问曰。上工治未病。何也。师曰。夫治未病者。见肝之病。知肝传脾。当先实脾。四季脾旺不受邪。即
勿补之。中工不晓相传。见肝之病。不解实脾。惟治肝也。夫肝之病。补用酸。助用焦苦。益用甘味之药调
之。酸入肝。焦苦入心。甘入脾。脾能伤肾。肾气微弱。则水不行。水不行。则心火气盛。则伤肺。肺被伤。
则金气不行。金气不行。则肝气盛。则肝自愈。此治肝补脾之要妙也。肝虚则用此法。实则不在用之。经曰
虚虚实实。补不足损有余。是其义也。余脏准此。（赵本。心火气盛下。更有心火气盛四字。肝气盛下。
有故实脾三字。并是。）
〔程〕治未病者。谓治未病之脏腑。非治未病之人也。愚谓见肝补脾则可。若谓补脾则伤肾。肾可
伤乎。火盛则伤肺。肺可伤乎。然则肝病虽愈。又当准此法。以治肺治肾。五脏似无宁日也。伤字当作制字
看。制之则五脏和平。而诸病不作矣。
〔尤〕按素问云。邪气之客于身也。以胜相加。肝应木
而胜脾土。以是知肝病当传脾也。实脾者。助令气旺使不受邪。所谓治未病也。设不知而徒治其肝。则肝病
未已。脾病复起。岂上工之事哉。肝之病。补用酸者。肝不足则益之以其本味也。与内经以辛补之之说不同。
然肝以阴脏。而含生气。以辛补者。所以助其用。补用酸者。所以益其体。言虽异。而理各当也。助用苦
焦者。千金所谓心旺则气感于肝也。益用甘味之药调之者。越人所谓损其肝者。缓其中也。酸入
肝以下十五句。疑非仲景原文。类后人谬添注脚。编书者误
收之也。盖仲景治肝补脾之要。在脾实而不受肝邪。非补脾以伤肾。纵火以刑金之谓。果尔则是所全者少。而
所伤者反多也。且脾得补。而肺将自旺。肾受伤必虚及其子。何制金强木之有哉。细按语意。见肝之病以下九
句。是答上工治未病之辞。补用酸三句。乃别出肝虚正治之法。观下文云。肝虚则用此法。实则不在用之。可
以见矣。盖脏腑惟虚者受之。而实者不受。脏邪惟实。则能传。而虚则不传。故治肝实者。先实脾土。以杜滋
蔓之祸。治肝虚者。直补本宫。以防外侮之端。此仲景虚实并举之要旨也。后人不察肝病缓中之理。
谬执甘先入脾之语。遂略酸与焦苦。而独于甘味。曲穷其说。以为是即治肝补脾之要妙。昔贤云。 辞知其所
蔽。此之谓耶。
〔鉴〕中工不晓虚实。虚者泻之。是为虚虚。实者补之。是为实实。非其义也。上工知
其虚实。补其不足。损其有余。是其义也。
案七十七难曰。经言。上工治未病。中工治已病者。何谓也。然所谓治未病者。见肝之病。则知肝当
传之与脾。故先实其脾气。无令得受肝之邪。故曰治未病焉。云云。八十一难曰。经言无实实虚虚。损不足
而益有余。并本条之义也。伤肾。三因。引本经作制肾。程注盖本于此。肝虚。三因。
作虚肝。今据尤注。以十五句为注脚。则文义相接。旨趣明晰。不必作虚肝也。
夫人禀五常。因风气而生长。风气虽能生万物。亦能害万物。如水能浮舟。亦能覆舟。若五脏元真通
畅。人即安和。客气邪风。中人多死。千般 难。不越三条。一者。经络受邪入脏腑。为内所因也。二者。
四肢九窍。血脉相传。壅塞不通。为外皮肤所中也。三者。房室金刃。虫兽所伤。以此
详之。病由都尽。若人能养慎。不令邪风干忤经络。适中经
络。未流传腑脏。即医治之。四肢才觉重滞。即导引吐纳。针灸膏摩。勿令九窍闭塞。更能无犯王法。禽兽
灾伤房室。勿令竭乏。服食节其冷热。苦酸辛甘。不遣形体有衰。病则无由入其腠理。腠者。是三焦通会元
真之处。为血气所注。理者。是皮肤脏腑之纹理也。（禀。徐彬本。沈本。金鉴。作秉。才。赵本。作才。）
〔沈〕此条是书中大旨。通部之纲领。前人误编次章。兹冠于首以正头绪。不致纷纭也。五常者。五行
也。夫人秉五常。即秉天地五行阴阳之常气。气。即风也。然风即东方甲乙。生发之气为四时六气之首。而
天气化生。长养万物。必随八风动荡之机而发。发则寒暑燥湿火。相随应时而化。人感此气而成。谓因风
气而生长。然风有邪正。正风者。即温和之风。生育万物也。邪风者。乃飘HT 之风。肃杀万物。故以风气虽
能生万物。亦能害万物。如水能浮舟。亦能覆舟之譬。五脏元真通畅。人即安和者。谓人之内气不虚。则不受
邪而为病也。若天气寒时而反热。热时而反寒。为客气邪风。中人多死。乃谓冲方来者。伤人之风也。凡人
身之病。不出表里阴阳。内因外因不内外之三因。故曰。千般 难。不越三条。一者经络受邪入脏腑。为内
所因。即大邪中表。感冒风寒。传经入里。乃经络受邪之病也。二者。邪从四肢九窍。入于血脉。肌肉筋骨。
壅塞不通。即拘挛瘫痪风痹之类。为外皮肤所中。是躯壳井荥俞合募原。受邪为病也。三者不从
六淫。而因房室虫兽所伤。为不内外因。即自作劳伤之病也。灵枢曰。虚邪不能独伤人。必因身形之虚。而后
客之。故得三焦之气。统领气血津液。充溢脏腑腠理。则邪不能入。所谓病则无由入其腠理。然三焦之气。
充溢躯壳脏腑。肌肉皮肤。相合罅隙之路为腠。故为三焦通会元真之处。为血气所
注。而精津血液。溉灌滋渗。脏腑筋骨。肌肉皮肤。出入之窍为理。故为皮肤脏腑之纹理。总皆赖三焦之气。
充溢脏腑。津液实之。则腠理密。而不受邪为病也。
〔尤〕按陈无择三因方。以六淫邪气所触。为外因。五
脏情志所感。为内因。饮食房室。跌扑金刃所伤。为不内外因。盖仲景之论。以客气邪风为主。故不从内伤
外感为内外。而以经络脏腑为内外。无择合天人表里立论。故以病从外来者为外因。从内生者为内因。其不
从邪气情志所生者为不内外因。亦最明晰。虽与仲景并传可也。
〔程〕腠理一作 理。三焦出气。以温肌肉。
元真之所凑会。血气之所灌渗也。理者。有粗理。有小理。有密理。有分理。有肉理。此皮肤之理也。
腑之环回周叠。脏之浓薄结直。此脏腑之理也。
案文子曰。人者。天地之心。五行之端。是以禀天地五行之气而生。荀子曰。水所以载舟。亦所以覆舟。
。疹同。疾也。陶弘景肘后百一方。以内疾外发他犯三者。分为上中下三卷。盖本于此条。而义少异。
无择则根据陶氏。所以与本条之旨不同。忤。逆也。戾也。一切经音义云。凡人自摩自
捏。伸缩手足。除劳去烦。名为导引。若使别人握搦身体。或摩或捏。即名按摩也。庄子刻意曰。吹呵呼吸。
吐故纳新。熊经鸟伸。为寿而已。道书。口吐浊气曰吐故。鼻纳清气曰纳新。此所谓内丹外丹也。膏摩。即
摩膏之谓。玉函经总例云。汤散丸药。针灸膏摩。一如其法。金鉴。以为按摩误。
问云。病患有气色见于面部。愿闻其说。师曰。鼻头色青。腹中痛。苦冷者死。（〔原注〕一云。腹
中冷若痛者死。）鼻头色微黑者。有水气。色黄者。胸上有寒。色白者。亡血也。设微赤
非时者死。其目正圆者 。不治。又色青为痛。色黑为劳。色赤为风。色黄者便难。色鲜明者有留饮。
〔徐〕此段乃医家之望法也。
〔鉴〕色者。青赤黄白黑也。气者。五色之光华也。
〔程〕内经曰。精明五色者。气之华也。故五色微胗。可以目察。鼻者。明堂也。明堂润泽以清。则无病。
〔尤〕鼻头。脾之部。青。肝之色。腹中痛者。土受木贼也。冷则阳亡。而寒水助邪。故死。肾者主水。黑。水之
色。脾负而肾气胜之。故有水气。色黄者。面黄也。其病在脾。脾病则生饮。故胸上有寒。寒。寒饮也。色
白。亦面白也。亡血者。不华于色故白。血亡则阳不可更越。设微赤。而非火令之时。其为虚阳上泛无疑。故
死。目正圆者。阴之绝也。痉为风强病。阴绝阳强。故不治。痛则血凝泣而不流。故色青。劳则伤肾。故色
黑。经云。肾虚者。面如漆柴也。风为阳邪。故色赤。脾病则不运。故便难。色鲜明者。有留
饮。经云。水病。人目下有卧蚕。面目鲜泽也。
〔徐〕目为五脏精华之所聚。神气之所生。正圆则目 不转。
而至于痉。是阴绝。产妇多痉。亦主阴也。今之正圆。阴绝无疑。故曰不治。
案灵五色篇曰。青黑为痛。黄赤为风。余当参考。
师曰。病患语声寂然。喜惊呼者骨节间病。语声喑喑然
不彻者。心膈间病。语声啾啾然。细而长者。头中病。（〔原注〕一作痛。）
〔徐〕此段乃医家闻法也。语声寂寂然。喜惊呼者。骨节间病。谓静嘿属阴。而厥阴肝木。在志为惊。在
声为呼。令寂寂而喜惊呼。知属厥阴。深入骨节间矣。语声喑喑然不彻者。心膈间病。谓声虽有五脏之分。皆
振响于肺金。故亮而不哑。今喑喑然不彻。是胸中大气不转。壅塞金气。故不能如空谷之音。所以知病在
胸中膈间。经谓。中盛脏满。气胜伤恐者。声如从室中言。是中气之湿也。其即此欤。语声啾
啾然。细而长者。头中病。谓头中有病。则唯恐音气之上攻。
故抑小其语声。而引长发细耳。
〔魏〕此亦约举其一二以该之。示人引伸触类之义也。
医灯续焰云。欲言复寂。忽又惊呼。非深入骨节之病不如此也。况骨节中属大筋。筋为肝合。骨乃胆主。
惊呼亦出于肝胆故耳。喑喑。低渺之声。听不明彻。必心膈间有所阻碍。啾啾。细长之声。头中有湿混其清
阳。故发声如此也。
案金鉴云。头字当是腹字。语声啾啾然细长者。谓唧唧哝哝。小而悠长也。因不敢使气急促动中。故
知腹中病也。腹中有病。而有气急促动中者。此说未为得矣。
师曰。息摇肩者。心中坚。息引胸中上气者咳。息张口短气者。肺痿唾沫。
〔魏〕又就气息示之。息摇肩。息而肩动也。心中坚。
气坚痞于心中。格阻其正气之升降。故息而肩摇也。而邪实正虚。犹当加意也。息引胸中上气者。咳。咳则
气乱而逆。故息引胸中。其气逆上。此咳家之息。而虚实之邪。又当别为谛审矣。息张口短气者。肺脏津枯气
耗之可验者也。故知为肺痿而兼有唾沫之外证可征信焉。盖必津枯气耗。而后口干沫粘。反欲多唾。唾又无
津。而但沫也。此肺病之洞然者也。
〔鉴〕摇肩。谓抬肩也。心中坚。谓胸中壅满也。呼吸引
胸中之气上逆。喉中作痒。梗气者咳病也。呼吸张口不能续。自似喘而不抬肩者。短气病也。咳时唾。痰嗽
也。若咳唾涎沫不已。非咳病也。乃肺痿也。
师曰。吸而微数。其病在中焦。实也。当下之。即愈。
虚者不治。在上焦者。其吸促。在下焦者。其吸远。此皆难治。呼吸动摇振振者。不治。
〔尤〕息兼呼吸而言。吸则专言入气也。中焦实。则气之
入者。不得下行。故吸微数。数。犹促也。下之则实去气通而愈。若不系实而系虚。则为无根失守之气。顷
将自散。故曰不治。或云。中焦实。而元气虚者。既不任受攻下。而又不能自和。故不治。亦通。其实在
上焦者。气不得入。而辄还则吸促。促。犹短也。实在下焦者。气欲归。而不骤及。则吸远。远。犹长也。
上下二病。并关脏气。非若中焦之实。可从下而去者。故曰难治。
〔魏〕至于呼吸之间。周身筋脉。
动摇振振然。是阳已脱。而气已散矣。又何以为治。故言不治也。右俱就气息。以决人之生死。人
之生死原乎气。就此决之。诚一定而无舛者矣。
案金鉴云。吸促之促字。当是远字。吸远之远字。当是促字。方合病义。必传写之讹。此说于
义相畔。不可从。
师曰。寸口脉动者。因其旺时而动。假令肝旺色青。四时各随其色。肝色青。而反色白。非其时
色脉。皆当病。
〔鉴〕寸口者。统言左右三部脉也。脉动法乎四时。命乎五脏。然必因其旺时而动。则为平脉也。假
令肝旺于春。随其时。色当青。脉当弦。此不病之色脉也。若色反白。脉反浮。此非其时。乃病之色脉也。
四时准此。
〔徐〕谓鼓而有力为动。
问曰。有未至而至。有至而不至。有至而不去。有至而达过。何谓也。师曰。冬至之后。甲子夜半。
少阳起。少阳之时。阳始生。天得温和。以未得甲子。天因温和。此为未至而至也。以得甲子。而天未温和。
为至而不至也。以得甲子。而天大寒不解。此为至而不去也。以得甲子。而天温。
如盛夏五六月时。此为至而太过也。
〔尤〕上之至。谓时至。下之至。谓气至。盖时有常数而不移。气无定刻而或迁也。冬至之后甲子。
谓冬至后六十日
也。盖古造历者。以十一月甲子朔。夜半冬至。为历元。根据此推之。则冬至后六十日。当复得甲子。而气盈
朔虚。每岁递迁。于是至日不必皆值甲子。当以冬至后六十日。花甲一周。正当雨水之候为正。雨水者。冰
雪解散。而为雨水。天气温和之始也。云少阳起者。阳方起而出地。阳始生者。阳始盛而生物。非冬至一阳
问：高明的医生治疗未发生的疾病，这是什么意思？
老师回答说：所谓治疗未发生的疾病，是指看到肝脏有病，知道肝病会传变给脾脏，应当先使脾脏充实（增强其功能）。如果在四季中脾气旺盛的时候，脾脏自然不受邪气侵袭，就不必特意去补脾。中等水平的医生不懂得这种脏腑相传的道理，看到肝脏有病，不知道要充实脾脏，只懂得治疗肝脏本身。对于肝脏的疾病，用酸味药来补益，用焦苦味药来辅助，用甘味药来调和。酸味入肝，焦苦味入心，甘味入脾。脾脏功能强健可以制约肾脏，肾气变得微弱，则水液代谢正常而不泛滥；水液不泛滥，则心火之气旺盛；心火旺盛则会克制肺金；肺金被克制，则肺气运行不畅；肺气运行不畅，则肝气相对偏盛，这样肝脏的病就能自愈。这就是“治肝补脾”的奥妙所在。这种方法适用于肝虚证，如果是肝实证则不适用。医经说：“不要使虚者更虚，实者更实”，即补益不足，削减有余，就是这个道理。其他脏腑的情况也可以参照此法类推。（赵开美本在“心火气盛”之下多出了“心火气盛”四个字，在“肝气盛”之下多出了“故实脾”三个字，这些都是衍文。）
程林注：治疗未发生的疾病，是指治疗尚未受病的脏腑，而不是治疗尚未生病的人。我认为看到肝病补脾是可以的，如果说补脾就会伤害肾脏，肾脏能被伤害吗？心火旺盛就会伤害肺，肺能被伤害吗？如果这样，那么肝病虽然好了，又应当参照这个方法来治疗肺和肾，五脏似乎就没有安宁的日子了。“伤”字应当看作“制约”的意思，制约得当则五脏和平，各种疾病就不会发生了。
尤在泾按：《素问》说：邪气侵犯人体，是按照五行相胜的关系相加的。肝属木而克脾土，因此知道肝病会传变给脾。所谓“实脾”，就是帮助脾脏使正气旺盛从而不受邪气侵袭，这就是所谓的“治未病”。如果不明白这一点而仅仅治疗肝脏，那么肝病还没好，脾病又起来了，这难道是高明医生的做法吗？治疗肝病用酸味药补益，是因为肝不足时，就用它本味的药物来补充。这与《内经》说的“以辛补之”说法不同。然而，肝作为阴脏，内含生气，用辛味补益是为了助长它的作用，用酸味补益是为了滋养它的形体。言语虽异，但道理各有所当。辅助用药用焦苦味，是《千金方》所说的“心旺则气感于肝”。用甘味药来调和，是《难经》所说的“损其肝者，缓其中”。从“酸入肝”以下十五句，怀疑不是张仲景的原文，像是后人错误添加的注释，编书的人误收进去了。大概张仲景“治肝补脾”的要旨，在于脾实而不受肝邪的侵袭，并不是通过补脾来伤害肾脏、纵容心火来刑克肺金。如果真的那样，那么保全的少，伤害的反倒多。而且脾得到补益，肺将会自然旺盛，肾受伤必然虚弱并波及到子脏（肝），哪里有什么制约肺金、强壮肝木的道理呢？仔细推敲语意，“见肝之病”以下九句，是回答“上工治未病”的话；“补用酸”三句，乃是另外提出肝虚证的正治方法。看下文说：“肝虚则用此法，实则不在用之”，就可以明白了。大概脏腑只有虚证才受邪，实证则不受邪；脏邪只有实证才能传变，虚证则不传变。所以治疗肝实证，先实脾土，以防止祸患蔓延；治疗肝虚证，直接补益本脏，以防外邪入侵。这是张仲景虚实并举的要旨。后人不察肝病需要“缓其中”的道理，错误地执着于“甘先入脾”的说法，于是省略了酸味和焦苦味，只对甘味进行曲解发挥，认为这就是“治肝补脾”的奥妙。古人说：“言辞能反映出认知的蔽塞”，说的就是这种情况。
徐彬注：中等水平的医生不懂虚实辨证，对虚证用泻法，这叫“虚虚”；对实证用补法，这叫“实实”，这不是正确的义理。高明医生知道虚实，补其不足，损其有余，这才是正确的义理。
按：《难经·七十七难》说：医经讲，上医治未病，中医治已病，这是什么意思？回答说：所谓治未病，是指看到肝脏有病，就知道肝病会传给脾脏，所以先充实脾气，不让它受到肝邪的侵害，所以叫治未病。等等。《难经·八十一难》说：医经讲不要“实实虚虚”，损伤不足而增加有余，也是本条的义理。“伤肾”在《三因方》中引作“制肾”。程林注可能基于此。“肝虚”在《三因方》中作“虚肝”，现在根据尤在泾的注解，将十五句视为注脚，则文义相接，旨趣明晰，不必改为“虚肝”。
大凡人的禀赋遵循五行常道，依靠风气而生长。风气虽然能滋生万物，也能危害万物，就像水能浮起船，也能倾覆船一样。如果五脏的真气通畅，人就会平安健康；若被客气的邪风所中，人往往会死亡。千般灾难，都不出三条原因：一是经络受邪进入脏腑，属于内所因；二是四肢九窍，血脉相传，壅塞不通，属于外皮肤所中；三是房室、金刃、虫兽所伤。详细分析这些，疾病的来源就穷尽了。如果人能调养谨慎，不让邪风干扰经络，在邪气刚侵入经络、尚未流传到脏腑时就医治它；四肢刚觉得沉重滞涩，就采用导引、吐纳、针灸、膏摩等方法，不让九窍闭塞；又能不触犯王法，避免禽兽灾害和房室过度，不让身体枯竭乏累；饮食调节冷热，节制苦酸辛甘五味，不让形体衰败，疾病就无法侵入腠理。腠，是三焦通会元真之气、血气灌注的地方；理，是皮肤和脏腑的纹理。（“禀”字，徐彬本、沈明宗本、《医宗金鉴》作“秉”。“才”字，赵开美本作“才”。）
沈明宗注：这一条是全书的大旨，通部的纲领。前人误将其编排在第二章，现在把它放在开头以端正头绪，不至于纷乱。五常，就是五行。人秉承五常，就是秉承天地五行阴阳的常气。气，就是风。然而风即东方甲乙，生发之气为四时六气之首，天气化生、长养万物，必须随着八风动荡的机制而发动。发动则寒暑燥湿火相随，应时而变化。人感受这些气而成形，所以说“因风气而生长”。然而风有邪正之分，正风就是温和之风，生育万物；邪风就是飘忽之风，肃杀万物。所以说风气虽能生万物，亦能害万物，用水能浮舟、亦能覆舟来比喻。五脏元真通畅，人即安和，是说人的内气不虚，则不受邪而为病。如果天气寒冷时反而热，热时反而冷，这叫客气邪风，中人往往致死，指的是冲方来的伤人之风。凡人身上的病，不出表里阴阳和内因、外因、不内外因这三因。所以说千般灾难，不越三条。一是经络受邪入脏腑，为内所因，即大邪中表，感冒风寒，传经入里，是经络受邪的病。二是邪从四肢九窍入于血脉、肌肉筋骨，壅塞不通，即拘挛瘫痪风痹之类，为外皮肤所中，是躯壳井荥俞合募原受邪为病。三是不从六淫，而因房室、虫兽所伤，为不内外因，即自作劳伤之病。《灵枢》说：虚邪不能单独伤人，必须因为身形之虚，而后客之。所以能得到三焦之气，统领气血津液，充溢脏腑腠理，则邪不能入，所谓“病则无由入其腠理”。然而三焦之气，充溢躯壳脏腑、肌肉皮肤，相合罅隙之路为腠，所以是三焦通会元真之处，为血气所注。而精津血液，灌溉滋渗，脏腑筋骨、肌肉皮肤出入之窍为理，所以是皮肤脏腑之纹理。总之都依赖三焦之气充溢脏腑，津液充实，则腠理密，而不受邪为病。
尤在泾按：陈无择《三因方》，以六淫邪气所触为外因，五脏情志所感为内因，饮食房室、跌扑金刃所伤为不内外因。大概张仲景的论述，以客气邪风为主，所以不从内伤外感分为内外，而以经络脏腑为内外。陈无择结合天人表里立论，所以以病从外来者为外因，从内生者为内因，其不从邪气情志所生者为不内外因，也最明晰。虽然与张仲景并行也可。
程林注：腠理一作理。三焦出气，以温肌肉，元真之所凑会，血气之所灌渗也。理者，有粗理、有小理、有密理、有分理、有肉理，此皮肤之理也。腑之环回周叠，脏之浓薄结直，此脏腑之理也。
按：《文子》说：人是天地之心，五行之端，所以禀受天地五行之气而生。《荀子》说：水所以载舟，亦所以覆舟。“疹”同“疢”，疾也。陶弘景《肘后备急方》，以内疾、外发、他犯三者，分为上中下三卷，大概基于本条，但义理稍异。陈无择则根据陶氏，所以与本条旨意不同。“忤”，逆也，戾也。《一切经音义》云：凡人自摩自捏，伸缩手足，除劳去烦，名为导引。若使别人握搦身体，或摩或捏，即名按摩。《庄子·刻意》曰：吹呵呼吸，吐故纳新，熊经鸟伸，为寿而已。道书：口吐浊气曰吐故，鼻纳清气曰纳新，此所谓内丹外丹也。膏摩，即摩膏之谓。《玉函经总例》云：汤散丸药，针灸膏摩，一如其法。《医宗金鉴》以为按摩误。
问：病人面部出现气色，希望听听其中的道理。
老师说：鼻头颜色发青，腹中痛，如果怕冷的就会死。（〔原注〕一说：腹中冷或者痛的就会死。）鼻头颜色微黑的，有水气；颜色黄的，胸上有寒饮；颜色白的，是亡血；假如微红且非正常季节出现的，就会死；眼睛直视不动、眼球正圆的，不治。另外，青色主痛，黑色主劳损，赤色主风，黄色主大便难，颜色鲜明润泽的有留饮。
徐彬注：这段是医家的望诊法。
徐彬注：色，指青赤黄白黑五色；气，指五色的光华。
程林注：《内经》说：精明五色，是气的荣华。所以五色的细微脉象，可以用目察知。鼻，是明堂。明堂润泽清明，则无病。
尤在泾注：鼻头，是脾的外候。青，是肝的颜色。腹中痛，是土受木贼（肝木克脾土）。冷则阳气亡失，而寒水助长邪气，所以死。肾主水，黑，是水的颜色。脾负弱而肾气胜之，所以有水气。色黄，指面色黄。病在脾，脾病则生饮，所以胸上有寒（寒指寒饮）。色白，指面白。亡血的人，不显光泽所以白。血亡则阳不可再越，假如微红，而非火令之时，无疑是虚阳上泛，所以死。目正圆，是阴绝。痉病是风强病，阴绝阳强，所以不治。痛则血凝泣而不流，所以色青。劳则伤肾，所以色黑。经云：肾虚者，面如漆柴也。风为阳邪，所以色赤。脾病则不运，所以便难。色鲜明者，有留饮。经云：水病，人目下有卧蚕，面目鲜泽也。
徐彬注：目为五脏精华之所聚，神气之所生。正圆则目不转，而至于痉，是阴绝。产妇多痉，亦主阴。今之正圆，阴绝无疑，故曰不治。
按：《灵枢·五色篇》说：青黑为痛，黄赤为风。其余应当参考。
老师说：病人说话声音寂静，喜欢突然惊呼的，是骨节间有病；说话声音喑哑不清彻的，是心膈间有病；说话声音啾啾然、细而长的，是头中有病。（〔原注〕一作痛。）
徐彬注：这段是医家的闻诊法。语声寂寂然，喜欢惊呼的，是骨节间病。谓静默属阴，而厥阴肝木，在志为惊，在声为呼。现在寂静而喜欢惊呼，知道属于厥阴，深入骨节间了。语声喑喑然不彻的，是心膈间病。谓声音虽有五脏之分，皆振响于肺金，故亮而不哑。现在喑喑然不彻，是胸中大气不转，壅塞金气，故不能如空谷之音，所以知道病在胸中膈间。经谓：中盛脏满，气胜伤恐者，声如从室中言，是中气之湿也。其即此欤？语声啾啾然，细而长的，是头中有病。谓头中有病，则唯恐音气之上攻，故抑小其语声，而引长发细耳。
魏荔彤注：这也是约举其一二以概其余，示人引伸触类之义。《医灯续焰》云：欲言复寂，忽又惊呼，非深入骨节之病不如此也。况骨节中属大筋，筋为肝合，骨乃胆主，惊呼亦出于肝胆故耳。喑喑，低渺之声，听不明彻，必心膈间有所阻碍。啾啾，细长之声，头中有湿混其清阳，故发声如此也。
按：《医宗金鉴》云：头字当是腹字。语声啾啾然细长者，谓唧唧哝哝，小而悠长也。因不敢使气急促动中，故知腹中病也。腹中有病，而有气急促动中者，此说未为得矣。
老师说：呼吸时肩膀摇动的，是心中坚满；呼吸时牵引胸中上气的，是咳嗽；呼吸时张口短气的，是肺痿唾沫。
魏荔彤注：又就气息示之。息摇肩，呼吸而肩动也。心中坚，气坚痞于心中，格阻其正气之升降，故息而肩摇也。而邪实正虚，犹当加意也。息引胸中上气者咳，咳则气乱而逆，故息引胸中，其气逆上，此咳家之息，而虚实之邪，又当别为谛审矣。息张口短气者，肺脏津枯气耗之可验者也。故知为肺痿而兼有唾沫之外证可征信焉。盖必津枯气耗，而后口干沫粘，反欲多唾，唾又无津，而但沫也。此肺病之洞然者也。
徐彬注：摇肩，谓抬肩也。心中坚，谓胸中壅满也。呼吸引胸中之气上逆，喉中作痒，梗气者咳病也。呼吸张口不能续，自似喘而不抬肩者，短气病也。咳时唾，痰嗽也。若咳唾涎沫不已，非咳病也，乃肺痿也。
老师说：吸气轻微频数的，病在中焦，是实证，应当用下法，即可痊愈。若是虚证则难治。在上焦的，吸气短促；在下焦的，吸气深长。这些都属于难治。呼吸时全身动摇振颤的，不治。
尤在泾注：息兼呼吸而言，吸则专言入气也。中焦实，则气之入者，不得下行，故吸微数。数，犹促也。下之则实去气通而愈。若不系实而系虚，则为无根失守之气，顷将自散，故曰不治。或云：中焦实，而元气虚者，既不任受攻下，而又不能自和，故不治，亦通。其实在上焦者，气不得入，而辄还则吸促。促，犹短也。实在下焦者，气欲归，而不骤及，则吸远。远，犹长也。上下二病，并关脏气，非若中焦之实，可从下而去者，故曰难治。
魏荔彤注：至于呼吸之间，周身筋脉，动摇振振然，是阳已脱，而气已散矣，又何以为治，故言不治也。右俱就气息，以决人之生死。人之生死原乎气，就此决之，诚一定而无舛者矣。
按：《医宗金鉴》云：吸促之促字，当是远字，吸远之远字，当是促字，方合病义，必传写之讹，此说于义相畔，不可从。
老师说：寸口脉的跳动，是随着时令旺盛而动的。假如肝旺时色青，四季各自随其色。肝色青，而反色白，非其时之色脉，都应当是病。
徐彬注：寸口者，统言左右三部脉也。脉动法乎四时，命乎五脏。然必因其旺时而动，则为平脉也。假令肝旺于春，随其时，色当青，脉当弦，此不病之色脉也。若色反白，脉反浮，此非其时，乃病之色脉也。四时准此。
问：有未到时节而气候先至的，有时节到了而气候没到的，有时节到了而气候不去的，有时节到了而气候过分的，这是什么意思？
老师说：冬至之后，甲子日的夜半，少阳之气始起。少阳之时，阳气开始生发，天气应当变得温和。如果还没到甲子日，天气就温和了，这叫“未至而至”。如果到了甲子日，天气却未温和，这叫“至而不至”。如果到了甲子日，天气依然大寒不解，这叫“至而不去”。如果到了甲子日，天气温暖得像盛夏五六月时，这叫“至而太过”。
尤在泾注：上之至，谓时至；下之至，谓气至。盖时有常数而不移，气无定刻而或迁也。冬至之后甲子，谓冬至后六十日也。盖古造历者，以十一月甲子朔，夜半冬至，为历元。根据此推之，则冬至后六十日，当复得甲子，而气盈朔虚，每岁递迁，于是至日不必皆值甲子，当以冬至后六十日，花甲一周，正当雨水之候为正。雨水者，冰雪解散，而为雨水，天气温和之始也。云少阳起者，阳方起而出地，阳始生者，阳始盛而生物，非冬至一阳...
Question: What is meant by the statement that a superior physician treats disease before it occurs?
The Master replied: The so-called treatment of disease before it occurs refers to observing liver pathology, understanding that liver disease may transmit to the spleen, and therefore first strengthening the spleen. If the spleen qi is prosperous during the four seasons and naturally resistant to pathogenic factors, no specific tonification of the spleen is necessary. An average physician, lacking knowledge of this inter-organ transmission, sees liver disease but fails to strengthen the spleen, focusing solely on treating the liver itself. In treating liver disease, sour herbs are used for tonification, scorched bitter herbs for assistance, and sweet herbs for harmonization. Sour flavor enters the Liver; scorched bitter flavor enters the Heart; sweet flavor enters the Spleen. A strong Spleen can control the Kidney; as Kidney qi becomes weak, water metabolism normalizes and does not flood; with water controlled, Heart fire becomes vigorous; excessive Heart fire then controls Lung metal; if Lung metal is impaired, its qi movement stagnates; consequently, Liver qi becomes relatively excessive, allowing the liver disease to heal spontaneously. This is the subtlety of "treating the liver by supplementing the spleen." This method applies to Liver deficiency patterns, not Liver excess patterns. The Classics state: "Do not make deficiency more deficient, nor excess more excess," meaning to tonify insufficiency and reduce excess. This principle applies analogously to other organs. (Zhao Kaimei's edition contains redundant characters: "Heart fire qi is vigorous" appears twice after the first mention, and "therefore strengthen the spleen" appears after "Liver qi is excessive"; these are interpolations.)
Cheng Lin commented: Treating disease before it occurs means treating organs that have not yet been affected by disease, not treating people who are not yet sick. I believe seeing liver disease and supplementing the spleen is acceptable, but saying that supplementing the spleen harms the Kidneys is questionable. Can the Kidneys truly be harmed? If Heart fire is excessive and harms the Lungs, can the Lungs truly be harmed? If so, even if the liver disease heals, one would subsequently need to treat the Lungs and Kidneys using this method, leaving the five Zang organs without peace. The character "shang" (harm) should be read as "zhi" (control/restrain). Proper restraint brings harmony to the five Zang organs, preventing various diseases.
You Jingjing noted: According to the *Su Wen* (Basic Questions), when pathogenic factors invade the body, they follow the cycle of mutual overcoming. The Liver belongs to Wood and overcomes Spleen Earth; thus, liver disease transmits to the spleen. "Strengthening the spleen" means boosting spleen qi to resist pathogens, which is the essence of "treating disease before it occurs." Ignoring this and treating only the liver means the liver disease remains while spleen disease arises, which is not the practice of a superior physician. Using sour herbs to tonify the liver addresses liver insufficiency by adding its native flavor. This differs from the *Nei Jing* (Inner Canon)'s statement that "pungent flavors tonify the liver." However, the Liver is a Yin organ containing Sheng Qi (vital generating energy); pungent flavors assist its function, while sour flavors nourish its substance. Though the wording differs, both principles are valid. Assisting with scorched bitter flavors aligns with the *Qian Jin Fang* (Thousand Golden Prescriptions) concept that "when Heart qi is vigorous, it influences the Liver." Using sweet herbs to harmonize aligns with the *Nan Jing* (Classic of Difficult Issues) saying, "To damage the Liver, soothe its center." The fifteen sentences starting from "Sour flavor enters the Liver" are suspected to be later annotations mistakenly included in the text. Zhang Zhongjing's true intent in "treating the liver by supplementing the spleen" lies in ensuring the spleen is solid to resist liver pathogens, not in harming the Kidneys via spleen tonification or inciting Heart fire to attack Lung metal. Such an approach would cause more harm than good. Furthermore, if the spleen is supplemented, the lungs will naturally prosper; if the kidneys are injured, they will weaken and affect their offspring (the Liver). Where is the logic in controlling Lung metal to strengthen Liver wood? Careful analysis suggests the first nine sentences answer the question on "superior physicians treating disease before it occurs," while the three sentences on "sour, bitter, and sweet" present the specific treatment for Liver deficiency. As stated later, "Use this method for liver deficiency, not for excess," it is clear that deficiency patterns receive pathogens while excess patterns do not; excess pathogens transmit, while deficiency pathogens do not. Therefore, treating liver excess involves strengthening spleen earth to prevent spread, while treating liver deficiency involves directly tonifying the home organ to prevent external invasion. This is Zhang Zhongjing's key principle of addressing both excess and deficiency. Later scholars misunderstood the principle of "soothing the center" for liver disease, erroneously clinging to "sweet enters the spleen," omitting sour and scorched bitter flavors, and over-interpreting sweet herbs as the essence of "treating the liver by supplementing the spleen." As the ancients said, "Words reveal cognitive limitations," which applies here.
Xu Bin commented: Average physicians fail to distinguish deficiency and excess; applying purgatives to deficiency constitutes "making deficiency more deficient," and applying tonics to excess constitutes "making excess more excess," which is incorrect. Superior physicians understand deficiency and excess, tonifying what is insufficient and reducing what is excessive.
Note: The *Nan Jing* (77th Difficulty) states: "Superior physicians treat disease before it occurs, average physicians treat disease after it has occurred." It explains that seeing liver disease implies knowing it will transmit to the spleen, hence strengthening spleen qi to prevent liver pathogens from invading. This is "treating disease before it occurs." The 81st Difficulty reiterates: "Do not make excess more excess or deficiency more deficiency, do not damage the insufficient and benefit the excessive." The term "shang shen" (harm kidney) in the main text corresponds to "zhi shen" (control kidney) in the *San Yin Fang*. Cheng Lin's note likely derives from this. The phrase "gan xu" (liver deficiency) in the *San Yin Fang* is written as "xu gan" (deficient liver). Based on You Jingjing's annotation treating the fifteen sentences as notes, the text flows logically without needing to change "gan xu."
Generally, human constitution follows the Five Constants (Five Phases), growing due to Wind-Qi. While Wind-Qi generates all things, it can also harm them, just as water can float a boat or capsize it. If the primordial truth (Yuan Zhen) within the five Zang organs flows smoothly, the person remains peaceful and healthy. Invasion by alien wind-pathogens often leads to death. The myriad calamities of disease do not exceed three categories: First, pathogens entering the meridians and transmitting to the zang-fu organs constitute the internal cause. Second, pathogens affecting the four limbs and nine orifices, causing blood and vessel congestion, constitute the external skin/muscle cause. Third, injuries from sexual activity, metal/blades, insects, or beasts constitute non-internal/external causes. Analyzing these exhausts the origins of disease. If one cultivates caution, preventing wind-pathogens from disrupting meridians, and treats them early—before they reach the zang-fu—or uses Dao Yin (guiding and pulling), Tu Na (breathing exercises), acupuncture, and ointment massage at the first sign of limb heaviness, keeping the nine orifices open, and avoids legal troubles, animal attacks, and sexual exhaustion, while regulating diet temperature and the five flavors (bitter, sour, pungent, sweet, salty) to prevent physical decline, disease cannot enter the Cou Li (skin texture and interstices). Cou Li are the places where San Jiao (Triple Burner) channels Yuan Zhen and blood/qi. Li refers to the textures of skin and organs. ("Bing" [inherit] is written as "Bing" [hold/grasp] in Xu Bin's, Shen Mingzong's editions, and *Yi Zong Jin Jian*. "Cai" [just] is written as "Cai" in Zhao Kaimei's edition.)
Shen Mingzong commented: This passage is the core thesis and outline of the book. Previous editors misplaced it in Chapter 2; placing it at the beginning corrects the sequence. The Five Constants refer to the Five Phases. Humans inherit the constant Qi of Heaven and Earth's Five Phases and Yin-Yang. This Qi is Wind. Wind corresponds to East, Jia/Yi, and is the primary Qi of seasonal generation. Heavenly Qi transforms and nurtures all things through the movement of Eight Winds, bringing cold, heat, dryness, dampness, and fire. Humans are formed by receiving these Qi. Thus, "growing due to Wind-Qi." Wind has righteous (Zheng) and evil (Xie) aspects. Righteous wind is gentle and nurturing; evil wind is erratic and destructive. Hence, "Wind generates but also harms." "Primordial truth flowing smoothly" means internal Qi is sufficient to resist pathogens. Abnormal weather (heat in cold seasons, cold in hot seasons) represents alien wind-pathogens, which are lethal. Diseases fall into three causes: Internal (meridian/pathogen to zang-fu), External (limbs/orifices/blood vessels), and Non-internal/External (sexual/dietary/injury). The *Ling Shu* states: Deficient pathogens cannot injure alone; they require bodily deficiency. Thus, San Jiao Qi governs blood/qi/fluids, filling organs and Cou Li, preventing pathogen entry. Cou Li are the gaps filled by San Jiao Qi and fluids, forming the barrier against disease.
You Jingjing noted: Chen Wuzhe's *San Yin Fang* classifies Six Excesses as External Causes, Five Emotions as Internal Causes, and diet/sex/injuries as Non-internal/External Causes. Zhang Zhongjing focuses on alien wind-pathogens, distinguishing internal/external by meridian/zang-fu involvement rather than injury origin. Chen Wuzhe distinguishes by origin (external vs. internal vs. neither). Both are clear and compatible.
Cheng Lin commented: Cou Li are where San Jiao Qi warms muscles and gathers Yuan Zhen/blood/qi. Li includes coarse, fine, dense, separated, and fleshy textures of skin, as well as the structures of fu and zang organs.
Note: *Wen Zi* states humans are the heart of Heaven and Earth and the start of Five Phases, born of their Qi. *Xun Zi* states water carries and capsizes boats. "Zhen" is synonymous with "Chen" (disease). Tao Hongjing's *Zhou Hou Bei Ji Fang* divided diseases into internal, external, and other causes. Chen Wuzhe followed Tao but differed from Zhang Zhongjing's intent. "Wu" means reverse/adverse. *Yi Qie Jing Yin Yi* defines Dao Yin as self-massage/stretching to remove fatigue, and An Mo as manual massage by others. *Zhuang Zi* mentions breathing techniques (Tu Na) and animal postures for longevity. "Tu Gu Na Xin" means exhaling turbid air and inhaling clear air. Gao Mo is massage with ointment. *Yu Han Jing* lists decoctions, powders, pills, acupuncture, and Gao Mo as equal methods. *Yi Zong Jin Jian* considers "An Mo" a misprint.
Question: Patients show facial complexion changes. Please explain.
The Master said: A blue nose tip indicates abdominal pain; if accompanied by aversion to cold, death ensues. (Note: Or says abdominal cold/pain leads to death.) A slightly black nose tip indicates fluid retention. A yellow nose tip indicates cold-fluid in the chest. A white nose tip indicates loss of blood. If slightly red out of season, death ensues. Eyes fixed straight ahead indicate untreatable conditions. Generally, blue indicates pain, black indicates chronic strain, red indicates wind, yellow indicates difficulty defecating, and bright/lustrous color indicates retained fluid.
Xu Bin commented: This section describes inspection (Wang) methods.
Xu Bin commented: Color (Se) refers to the five hues; Qi (Qi) refers to their luster.
Cheng Lin commented: The *Nei Jing* states colors are the brilliance of Qi. Subtle pulse/color signs can be observed visually. The nose is the Ming Tang (Bright Hall). A moist, clear Ming Tang indicates health.
You Jingjing commented: The nose tip reflects the Spleen. Blue is Liver color. Abdominal pain indicates Wood attacking Earth. Cold implies Yang collapse and Water aiding pathogens, leading to death. Kidneys govern Water; Black is Water color. Spleen weakness allows Kidney Qi to dominate, causing fluid retention. Yellow face indicates Spleen disease generating fluid retention (Cold-fluid). White face indicates blood loss lacking luster. If blood is lost, Yang cannot escape; slight redness out of season indicates floating deficient Yang, leading to death. Fixed eyes indicate Yin exhaustion. Spasm is a Wind-strength disease with Yin exhaustion and Yang hyperactivity, hence untreatable. Pain causes blood stasis (blue). Strain damages Kidneys (black). *Nei Jing* states Kidney deficiency yields a face like lacquered charcoal. Wind is Yang pathogen (red). Spleen dysfunction causes constipation (yellow). Bright luster indicates retained fluid (*Nei Jing*: edema patients have puffy eyes under the eyes and bright faces).
Xu Bin commented: Eyes gather the essence of the five Zang and generate Spirit. Fixed eyes indicate spasm and Yin exhaustion. Postpartum spasms also relate to Yin. Fixed eyes definitely indicate Yin exhaustion, hence untreatable.
Note: *Ling Shu · Wu Se Pian* states blue/black indicate pain, yellow/red indicate wind. Further reference is needed.
The Master said: Silent speech with sudden shouting indicates joint disease. Hoarse, muffled speech indicates Heart/Diaphragm disease. Whispering, thin, long speech indicates head disease. (Note: Or says pain.)
Xu Bin commented: This section describes auscultation (Wen) methods. Silence with sudden shouting relates to Jueyin Liver Wood, which governs fright and shouting. Deep penetration into joints is indicated. Hoarse speech indicates obstruction of Upper Jiao Qi in the Chest/Diaphragm, blocking Lung Metal resonance. Whispering/thin/long speech indicates fear of sound rising from head pathology, suppressing voice.
Wei Litong commented: This illustrates drawing inferences. *Yi Deng Xu Yan* states sudden silence followed by shouting indicates deep joint disease. Joints relate to tendons (Liver) and bones (Gallbladder); shouting originates from Liver/Gallbladder. Muffled sound indicates Heart/Diaphragm obstruction. Thin/long sound indicates dampness clouding Clear Yang in the head.
Note: *Yi Zong Jin Jian* suggests "Head" should be "Abdomen," interpreting whispering/thin/long speech as mumbling due to fear of moving Qi in the abdomen. This interpretation is rejected as inconsistent.
The Master said: Shoulder movement during respiration indicates fullness in the Heart/Chest. Respiration drawing Qi upward from the chest indicates cough. Open-mouthed shortness of breath indicates Lung萎 (Flaccidity) with frothy saliva.
Wei Litong commented: Shoulder movement indicates Qi stagnation in the Heart obstructing normal ascent/descent. Cough involves chaotic, rebellious Qi. Open-mouthed shortness of breath indicates Lung fluid depletion and Qi consumption, confirming Lung Flaccidity with frothy saliva (dry mouth, sticky froth).
Xu Bin commented: Shoulder lifting indicates chest fullness. Upward drawing Qi with throat tickle indicates cough. Open-mouthed breathing resembling panting without shoulder lifting indicates shortness of breath. Cough with sputum is phlegm-cough. Persistent frothy sputum indicates Lung Flaccidity, not simple cough.
The Master said: Rapid, shallow inhalation indicates excess in the Middle Jiao; purgation cures it. Deficiency makes it untreatable. Inhalation that is rapid/short indicates Upper Jiao pathology. Inhalation that is slow/deep indicates Lower Jiao pathology. These are difficult to treat. Trembling during respiration indicates untreatable Yang collapse.
You Jingjing commented: "Xi" refers to inhalation. Middle Jiao excess blocks downward Qi flow, causing rapid inhalation. Purgation resolves excess. If deficiency, Qi is rootless and dissipates, hence untreatable. Some argue Middle Jiao excess with deficient Yuan Qi cannot tolerate purgation nor self-regulate, hence untreatable. Upper Jiao excess prevents Qi entry, causing rapid return (short inhalation). Lower Jiao excess delays Qi return, causing deep inhalation. These involve Zang Qi dysfunction, unlike Middle Jiao excess which can be purged, hence difficult.
Wei Litong commented: Trembling during respiration indicates Yang departure and Qi dispersion, making treatment impossible. Respiration determines life and death based on Qi.
Note: *Yi Zong Jin Jian* suggests "Rapid" and "Deep" are swapped in transmission errors. This is rejected as contradictory to pathology.
The Master said: Cun Kou pulse movements follow seasonal prosperity. For example, Liver prospers in Spring with blue color. Each season has corresponding colors. If Liver is blue but color is white, or pulse/color mismatch the season, disease is present.
Xu Bin commented: Cun Kou covers left and right three positions. Pulses follow seasons and Zang organs. Prosperous timing indicates normal pulse. Liver prospers in Spring with blue color and wiry pulse. White color and floating pulse indicate disease. This applies to all seasons.
Question: What are "arriving before time," "arriving late," "lingering past time," and "excessive arrival"?
The Master said: After Winter Solstice, on the Jia Zi day at midnight, Shaoyang Qi begins. At this time, Yang starts to grow, and weather becomes warm. If weather is warm before Jia Zi day, it is "arriving before time." If weather is not warm on Jia Zi day, it is "arriving late." If severe cold persists on Jia Zi day, it is "lingering past time." If weather is excessively warm like midsummer on Jia Zi day, it is "excessive arrival."
You Jingjing commented: "Arrival" refers to solar terms (time) and climatic Qi. Time is fixed; Qi varies. Jia Zi after Winter Solstice is 60 days later. Ancient calendars set Winter Solstice on Jia Zi midnight. Due to calendar drift, Winter Solstice doesn't always fall on Jia Zi. The correct point is 60 days after Winter Solstice, coinciding with Rain Water (Yu Shui), when ice melts and warmth begins. "Shaoyang rises" means Yang emerges from the earth; "Yang begins to grow" means Yang strengthens to generate life, distinct from the single Yang of Winter Solstice...