假令伏气已发当须脉之
审
在何经得脉微弱者知邪在少阴少阴之脉循喉咙寒气客之必发咽痛肾司开阖少阴治在下焦寒邪内甚则开阖不治下焦不约
必成下利故云虽尔咽痛复欲下利
问曰人病恐怖者其脉何状师曰脉形如循丝累累然其面白脱色也
成 内经曰血气者人之神恐怖者血气不足而神气弱也脉形似循丝累累然面白脱色者针经曰血夺者色夭然不泽其
脉
空虚是知恐怖为血气不足
问曰人不饮其脉何类师曰其脉自涩唇口干燥也
成 涩为阴虽主亡津液而唇口干燥以阴为主内故不饮也此节疑有缺文
问曰人愧者其脉何类师曰脉浮而面色乍白乍赤
成 愧者羞也愧则神气怯弱故脉浮而面色改变不常也
问曰经说脉有三菽六菽重者何谓也师曰脉者人以指按之如三菽之重者肺气也如六菽之重者心气也如九菽之重者脾
气也如十二菽之重者肝气也按之至骨者肾气也
成 菽豆也难经曰如三菽之重与皮毛相得者肺部也如六菽之重与血脉相得者心部也如九菽之重与肌肉相得者脾
部
也如十二菽之重与筋平者肝部也按之至骨举指来疾者肾部也各随所主之分以候脏气
假令下利寸口关上尺中悉不见脉然尺中时一小见脉再举头者肾气也若见损脉来至为难治
成 脉经曰冷气在胃中故令脉不通下利不见脉则冷气客于脾胃今尺中时一小见为脾虚肾气所乘脉再举头者脾为
肾
所乘也宕尺中之脉更或减损为肾气亦衰脾复胜之鬼贼相形故云难治是脾胜不应时也
问曰脉有相乘有纵有横有逆有顺何也师曰水行乘火金行乘木名曰纵火行乘水木行乘金名曰横水行乘金火行乘木名
曰逆金行乘水木行乘火名曰顺也
成 金胜木水胜火纵者言纵任其气乘其所胜横者言其气横逆反乘所不胜也纵横与恣纵恣横之义通水为金子火为
木
子子行乘母其气逆也母行乘子其气顺也
问曰脉有残贼何谓也师曰脉有弦紧浮滑沉涩此六者名曰残贼能为诸脉作病也
成 为人病者名曰八邪风寒暑湿伤于外也饥饱劳逸伤于内也经脉者荣卫也荣卫者阴阳也其为诸经脉作病者必由
风
寒暑湿伤于荣卫客于阴阳之中风则脉浮寒则脉紧中暑则脉滑中湿则脉涩伤于阴则脉沉伤于阳则脉浮所以谓之残贼者伤
良曰残害良曰贼以能伤害正气也
问曰脉有灾怪何谓也师曰假令人病脉得太阳与形证相应因进汤服比进汤服后食顷病患乃大吐或下利腹中痛师曰我
成无己注:以脉的浮沉来区分阴阳,认为太阳病和少阴病都有紧脉,但浮而紧的是太阳病,沉而紧的是少阴病。又因为文中只提到“寸口”,不能简单地以关前为阳、关后为阴,所以不得不以浮沉来区分。然而古人所说的“寸口”往往兼指关部和尺部,如《难经》及本章后面所说“水下二刻,一周循环,当复寸口,虚实见焉”,都是指手太阴肺经的经渠穴。明白了这一点,就不必强行解释,从而避免了在寸部诊察下焦的谬误了。这里所说的邪气,似是湿邪,大概是指天上的湿气,即雾、露、雨等。天本乎气,所以中于上、中二焦,病在表、在经络;地本乎形,所以中于下焦,病在里、在筋骨。现在既然明确说清邪是雾露之气,那么所谓浊邪就不是地的湿气了。《黄帝内经》说:“风邪从上先受之,湿邪从下先受之。”又说:“清湿地气之中人也,必从足始。”如果浊邪是寒邪,那么足太阳膀胱经应当先受邪,不应唯独中伤下焦而出现足膝逆冷、大小便失禁的症状。有人问:既然如此,这与湿痹的脉证有什么不同呢?回答说:湿痹病情重,而此病较轻。只有病情重时,湿气才会内流并趋向下部,所以其脉沉细,症状是关节疼痛且烦躁,身体颜色像熏黄一样。只有病情轻时,所伤的只是阴冷之气,所以其脉紧,症状是头痛、项强、腰痛,与伤寒相同。只有浊邪中伤下焦时,才与伤寒不同,因为它直接侵犯脏腑、筋骨、肌肉,而不止于经络。
患者感到内心战栗,身体不颤抖,只是心里惊恐不安。《难经》论述五邪,以中湿为肾邪,其病表现为足胫寒冷且逆冷,所以此处说足膝逆冷,明显是肾中的湿邪。至于大小便失禁,则是刘河间所说的:邪气客于肾部及手足厥阴之经,导致廷孔(尿道口)郁结极甚,气血不能宣通,造成痿痹,神志功能无所用,所以津液渗入膀胱,随即溺尿遗失,不能收摄控制。那么如何治疗呢?回答说:治疗天之湿邪,应当同于司天之法,“湿上甚而热者,平以苦温,佐以甘辛,以汗为效而止”,应当在伤寒治法中选用。治疗地之湿邪,应当因应在泉之法,“湿淫于内,治以苦热,佐以酸淡,以苦燥之,以淡泄之”,如四逆汤、白通汤之类也可以。
三焦是原气的别使,主要通行上、中、下三部的真气,经历五脏六腑。通行三气,就是纪氏所说的下焦禀受真元之气,也就是元气。上达至中焦,中焦接受水谷精悍之气,化为营气和卫气。营卫之气与真元之气通行,达于上焦。三焦通畅,则上下内外左右都通畅。现在表气微虚,里气微急,三焦混杂混乱,导致内外不通。上焦有病,则郁热内发,出现口腔溃疡、牙龈腐蚀;中焦有病,则脾不能运化,胃所纳的食物无法消化,导致胃中浑浊。胃中浑浊,就没有水谷的精气作为营气,没有水谷的悍气作为卫气,那么营卫如何能通畅呢?营卫不通,血液就会凝滞冻结而不流动。人之所以生存,依靠的是营卫。营卫不通,能长久吗?营行脉中,卫行脉外,不可能同时通畅,必有先后顺序。想知道营与卫谁先通畅,从哪里验证呢?如果卫气先通,必定先出现小便赤黄,然后发生痈脓;如果营气先通,必定先打喷嚏、咽喉堵塞,然后下血,血色如猪肝一样。《内经》说:三焦是决渎之官,水道由此通畅;膀胱是州都之官,津液藏于此,气化后才能排出。这难道仅仅从下焦膀胱的气化而来吗?肺主通调水道,下输膀胱,而脾病患者九窍不通,小便不利,说明小便也依赖于上、中二焦的气化。所以卫气通畅则小便赤黄。《内经》论述打喷嚏,有的因寒气下临、心气上从,有的因热气下临、肺气上从。李东垣说:阳气不得出者称为“塞”,阴气不得下降者称为“噎”。又说:“塞”由五脏所主,属阴、属血;“噎”由六腑所主,属阳、属气。二者都是由阴中伏阳所致。由此看来,打喷嚏和噎塞都是阴阳寒热相搏的征候。所以说,寒厥相互追逐,被热邪所拥,血液凝滞自下,状如猪肝。卫气的作用是温煦分肉、充实皮肤、肥厚腠理、主管开阖,所以它的通畅表现为溃脓;营气的作用是将其津液注入脉中,化生为血,以荣养四肢百骸,灌注五脏六腑,所以它的通畅表现为下血。如果营卫之气终究不通,则阴阳俱厥,脾气孤弱,不能散精上归于肺,通调水道,所以五脏的津液注下,下焦不闭合,频繁去厕所却难以排出,这是因为没有气来推动的缘故。脐中感觉像被捣击一样,拘急而痛,这是肾间动气即将断绝的缘故。所以说生命难以保全。
脉象阴阳俱紧,口中呼气,唇口干燥,蜷缩而卧,足冷,鼻中流涕,舌上苔滑,不要妄加治疗。到了第七天,如果病人微微发热,手足温暖,这是将要痊愈的迹象。或者到了八日以上,反而大发热,这是难治。如果有恶寒,必定想呕吐;如果腹内痛,必定想腹泻。这种脉象和证候,表里阴阳混淆,处于未确定的疑似之间,千万不要妄投药物,慢慢等待。如果在七日之外,出现当解之候,微热、手足温,则是邪气解除而自愈。如果八日以上,当解不解,反而发大热,这是逆证,不可治。
脉象阴阳俱紧,直到出现吐利,如果脉象独独不解(仍紧),人才能够安宁,这是欲解。如果脉迟,到了六七日,不欲食,这是晚发,因为有水饮停聚,所以为未解。如果饮食正常,则是欲解。
成无己注:脉阴阳俱紧,说明寒气盛于上下。至于吐利之后,紧脉不罢,是因为脉象独独不解。紧脉消失,人才能安,这是欲解。如果脉迟,到了六七日,不欲食,是因为吐利后脾胃大虚。《内经》说:“饮入于胃,游溢精气,上输于脾,脾气散精,上归于肺,通调水道,下输膀胱,水精四布,五经并行。”如果脾胃气强,则能输散水饮之气;如果脾胃气虚,则水饮内停。所谓“晚发”,是指后来的疾病。如果到了六七日而想进食,则脾胃已和,寒邪已散,所以说欲解。○ 紧病脉当作三节来看待。
病至六七日,手足三部脉皆至(有力),大烦而口噤不能言,其人躁扰,必定要痊愈。
成无己注:烦热。在传经之时,病患身体大烦,口噤不能言,内部躁扰,这是阴阳争胜。如果手足三部脉皆至,说明正气胜,邪气微,阳气复,寒气散,必定要痊愈。
如果脉象调和,病人虽然大烦,但眼睑内侧发黄,这是欲解。
成无己注:《脉经》说:病患两目中有黄色起者,其病方愈。治病以脉为主。如果目黄、大烦、脉不和,是邪胜,病进。如果目黄、大烦而脉和,是正气已和,所以说欲解。
脉浮而数。浮为风,数为虚。风为热,虚为寒。风虚相搏,则洒淅恶寒。
成无己注:《内经》说:有者为实,无者为虚。气并则无血,血并则无气。风则伤卫,数则无血。浮数之脉,风邪并于卫,卫胜则荣虚。卫为阳,风搏于卫,所以为热;荣为阴,荣气虚,所以为寒。风并于卫,发热恶寒之证具备。
张景岳注:古今都以数脉为热,如今仲景以数脉为虚寒,为什么呢?数则为虚,是阴阳偏负的道理,并非专寒而专热。浮为阳,浮数为阳虚;沉为阴,沉数为阴虚。阳虚则恶寒,药用温热以抑阴扶阳;阴虚则发热,药用寒凉以抑阳扶阴。使二气平衡,病自愈。况且如病在表,脉浮而数,乃阴盛阳虚,汗之则愈,下之则死;病在里,脉沉而数,乃阳盛阴虚,下之则愈,汗之则死。经论昭然,并无差别。
脉浮而滑。浮为阳,滑为实。阳实相搏,其脉数疾,卫气失度。浮滑之脉,数疾发热汗出者,此为不治。
成无己注:浮为邪气并于卫而卫气胜,滑为邪气并于荣而荣气实。邪气胜实,壅拥于荣卫,则荣卫行速,故脉数疾。一息六至曰数。平人脉一息四至,卫气行六寸。今一息六至,则卫气行九寸,计过平人之半,是脉数疾,知卫气失其常度也。浮滑数疾之脉,发热汗出,而当解。若不解者,精气脱也,必不可治。《经》曰:脉阴阳俱盛大,汗出不解者死。
伤寒咳逆上气,其脉散者死,谓其形损故也。
成无己注:《千金方》以喘嗽为咳逆上气,者是肺病。散者,心脉也。是心火刑于肺金。《内经》说:心之肺谓之死阴,死阴之属不过三日而死。以形见其损伤,故也。此内伤也。
问曰:脉有三部,阴阳相乘,荣卫血气,在人体躬,呼吸出入,上下于中,因息游布,津液流通,随时动作,效象形容。春弦秋浮,冬沉夏洪,察色观脉,大小不同,一时之间,变无常经。尺寸参差,或短或长,上下乖错,或存或亡,病辄改易,进退低昂。心迷意惑,动失纪纲。愿为具陈,令得分明。师曰:子之所问,道之根源。脉有三部,尺寸及关。
成无己注:寸为上部,关为中部,尺为下部。按此下,后人以为出王叔和。今按《脉经》载张仲景论脉止此一条,则知非叔和自撰也。
荣卫流行,不失衡铨。
成无己注:衡铨者,秤也,可以称量轻重。《内经》说:春应中规,夏应中矩,秋应中衡,冬应中权。荣行脉中,卫行脉外,荣卫与脉相随,上下应四时,不失其常度也。
肾沉,心洪,肺浮,肝弦,此自经常,不失铢分。
成无己注:肾北方水,旺于冬而脉沉;心南方火,旺于夏而脉洪;肺西方金,旺于秋而脉浮;肝东方木,旺于春而脉弦。此为经常,铢分之不差也。
出入升降,漏刻周旋,水下二刻,一周循环。
成无己注:人身之脉计长一十六丈二尺。一呼脉行三寸,一吸脉行三寸,一呼一吸为一息,脉行六寸。一日一夜漏水下百刻,人一萬三千五百息,脉行八百一十丈,五十度周于身。则一刻之中,人一百三十五息,脉行八丈一尺。水下二刻,人二百七十息,脉行一十六丈二尺,一周于身也。脉经之行,终而复始,若循环之无端也。
当复寸口,虚实见焉。
成无己注:经脉之始,从中焦注于手太阴寸口。二百七十息,脉行一周身,复还至于寸口。寸口为脉之经始,故以诊视虚实焉。《经》曰:虚实死生之要,皆见于寸口之中。
变化相乘,阴阳相干。风则浮虚,寒则牢坚。沉潜水蓄,支饮急弦。动则为痛,数则热烦。
成无己注:风伤阳,故脉浮虚;寒伤阴,故脉牢坚。搐积于内者谓之水蓄,故脉沉潜;支散于外者谓之支饮,故脉急弦。动则阴阳相搏,相搏则痛生焉。数为阳邪气胜,阳胜则热,烦焉。
设有不应,知变所缘。三部不同,病各异端。
成无己注:脉与病不相应者,必缘传变之所致。三部以候五脏之气,随部察其虚实焉。
太过可怪,不及亦然。邪不空见,中必有奸。审察表里,三焦别焉。知其所舍,消息诊看,料度脏腑,独见若神。为子条记,传与贤人。
成无己注:太过不及之脉,皆有邪气干于正气。审察在表在里,入腑入脏,随其所舍而治之。
师曰:呼吸者,脉之头也。
成无己注:《难经》说:一呼脉行三寸,一吸脉行三寸。以脉随呼吸而行,故言脉之头也。此乃诊脉入门之要法。
初持脉,来疾去迟,此出疾入迟,名曰内实外虚也。
成无己注:外为阳,内为阴。《内经》说:来者为阳,去者为阴。是出以候外,入以候内。疾为有余,有余则实;迟为不足,不足则虚。来疾去迟者,阳有余而阴不足,故曰内虚外实。来迟去疾者,阳不足而阴有余,故曰内实外虚。(注:原文此处逻辑似有矛盾,通常来疾去迟为外实内虚,来迟去疾为内实外虚,译文依原文直译,但需注意中医理论中“来”指脉搏升起,“去”指脉搏回落。原文成注解释为“来疾去迟...故曰内虚外实”,后文又提“来迟去疾...故曰内实外虚”,此处依原文文字翻译。)
问曰:上工望而知之,中工问而知之,下工脉而知之。愿闻其说。师曰:病家人请云:病患苦发热,身体疼。病患自卧。师到,诊其脉沉而迟者,知其瘥也。何以知之?表有病者,脉当浮大。今脉反沉迟,故知愈也。
成无己注:望以观其形证,问以知其病所苦,脉以别其表里。病苦发热身疼,邪在表也。当卧不安而脉浮数。今病患自卧而脉沉迟者,表邪缓也。是有里脉而无表证,则知表邪当愈也。
假令病患云:腹内卒痛。病患自坐。师到,脉之浮而大者,知其瘥也。何以知之?若里有病者,脉当沉而细。今脉浮大,故知愈也。
成无己注:腹痛者,里寒也。痛甚则不能起而脉沉细。今病患自坐而脉浮大者,里寒散也。是有表脉而无里证也,则知里邪当愈。是望证、问病、切脉三者相参而得之,可为十全之医。《针经》曰:知一为上,知二为神,知三神且明矣。
师曰:病家人来请云:病患发热烦极。明日,师到,病患向壁卧,此热已去也。其脉已和,故言已愈。发热烦极,则不能静卧。今向壁静卧,知热已去。
设令向壁卧,闻师到,不惊起而盼视,若三言三止,脉之咽唾者,此诈病也。设令脉自和,处言汝病大重,当须服吐下药,针灸数十百处,乃愈。
成无己注:诈病者,非善人。以言恐之,使其畏惧,则愈。医者意也,此其是欤?此非治法,设为诈病规模,彼以诈病,此以诈治。
师持脉,病患欠者,无病也。
成无己注:《针经》说:阳引而上,阴引而下,阴阳相引,故欠。阴阳不相引则病,阴阳相引则和。是欠者,无病也。
脉之呻者,病也。
成无己注:呻,呻吟之声。身有所苦,则然也。
言迟者,风也。
成无己注:风客于中,则经络急,舌强难运用也。
摇头言者,里痛也。
成无己注:里有病,欲言,则头为之战摇。
行迟者,表强也。
成无己注:表强者,由筋络引急,而行步不利也。
坐而伏者,短气也。
成无己注:短气,里不和也。故坐而喜伏。
坐而下一脚者,腰痛也。
成无己注:《内经》说:腰者,身之大关节也。腰痛为大关节不利,故坐不能正,下一脚以缓腰中之痛也。
里实护腹,如怀卵物者,心痛也。
成无己注:心痛则不能伸仰,护腹以按其痛。
师曰:伏气之病,以意候之。今月之内,欲有伏气。假令旧有伏气,当须脉之。若脉微弱者,当喉中痛,似伤非喉痹也。病患云实咽中痛,今复欲下利。
成无己注:冬时感寒,伏藏于经中,不即发者,谓之伏气。至春分之时,伏寒欲发,故云今月之内欲有伏气。假令伏气已发,当须脉之,审在何经。得脉微弱者,知邪在少阴。少阴之脉循喉咙,寒气客之,必发咽痛。肾司开阖,少阴治在下焦,寒邪内甚,则开阖不治,下焦不约,必成下利。故云虽尔咽痛,复欲下利。
问曰:人病恐怖者,其脉何状?师曰:脉形如循丝累累然,其面白脱色也。
成无己注:《内经》说:血气者,人之神。恐怖者,血气不足而神气弱也。脉形似循丝累累然,面白脱色者,《针经》说:血夺者,色夭然不泽,其脉空虚。是知恐怖为血气不足。
问曰:人不饮,其脉何类?师曰:其脉自涩,唇口干燥也。
成无己注:涩为阴,虽主亡津液,而唇口干燥以阴为主内,故不饮也。此节疑有缺文。
问曰:人愧者,其脉何类?师曰:脉浮而面色乍白乍赤。
成无己注:愧者,羞也。愧则神气怯弱,故脉浮而面色改变不常也。
问曰:经说脉有三菽、六菽重者,何谓也?师曰:脉者,人以指按之,如三菽之重者,肺气也;如六菽之重者,心气也;如九菽之重者,脾气也;如十二菽之重者,肝气也;按之至骨者,肾气也。
成无己注:菽,豆也。《难经》说:如三菽之重,与皮毛相得者,肺部也;如六菽之重,与血脉相得者,心部也;如九菽之重,与肌肉相得者,脾部也;如十二菽之重,与筋平者,肝部也;按之至骨,举指来疾者,肾部也。各随所主之分,以候脏气。
假令下利,寸口、关上、尺中悉不见脉,然尺中时一小见,脉再举头者,肾气也。若见损脉来至,为难治。
成无己注:《脉经》说:冷气在胃中,故令脉不通。下利不见脉,则冷气客于脾胃。今尺中时一小见,为脾虚肾气所乘。脉再举头者,脾为肾所乘也。宕尺中之脉,更或减损,为肾气亦衰,脾复胜之,鬼贼相形,故云难治。是脾胜不应时也。
问曰:脉有相乘,有纵,有横,有逆,有顺,何也?师曰:水行乘火,金行乘木,名曰纵;火行乘水,木行乘金,名曰横;水行乘金,火行乘木,名曰逆;金行乘水,木行乘火,名曰顺也。
成无己注:金胜木,水胜火,纵者,言纵任其气乘其所胜。横者,言其气横逆,反乘所不胜也。纵横与恣纵、恣横之义通。水为金之子,火为木之子。子行乘母,其气逆也;母行乘子,其气顺也。
问曰:脉有残贼,何谓也?师曰:脉有弦、紧、浮、滑、沉、涩,此六者,名曰残贼,能为诸脉作病也。
成无己注:为人病者,名曰八邪。风寒暑湿,伤于外也;饥饱劳逸,伤于内也。经脉者,荣卫也;荣卫者,阴阳也。其为诸经脉作病者,必由风寒暑湿伤于荣卫,客于阴阳之中。风则脉浮,寒则脉紧,中暑则脉滑,中湿则脉涩,伤于阴则脉沉,伤于阳则脉浮。所以谓之残贼者,伤良曰残,害良曰贼,以能伤害正气也。
问曰:脉有灾怪,何谓也?师曰:假令人病,脉得太阳,与形证相应,因进汤服。比进汤服后,食顷,病患乃大吐,或下利,腹中痛。师曰:我
Cheng Wuji's commentary: Differentiating Yin and Yang by the floating (Fu) and sinking (Chen) qualities of the pulse, it is stated that both Taiyang (Greater Yang) and Shaoyin (Lesser Yin) syndromes present with a tight (Jin) pulse. However, a floating and tight pulse indicates a Taiyang syndrome, while a sinking and tight pulse indicates a Shaoyin syndrome. Furthermore, since the text only mentions the Cun Kou (Inch Port), one cannot simply define the area anterior to the Guan (Bar) as Yang and the area posterior to the Guan as Yin; thus, differentiation must rely on floating versus sinking. Nevertheless, what the ancients referred to as "Cun Kou" often included the Guan and Chi (Cubit) positions. For instance, as mentioned in the *Nan Jing* (Classic of Difficult Issues) and later in this chapter: "When water drops two marks, the circulation completes one cycle, returning to the Cun Kou, where deficiency and excess become apparent." This refers to the Jing-Well point Jingqu (LU8) of the Hand-Taiyin Lung Meridian. Understanding this avoids forced interpretations and prevents the error of diagnosing the Lower Jiao at the Cun position. The pathogenic factor described here seems to be dampness, likely referring to heavenly dampness such as fog, dew, and rain. Heaven is based on Qi; thus, invasion affects the Upper and Middle Jiao, manifesting in the exterior and meridians. Earth is based on Form; thus, invasion affects the Lower Jiao, manifesting in the interior and sinews/bones. Since it is explicitly stated that clear pathogenic factors are fog and dew, the so-called turbid pathogenic factor is not earthly dampness. The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: "Wind pathogens affect the upper part first; damp pathogens affect the lower part first." It also says: "Invasion by clear cold and damp earthy qi always begins from the feet." If the turbid pathogen were cold, the Foot-Taiyang Bladder Meridian should be affected first, rather than solely affecting the Lower Jiao with symptoms of coldness in the feet and knees and incontinence of urine and feces. One might ask: If so, how does this differ from the pulse and symptoms of Damp Bi (Dampness Obstruction)? The answer is: Damp Bi is severe, whereas this condition is mild. Only when severe does dampness flow inward and tend downward, resulting in a sinking and fine pulse, joint pain with restlessness, and a body color resembling smoked yellow. When mild, only the Yin-cold qi is injured, resulting in a tight pulse, headache, neck stiffness, and lower back pain, similar to Cold Damage (Shanghan). Only when the turbid pathogen attacks the Lower Jiao does it differ from Cold Damage, because it directly invades the Zang-Fu organs, sinews, bones, muscles, and skin, not merely the meridians.
The patient feels inner trembling, without bodily shivering, but with mental palpitations and fear. The *Nan Jing* discusses the Five Pathogens, identifying dampness invasion as a Kidney pathogen, with symptoms of coldness and reversal in the lower legs and calves. Thus, the mention of coldness and reversal in the feet and knees clearly indicates dampness in the Kidney. Regarding incontinence, Liu Hejian stated: "When pathogens invade the Kidney region and the Jueyin meridians of the hand and foot, the urethral orifice becomes extremely congested, preventing the free flow of Qi and Blood, leading to flaccidity and paralysis. With no functional use of the Shen (Spirit), fluids seep into the Bladder, causing involuntary urination and loss of control." How then should it be treated? The answer is: To treat heavenly dampness, follow the method of Si Tian (Sovereign Heaven): "For dampness excessive above with heat, level it with bitter-warm herbs, assist with sweet-acrid ones, aiming for sweating as the effect and stopping thereafter." Select from Cold Damage treatments. To treat earthly dampness, follow the method of Zai Quan (Host Earth): "For dampness overflowing within, treat with bitter-hot herbs, assist with sour-pale ones, dry with bitter, drain with pale." Decoctions like Sini Tang (Frigid Extremities Decoction) or Baitong Tang may also be used.
The San Jiao (Triple Burner) is the special envoy of Yuan Qi (Source Qi), responsible for circulating the Qi of the Upper, Middle, and Lower Jiao through the Zang-Fu organs. Circulating these three Qis aligns with Ji Shi's description: the Lower Jiao receives the True Yuan Qi (Primordial Qi), which ascends to the Middle Jiao. The Middle Jiao receives the essence of food and drink, transforming it into Ying (Nutritive) and Wei (Defensive) Qi. Ying and Wei Qi, combined with Primordial Qi, circulate to the Upper Jiao. When the San Jiao is unobstructed, the upper, lower, interior, and exterior, left and right all communicate. Currently, the exterior Qi is slightly deficient, and the interior Qi is slightly urgent. The San Jiao is confused and mixed, leading to obstruction between interior and exterior. Disease in the Upper Jiao causes stagnant heat to arise internally, resulting in mouth ulcers and gum erosion. Disease in the Middle Jiao impairs the Spleen's transformation and Stomach's reception, causing turbidity in the Stomach. Turbidity in the Stomach means there is no essence from food and drink to serve as Ying Qi, nor is there heroic Qi to serve as Wei Qi. How can Ying and Wei Qi then circulate? If Ying and Wei Qi do not circulate, blood coagulates and freezes, ceasing to flow. Human life depends on Ying and Wei Qi. Can one survive long if Ying and Wei Qi do not circulate? Ying circulates within the vessels, and Wei circulates outside; they cannot become unobstructed simultaneously but have a sequence. To know whether Ying or Wei Qi becomes unobstructed first, how can we verify it? If Wei Qi becomes unobstructed first, there will first be dark yellow urine, followed by the formation of abscesses and pus. If Ying Qi becomes unobstructed first, there will first be sneezing and throat blockage, followed by bloody stool resembling pig liver. The *Neijing* states: "The San Jiao is the official of dredging, ensuring the smooth flow of waterways; the Bladder is the official of the capital, storing fluids, which are excreted only after Qi transformation." Does this not imply that it relies solely on the Qi transformation of the Lower Jiao Bladder? The Lungs govern the regulation of waterways, directing them downward to the Bladder. In Spleen disease, the nine orifices are obstructed, and urination is difficult, indicating that urination also depends on the Qi transformation of the Upper and Middle Jiao. Therefore, when Wei Qi is unobstructed, urine is dark yellow. The *Neijing* discusses sneezing: sometimes caused by cold Qi descending and Heart Qi ascending, or hot Qi descending and Lung Qi ascending. Li Dongyuan said: "When Yang Qi cannot exit, it is called 'Se' (Obstruction); when Yin Qi cannot descend, it is called 'Ye' (Choking)." He further stated: "'Se' is governed by the Five Zang organs, belonging to Yin and Blood; 'Ye' is governed by the Six Fu organs, belonging to Yang and Qi." Both arise from Yang hidden within Yin. From this, we see that sneezing and choking are signs of clashing between Yin/Yang and Cold/Heat. Thus, it is said: "Cold jue chasing each other,擁ed by Heat, blood coagulates and flows down, resembling pig liver." Wei Qi warms the flesh, fills the skin, thickens the pores, and controls opening and closing; thus, its unobstruction manifests as pus discharge. Ying Qi injects its fluids into the vessels to transform into blood, nourishing the four extremities and infusing the Zang-Fu organs; thus, its unobstruction manifests as bloody stool. If Ying and Wei Qi ultimately remain obstructed, both Yin and Yang experience jue (reversal/collapse). The Spleen Qi becomes isolated and weak, unable to scatter essence upward to the Lungs to regulate waterways. Consequently, fluids from the Five Zang organs flow downward, the Lower Jiao fails to close, frequent trips to the toilet occur with difficulty in passing, due to lack of Qi to push. The navel feels like being pounded, with tension and pain, indicating the impending extinction of the動 Qi (Moving Qi) between the Kidneys. Thus, it is said that life is hard to preserve.
If the pulse is tight in both Yin and Yang positions, with breath issuing from the mouth, dry lips and tongue, curled-up posture, cold feet, runny nose, and a slippery coating on the tongue, do not treat rashly. After seven days, if the patient has slight fever and warm hands and feet, this indicates recovery. Or, if after eight days, there is instead high fever, this is difficult to treat. If there is aversion to cold, vomiting is likely; if there is abdominal pain, diarrhea is likely. With this pulse and these symptoms, where interior/exterior and Yin/Yang are confused and uncertain, do not administer medicine rashly; wait patiently. If beyond the seventh day, signs of resolution appear—slight fever and warm hands and feet—it means the pathogen is resolving and self-healing. If beyond the eighth day, resolution does not occur, and high fever develops instead, this is a counter-indication and incurable.
If the pulse is tight in both Yin and Yang positions, continuing through vomiting and diarrhea, if the pulse remains tight (unresolved), the person can only find peace when the tightness disappears, indicating recovery. If the pulse is slow, reaching six or seven days with anorexia, this is a late onset due to fluid retention, indicating non-recovery. If appetite returns, it indicates recovery.
Cheng Wuji's commentary: A tight pulse in both Yin and Yang positions indicates severe cold affecting the upper and lower. After vomiting and diarrhea, if the tight pulse persists, it is because the pulse alone remains unresolved. When the tightness disappears, the person finds peace, indicating recovery. If the pulse is slow, reaching six or seven days with anorexia, it is due to great deficiency of the Spleen and Stomach after vomiting and diarrhea. The *Neijing* states: "Fluids enter the Stomach, their essence floats up, is transported to the Spleen, scattered by the Spleen, returned to the Lungs, regulates waterways, descends to the Bladder, distributes water essence everywhere, and runs through the five meridians." If Spleen and Stomach Qi are strong, they can transport and disperse fluid-dampness. If Spleen and Stomach Qi are deficient, fluid-dampness stagnates internally. "Late onset" refers to subsequent illness. If by six or seven days the patient desires food, the Spleen and Stomach have harmonized, and cold pathogens have dispersed, hence "recovery." ○ The tight pulse disease should be read in three sections.
After six or seven days of disease, if the pulses at the three positions of the hands and feet are all present (strong), accompanied by great vexation, lockjaw, inability to speak, and restlessness, recovery is certain.
Cheng Wuji's commentary: Vexation and heat. During transmission of meridians, if the patient has great bodily vexation, lockjaw, inability to speak, and internal restlessness, this is a struggle between Yin and Yang. If the pulses at the three positions of the hands and feet are all present, it indicates righteous Qi prevails, pathogenic Qi is weak, Yang Qi recovers, and cold disperses; recovery is certain.
If the pulse is harmonious, and although the patient is greatly vexed, the inner aspect of the eyelids shows yellow, this indicates recovery.
Cheng Wuji's commentary: The *Mai Jing* (Pulse Classic) states: "If yellow appears in the eyes of the patient, the disease is about to heal." Treatment prioritizes the pulse. If the eyes are yellow, there is great vexation, and the pulse is discordant, pathogenic Qi prevails, and the disease progresses. If the eyes are yellow, there is great vexation, but the pulse is harmonious, righteous Qi has harmonized, hence "recovery."
A floating and rapid pulse. Floating indicates Wind; Rapid indicates Deficiency. Wind generates Heat; Deficiency generates Cold. The clash of Wind and Deficiency causes chills and shivering.
Cheng Wuji's commentary: The *Neijing* states: "Having is Excess; Not having is Deficiency." When Qi combines, Blood is lacking; when Blood combines, Qi is lacking. Wind injures Wei (Defensive) Qi; Rapid pulse indicates lack of Blood. In a floating-rapid pulse, Wind pathogen combines with Wei Qi, making Wei Qi victorious and Ying (Nutritive) Qi deficient. Wei is Yang; Wind combats Wei, causing Heat. Ying is Yin; Ying Qi deficiency causes Cold. Wind combining with Wei results in both fever and aversion to cold.
Zhang Jingyue's commentary: Ancient and modern practitioners consider the rapid pulse as Heat. Why does Zhang Zhongjing consider it Deficient-Cold? Rapid indicates Deficiency, reflecting the principle of Yin-Yang imbalance, not exclusively Cold or Heat. Floating is Yang; floating-rapid indicates Yang deficiency. Sinking is Yin; sinking-rapid indicates Yin deficiency. Yang deficiency causes aversion to cold; treat with warm-hot herbs to suppress Yin and support Yang. Yin deficiency causes fever; treat with cool-cold herbs to suppress Yang and support Yin. Balance the two Qi, and the disease heals naturally. Moreover, if the disease is in the exterior with a floating-rapid pulse, it is Yin excess and Yang deficiency; sweating cures it, purgation kills it. If the disease is in the interior with a sinking-rapid pulse, it is Yang excess and Yin deficiency; purgation cures it, sweating kills it. The classics are clear; there is no difference.
A floating and slippery pulse. Floating is Yang; Slippery is Excess. Yang and Excess clashing results in a rapid and hurried pulse, with Wei Qi losing its measure. With a floating-slippery pulse, rapid/hurried rate, fever, and sweating, this is untreatable.
Cheng Wuji's commentary: Floating indicates pathogen combining with Wei Qi, making Wei Qi victorious. Slippery indicates pathogen combining with Ying Qi, making Ying Qi excess. Pathogenic victory and excess congest Ying and Wei, accelerating their movement, hence the rapid/hurried pulse. Six beats per respiration is called Rapid. A healthy person has four beats per respiration, with Wei Qi moving six cun. Now, with six beats per respiration, Wei Qi moves nine cun, exceeding the healthy standard by half. Thus, the rapid/hurried pulse indicates Wei Qi has lost its normal measure. With a floating-slippery-rapid/hurried pulse, fever, and sweating, the disease should resolve. If it does not resolve, Essence and Qi are depleted, and it is incurable. The Classics state: "If Yin and Yang pulses are both full and large, and sweating does not resolve the disease, death ensues."
In Cold Damage, coughing and rebellious Qi rising with a scattered pulse indicates death, due to physical depletion.
Cheng Wuji's commentary: The *Qianjin Fang* identifies wheezing and coughing as coughing and rebellious Qi rising, a Lung disease. A scattered pulse is a Heart pulse. This indicates Heart Fire punishing Lung Metal. The *Neijing* states: "Heart affecting the Lung is called Dead Yin. Those belonging to Dead Yin die within three days." This is evident from the physical depletion. This is an internal injury.
Question: The pulse has three positions. Yin and Yang interact. Ying, Wei, Blood, and Qi reside in the body. Through breathing, entering and exiting, moving up and down, distributing via breath, and circulating fluids, they act according to time, showing effects and forms. Spring pulses are wiry, Autumn floating, Winter sinking, Summer surging. Observing color and pulse, sizes differ. Within a moment, changes have no fixed pattern. Cun and Chi vary, short or long, upper and lower mismatched, existing or absent. Diseases change, advancing or retreating. Confused and perplexed, losing guidelines, I wish you to explain fully so I may understand clearly. Master said: Your question touches the root of the Dao. The pulse has three positions: Cun, Chi, and Guan.
Cheng Wuji's commentary: Cun is the Upper position, Guan is the Middle, Chi is the Lower. Later scholars attribute this to Wang Shuhe. However, checking the *Mai Jing*, Zhang Zhongjing's pulse discussion ends with this single passage, proving it was not written by Shuhe himself.
Ying and Wei circulate freely, never losing balance.
Cheng Wuji's commentary: Heng and Quan refer to scales, used to weigh weight. The *Neijing* states: Spring corresponds to the compass, Summer to the square, Autumn to the balance, Winter to the weight. Ying circulates within vessels, Wei outside. Ying and Wei follow the vessels, responding to the four seasons, maintaining constant measures.
Kidney pulse sinks, Heart surges, Lung floats, Liver wiry. These are constant laws, never deviating by a hair's breadth.
Cheng Wuji's commentary: Kidney is Water of the North, flourishing in Winter with a sinking pulse. Heart is Fire of the South, flourishing in Summer with a surging pulse. Lung is Metal of the West, flourishing in Autumn with a floating pulse. Liver is Wood of the East, flourishing in Spring with a wiry pulse. These are constant laws, accurate to the smallest degree.
Entering and exiting, ascending and descending, cycles with water marks. Under two water marks, one complete cycle.
Cheng Wuji's commentary: The human pulse vessel is 16 zhang 2 chi long. One exhalation moves the pulse 3 cun; one inhalation moves it 3 cun. One breath (exhale-inhale) is one respiration, moving 6 cun. In one day and night, water drops 100 marks. The person takes 13,500 respirations, the pulse travels 810 zhang, completing 50 cycles around the body. In one mark, the person takes 135 respirations, the pulse travels 8 zhang 1 chi. Under two water marks, the person takes 270 respirations, the pulse travels 16 zhang 2 chi, completing one cycle around the body. Pulse circulation ends and restarts, like a circle without beginning or end.
Returning to the Cun Kou, deficiency and excess become apparent.
Cheng Wuji's commentary: Meridian Qi starts from the Middle Jiao, flowing to the Hand-Taiyin Cun Kou. In 270 respirations, the pulse completes one cycle around the body and returns to the Cun Kou. Cun Kou is the starting point of pulse diagnosis, thus used to examine deficiency and excess. The Classics state: The essentials of life and death in deficiency and excess are all seen in the Cun Kou.
Changes multiply upon each other; Yin and Yang interfere. Wind presents as floating-deficient; Cold as firm-solid. Sinking and submerged indicate water accumulation; branch-fluid presents as urgent-tight. Movement indicates pain; Rapid indicates heat and vexation.
Cheng Wuji's commentary: Wind injures Yang, hence the pulse is floating-deficient. Cold injures Yin, hence the pulse is firm-solid. Accumulated internally is called water accumulation, hence sinking/submerged pulse. Scattered externally is called branch-fluid, hence urgent-tight pulse. Movement indicates Yin-Yang clashing; clashing generates pain. Rapid indicates Yang pathogen victory; Yang victory generates heat and vexation.
If there is inconsistency, know the cause of change. Three positions differ; diseases have different origins.
Cheng Wuji's commentary: When pulse and disease do not correspond, it must be due to transmission changes. The three positions observe the Qi of the Five Zang organs; examine deficiency and excess according to the position.
Excess is strange; deficiency is likewise so. Pathogens do not appear empty; there must be treachery within. Examine interior and exterior; distinguish the San Jiao. Know where it resides, observe and diagnose, estimate the Zang-Fu, seeing uniquely like a spirit. Record these details for you, to pass on to worthy men.
Cheng Wuji's commentary: Excess and deficiency pulses all involve pathogens interfering with righteous Qi. Examine whether it is in the exterior or interior, entering Fu or Zang organs, and treat according to where it resides.
Master said: Respiration is the head of the pulse.
Cheng Wuji's commentary: The *Nan Jing* states: One exhalation moves the pulse 3 cun; one inhalation moves it 3 cun. Because the pulse follows respiration, it is called the head of the pulse. This is the essential method for entering pulse diagnosis.
Initially holding the pulse, coming fast and going slow. This comes fast and goes slow, named Interior Excess and Exterior Deficiency.
Cheng Wuji's commentary: Exterior is Yang, Interior is Yin. The *Neijing* states: Coming is Yang, Going is Yin. Coming observes the exterior, Going observes the interior. Fast indicates surplus, surplus means Excess. Slow indicates insufficiency, insufficiency means Deficiency. Coming fast and going slow indicates Yang surplus and Yin insufficiency, hence Interior Deficiency and Exterior Excess. Coming slow and going fast indicates Yang insufficiency and Yin surplus, hence Interior Excess and Exterior Deficiency.
Question: The superior physician knows by observation, the average physician by inquiry, the inferior physician by pulse. I wish to hear your explanation. Master said: The patient's family reports: The patient suffers from fever and body pain. The patient lies down voluntarily. When the master arrives, feeling the pulse sinking and slow, he knows the patient is recovering. Why do I know this? When there is disease in the exterior, the pulse should be floating and large. Now the pulse is contrary, sinking and slow, hence I know it is healing.
Cheng Wuji's commentary: Observation examines form and symptoms; inquiry learns of suffering; pulse distinguishes interior and exterior. Suffering from fever and body pain indicates pathogen in the exterior. One should lie down uncomfortably with a floating-rapid pulse. Now the patient lies down voluntarily with a sinking-slow pulse, indicating the exterior pathogen is slackening. There is an interior pulse but no exterior symptom, hence knowing the exterior pathogen will heal.
Suppose the patient says: Sudden abdominal pain. The patient sits voluntarily. When the master arrives, feeling the pulse floating and large, he knows the patient is recovering. Why do I know this? If there is disease in the interior, the pulse should be sinking and fine. Now the pulse is floating and large, hence I know it is healing.
Cheng Wuji's commentary: Abdominal pain indicates interior cold. Severe pain prevents rising, with a sinking-fine pulse. Now the patient sits voluntarily with a floating-large pulse, indicating interior cold has dispersed. There is an exterior pulse but no interior symptom, hence knowing the interior pathogen will heal. By combining observation of symptoms, inquiry of disease, and palpation of pulse, one can be a perfect physician. The *Needle Classic* states: Knowing one is superior, knowing two is divine, knowing three is enlightened and bright.
Master said: The patient's family comes requesting: The patient has fever and extreme vexation. Tomorrow, when the master arrives, the patient faces the wall lying down. This heat has gone. The pulse is harmonious, hence saying healed. Extreme fever and vexation prevent quiet lying. Now facing the wall quietly lying, knowing the heat has gone.
If facing the wall lying down, hearing the master arrive, not startling up but looking around, speaking three words then stopping three times, swallowing saliva when feeling the pulse, this is feigned illness. Suppose the pulse is naturally harmonious, yet claims the disease is severe, requiring emetic/purgative drugs and dozens or hundreds of acupuncture points to cure.
Cheng Wuji's commentary: Feigned illness is performed by those not good-hearted. Use words to frighten them, making them fearful, and they will heal. The physician uses intuition; is this correct? This is not a treatment method. Setting up a framework for feigned illness, they feign illness, and I feign treatment.
When the master holds the pulse, if the patient yawns, there is no disease.
Cheng Wuji's commentary: The *Needle Classic* states: Yang draws upward, Yin draws downward; Yin and Yang draw each other, hence yawning. If Yin and Yang do not draw each other, there is disease; if they draw each other, there is harmony. Thus, yawning indicates no disease.
If the pulse reveals groaning, there is disease.
Cheng Wuji's commentary: Groaning is the sound of moaning. The body suffers, hence this occurs.
Speaking slowly indicates Wind.
Cheng Wuji's commentary: Wind lodging in the interior causes meridians and collaterals to tighten, the tongue becomes stiff, and movement is difficult.
Shaking the head while speaking indicates interior pain.
Cheng Wuji's commentary: Disease in the interior causes the head to tremble when speaking.
Walking slowly indicates exterior stiffness.
Cheng Wuji's commentary: Exterior stiffness, caused by tendon and collateral contraction, makes walking difficult.
Sitting and bending forward indicates shortness of breath.
Cheng Wuji's commentary: Shortness of breath indicates interior disharmony. Hence sitting and preferring to bend forward.
Sitting with one leg extended indicates lower back pain.
Cheng Wuji's commentary: The *Neijing* states: The waist is the major joint of the body. Lower back pain causes major joint dysfunction, preventing proper sitting. Extending one leg relieves the pain in the waist.
Interior excess, protecting the abdomen as if holding an egg, indicates heart pain.
Cheng Wuji's commentary: Heart pain prevents extending and lying flat; protecting the abdomen presses the pain.
Master said: Latent Qi disease is anticipated by intention. Within this month, latent Qi is expected. Suppose there was old latent Qi; one must feel the pulse. If the pulse is weak and faint, there should be throat pain, resembling injury but not throat bi. The patient says there is real throat pain, and now desires diarrhea.
Cheng Wuji's commentary: Feeling cold in winter, hiding in the meridians without immediate onset, is called latent Qi. At the Spring Equinox, latent cold desires to emerge, hence "within this month latent Qi is expected." Suppose latent Qi has emerged; one must feel the pulse to determine the meridian. Obtaining a weak and faint pulse indicates the pathogen is in Shaoyin. The Shaoyin meridian runs along the throat; cold lodging there必然 causes throat pain. The Kidney governs opening and closing; Shaoyin manages the Lower Jiao. Severe internal cold disrupts opening and closing, the Lower Jiao fails to constrain,必然 causing diarrhea. Hence, even with throat pain, diarrhea is expected.
Question: When a person suffers from terror, what is the pulse shape? Master said: The pulse shape resembles tracing threads continuously; the face is pale and loses color.
Cheng Wuji's commentary: The *Neijing* states: Blood and Qi are the Spirit of man. Terror indicates insufficient Blood and Qi and weak Shen Qi. The pulse resembles tracing threads continuously; the face is pale and loses color. The *Needle Classic* states: When Blood is stolen, the complexion is dull and lusterless, and the pulse is empty. Thus, terror indicates insufficient Blood and Qi.
Question: When a person does not drink, what is the pulse like? Master said: The pulse is naturally choppy; lips and mouth are dry.
Cheng Wuji's commentary: Choppy is Yin. Although it mainly governs loss of body fluids, dry lips and mouth are dominated by Yin internally, hence no drinking. This section likely has missing text.
Question: When a person feels ashamed, what is the pulse like? Master said: The pulse is floating, and the face alternates between white and red.
Cheng Wuji's commentary: Shame is embarrassment. Shame causes the Shen Qi to be timid and weak, hence the pulse is floating, and the face changes irregularly.
Question: The Classics say the pulse has weights of three beans and six beans. What does this mean? Master said: The pulse: when pressed with the finger with the weight of three beans, it is Lung Qi; with six beans, Heart Qi; with nine beans, Spleen Qi; with twelve beans, Liver Qi; pressed to the bone, Kidney Qi.
Cheng Wuji's commentary: Dou means bean. The *Nan Jing* states: Weight of three beans, touching skin and hair, is Lung position. Weight of six beans, touching blood vessels, is Heart position. Weight of nine beans, touching muscle, is Spleen position. Weight of twelve beans, level with sinew, is Liver position. Pressed to the bone, lifting the finger quickly, is Kidney position. Each corresponds to its respective division to observe Zang Qi.
Suppose diarrhea, with no pulse seen at Cun, Guan, or Chi. However, at Chi, occasionally a small appearance, with the pulse raising its head twice, indicates Kidney Qi. If damaged pulses appear, it is difficult to treat.
Cheng Wuji's commentary: The *Mai Jing* states: Cold qi in the Stomach causes pulse obstruction. Diarrhea without pulse indicates cold qi lodging in Spleen and Stomach. Now, occasional small appearance at Chi indicates Spleen deficiency attacked by Kidney Qi. Pulse raising its head twice indicates Spleen is overcome by Kidney. If the Chi pulse diminishes further, Kidney Qi also declines, Spleen overcomes again, ghost and thief oppose each other, hence difficult to treat. This is Spleen overcoming at an inappropriate time.
Question: The pulse has multiplication, vertical, horizontal, reverse, and順 (smooth). What does this mean? Master said: Water multiplying Fire, Metal multiplying Wood is called Vertical (Zong). Fire multiplying Water, Wood multiplying Metal is called Horizontal (Heng). Water multiplying Metal, Fire multiplying Wood is called Reverse (Ni). Metal multiplying Water, Wood multiplying Fire is called Smooth (Shun).
Cheng Wuji's commentary: Metal overcoming Wood, Water overcoming Fire: Vertical means allowing Qi to multiply what it overcomes. Horizontal means Qi rebels horizontally, multiplying what it does not overcome. Zong/Heng shares meaning with Zi Zong/Zi Heng. Water is son of Metal; Fire is son of Wood. Son multiplying mother is Reverse; Mother multiplying son is Smooth.
Question: The pulse has destructive and harmful elements. What does this mean? Master said: The pulse has wiry, tight, floating, slippery, sinking, and choppy. These six are called destructive and harmful, capable of causing disease in various pulses.
Cheng Wuji's commentary: For human disease, called Eight Evils. Wind, Cold, Summerheat, Dampness injure externally; hunger, fullness, fatigue, labor injure internally. Meridians are Ying and Wei; Ying and Wei are Yin and Yang. For causing disease in various meridians, it must be by Wind, Cold, Summerheat, Dampness injuring Ying and Wei, lodging in Yin and Yang. Wind causes floating pulse; Cold causes tight pulse; Summerheat causes slippery pulse; Dampness causes choppy pulse; Injury to Yin causes sinking pulse; Injury to Yang causes floating pulse. Called destructive and harmful because harming goodness is called Can (damage), harming goodness is called Zei (thief), as they harm righteous Qi.
Question: The pulse has disaster and strangeness. What does this mean? Master said: Suppose a person is ill, pulse obtains Taiyang, corresponding to form and symptoms, therefore administering decoction. After taking the decoction, shortly after eating, the patient suddenly vomits greatly, or has diarrhea, abdominal pain. Master said: I