六十一难曰∶经言望而知之谓之神，闻而知之谓之圣，问而知之谓之工，切脉而知之谓之
巧，何谓也？
望，谓望病患五脏之色见于面者，各有分部，以应相生相克之候也。闻，谓闻病患之声音，
以察病之所在也。问，谓问病患之所患，及其爱憎喜怒，以求病之原也。切，谓切病患之脉，
而得病出何脏何腑也。神，神化不测之谓。圣，至于至极之谓。工，专精之谓。巧，心智灵变
之谓。此与《灵枢·邪气脏腑病形篇》微有不同，经言或别有所本也。
然∶望而知之者，望见其五色以知其病。
望而知之者，望其资禀色泽间之神气。《灵枢》所谓粗守形，上守神者是也。然人之神气，
在有意无意之间，流露最真。医者清心凝神，一会即觉，不宜过泥，泥则私意一起，医者与病
者神气相混，反觉疑似，难以捉摸，此又以神会神之妙理也。神气云何？有光有体是也。光者，
外面明朗，体者，里面润泽，光无形，主阳主气，体有象，主阴主血，气血无乖，阴阳不争，
自然光体俱备矣。《素问·五脏生成篇》曰∶五脏之气，故色见青如草兹者死，黄如枳实者死，
黑如 者死，赤如 血者死，白如枯骨者死，此五色之见死也。夫五色干枯，以气血俱亡，无
光无体，神气已去者也，故主死。又青如翠羽者生，赤如鸡冠者生，黄如蟹腹者生，白如豕膏
者生，黑如乌羽者生，此五色之见生也。是以气血未伤，有光有体，不能内含，而亦不外露者
也，故虽病而主生。又，生于心，如以缟裹朱；生于肺，如以缟裹红；生于肝，如以缟裹绀；
生于脾，如以缟裹栝蒌实；生于肾，如以缟裹紫，此五脏所生之外荣也。夫平人五脏既和，其
色禀胃气而出于皮毛之间，胃气色黄，皮毛色白，精气内含，宝光外发，既不浮露，又不混蒙，
故曰如缟裹也。观《内经》论色，分死、病、平三等，虽未明言神气，而神气即寓其中。然五
色内应五脏，此道其常，而病则有变，甚有五色不应五脏者，此又变中之变也。若能察神气，
因其常而识其变，则于望色之道，得其要领矣。
闻而知之者，闻其五音，以别其病。
闻而知之者，闻其音声，分别清浊，以察其病也。土者其数五，五者，音也，故音声发于脾
土，而响于肺金也。在心主言，心开窍于舌，舌者，音声之机也。肝主语，肝循喉咙，入颃颡。
喉咙者，气之所以上下者也。颃颡者，分气之所泄也。肝心气和，而后言语清亮也。然又从肾
间动气之所发，故肾气短促，上气不能接下气矣。是以发言歌咏，出于五脏神之五志，故有音
声，语言不清者，当责之心肝，能语言，而无音声者，当责之脾肺；能言语，有音声，而气不
接续者，当责之两肾，此音声之原委也。若经以五音配五脏，肝音角，其声呼，心音征，其声
笑；脾音宫，其声歌；肺音商，其声哭；肾音羽，其声呻。若明其原委，辨其清浊，分其阴阳，
审其虚实，以察病情，于闻声一法，庶乎近矣。
问而知之者，问其所欲五味，以知其病所起所在也。
问而知之者，问察其原委也。夫工于问者，非徒问其证，殆欲即其证以求其病因耳。脱营失
精，可于贵贱贫富间问之，更当次第问其人。平昔有无宿疾，有无恚怒忧思，食喜淡喜浓喜燥
喜润，嗜茶嗜酒。再问其病初起何因，前见何证，后变何证。恶寒恶热，孰重孰轻。有汗无汗，
汗多汗少，汗起何处，汗止何处。头痛身痛，痛在何时，痛在何处。口淡口苦，渴与不渴，思
饮不思饮，饮多饮少，喜热喜凉，思食不思食，能食不能食，食多食少，化速化迟。胸心胁腹，
有无胀痛。二便通涩，大便为燥为溏，小便为清为浊，色黄色淡。妇人则问其有无胎产，月事
先期后期，有无胀痛，可有带下，是赤是白，或多或少。种种详诘，就其见证，审其病因，方
得治病求本之旨也。
切脉而知之者，诊其寸口，视其虚实，以知其病在何脏腑也。
切而知之者，诊其寸口，以知其病也，非《内经》遍诊动脉之法也。或问《内经》遍诊动脉，
只设浮沉缓急，大小滑涩之八脉，特于对待微甚悬绝，着其相去三等，而脉之情变已精，后世
繁为二十九脉，愈求精而脉愈晦者，因独取寸口之误耶，曰∶非也。张氏云∶后世知识脉难，
而不知古人审脉之更难也。所谓识脉者，浮，不沉也。沉，不浮也。迟，不及也。数，太过也。
虚，不实也。实，不虚也。滑，不涩也。涩，不滑也。长，不短也。短，不长也。大，不小也。
小，不大也。缓，不逮也。弱，不盛也。伏，不见也。软，无力也。微，不显也。散，不聚也。
洪，洪大也。细，微细也。代，更代也。牢，坚牢也。动者，滑大于关上也。弦者，状如弓弦，
按之不移也。紧者，如转索无常也。芤者，浮大而按之中空也。革者，中空而外坚也。结者，
缓而有止也。促者，数而有止。以对待之法识之，犹易分别于指下。所谓审脉者，体认所见之
脉何因，所主之病何证，以心印之而后得也。仲景平脉篇曰∶浮为在表，沉为在里，数为在腑，
迟为在脏。又曰∶浮则为风，浮则为热，浮为气实，浮为气虚，浮则无血，浮则为虚。是将为
外感乎，为内伤乎，为气乎，为血乎，为实乎，为虚乎，是必审其证之表里阴阳，寒热虚实，
病之久病新病，脉之有力无力，而断之以意，然后参之以望闻问，必四诊咸备，庶几可保万全。
故曰∶审脉之更难也，可不慎欤？
经言以外知之曰圣，以内知之曰神，此之谓也。
视色闻声者，以外知之也，故曰圣。问因切脉者，以内知之也，故曰神。此总结上文四诊之
意也。
上第四卷，四十八难至六十一难，论病。
第六十一难说：医经中说，通过观察就能诊断疾病称为“神”，通过听声音就能诊断疾病称为“圣”，通过询问就能诊断疾病称为“工”，通过切脉就能诊断疾病称为“巧”，这是什么意思呢？
望，是指观察病患面部显现的五脏颜色，面部各部位有对应的脏腑分部，以此来判断相生相克的病候。闻，是指听取病患的声音，以此来探查病变的部位。问，是指询问病患的病痛所在，以及其好恶、喜怒等情绪，以此来探求疾病的根源。切，是指切按病患的脉搏，从而得知疾病出自何脏何腑。神，是指神妙变化、不可测度的境界。圣，是指达到至高至极的境界。工，是指技艺专精。巧，是指心智灵敏多变。这与《灵枢·邪气脏腑病形篇》中的说法略有不同，医经或许另有本源。
然而，所谓“望而知之”，是通过观察五色来知晓病情。
所谓“望而知之”，是观察患者禀赋色泽间的神气。这就是《灵枢》所说的“粗工守形，上工守神”。人的神气，在有意无意之间流露最为真实。医者需清心凝神，一接触便能察觉，不宜过于拘泥，一旦拘泥则私意产生，医者与患者的神气相互混杂，反而觉得疑似难辨，难以捉摸，这又是以神会神的微妙道理。什么是神气？就是有光有体。光，指外表明朗；体，指内部润泽。光无形，主阳主气；体有形，主阴主血。气血不乖违，阴阳不争竞，自然光与体都具备了。《素问·五脏生成篇》说：五脏之气，所以面色呈现如死草般的青色者死，如枳实般的黄色者死，如枯骨般的白色者死，如凝血般的赤色者死，如屋漏般的黑色者死，这是五色呈现的死候。五色干枯，是因为气血俱亡，无光无体，神气已去，所以主死。又青色如翠鸟羽毛者生，赤色如鸡冠者生，黄色如蟹腹者生，白色如猪油者生，黑色如乌鸦羽毛者生，这是五色呈现的生候。这是因为气血未受损伤，有光有体，既不能内含过度，也不外露过分，所以虽然生病但主生。另外，心脏生的气，像用白绢包裹朱砂；肺脏生的气，像用白绢包裹红色；肝脏生的气，像用白绢包裹青紫色；脾脏生的气，像用白绢包裹瓜蒌实；肾脏生的气，像用白绢包裹紫色，这是五脏所生的外在荣华表现。健康人五脏调和，其颜色禀受胃气而显露于皮毛之间，胃气色黄，皮毛色白，精气内含，宝光外发，既不浮露，又不混蒙，所以说像白绢包裹一样。观察《内经》论色，分为死、病、平三等，虽然没有明言神气，但神气即寓含其中。然而五色内应五脏，这是讲常态，而生病时则有变化，甚至有五色不应五脏的情况，这又是变中之变。如果能察知神气，依据常态来识别变化，那么在望色的方法上，就掌握了要领了。
所谓“闻而知之”，是通过听取五音来辨别疾病。
所谓“闻而知之”，是听取其声音，分辨清浊，以此来察知病情。土的数字是五，五是音，所以声音发源于脾土，而回响于肺金。在心，主司言语，心开窍于舌，舌是发声的关键。肝主司语言，肝经脉循行喉咙，进入颃颡（咽喉上部软腭处）。喉咙是气上下通行的地方。颃颡是分气的地方。肝气和心气调和，然后言语才能清亮。然而声音又从肾间的动气发出，所以肾气短促，上气不能接下气。因此发言歌咏，出于五脏之神和五志，所以有声。语言不清的，应当责之于心肝；能说话但没有声音的，应当责之于脾肺；能说话且有声音，但气息不接续的，应当责之于两肾，这是声音的源流。如果按照经典将五音配属五脏，肝音为角，其声为呼；心音为徵，其声为笑；脾音为宫，其声为歌；肺音为商，其声为哭；肾音为羽，其声为呻。如果明了其源流，辨别清浊，区分阴阳，审察虚实，以此来察知病情，那么在闻声这一方法上，就差不多接近道了。
所谓“问而知之”，是通过询问其对五味（酸苦甘辛咸）的欲望，来知晓疾病的发生原因和所在部位。
所谓“问而知之”，是询问并察知疾病的原委。善于问诊的人，不仅仅是询问症状，更是想要根据症状来探求病因。例如脱营证、失精证，可以通过询问患者的贵贱贫富状况来了解，更应当按顺序详细询问其人。平时是否有宿疾，是否有愤怒忧思，饮食喜好清淡还是浓味，喜好燥性还是润性，是否嗜茶嗜酒。再询问疾病初起的原因，先前出现什么症状，后来变成什么症状。恶寒与恶热，哪个重哪个轻。有汗无汗，汗多汗少，汗从哪里出，汗在哪里止。头痛身痛，疼痛在什么时候，疼痛在什么部位。口淡口苦，口渴还是不渴，想喝水还是不想喝水，喝水多还是少，喜欢热饮还是冷饮，想吃东西还是不想吃，能吃还是不能吃，吃多吃少，消化快还是慢。胸、心、胁、腹，是否有胀痛。大小便通利还是涩滞，大便是干燥还是溏薄，小便清澈还是浑浊，颜色是黄还是淡。妇女则询问是否有胎产，月经是先期还是后期，是否有胀痛，是否有带下，带下是赤色还是白色，量多量少。种种详细诘问，结合所见症状，审察病因，才能得到治病求本的宗旨。
所谓“切脉而知之”，是通过诊察寸口脉，观察其虚实，来知晓疾病在何脏腑。
所谓切而知之，是诊察寸口脉来知晓病情，这不是《内经》遍诊动脉的方法。有人问，《内经》遍诊动脉，只设立浮、沉、缓、急、大、小、滑、涩这八种脉象，特别在于对比它们的微甚、悬绝，标明它们相差三个等级，这样脉的情状变化已经很精细了，后世繁复地列出二十九种脉象，越是求精细反而脉象越晦涩，是因为独取寸口的错误吗？回答说：不是。张氏说：后世的人认为识脉难，却不知道古人审脉更难。所谓识脉，就是知道：浮，是不沉；沉，是不浮；迟，是不及（慢）；数，是太过（快）；虚，是不实；实，是不虚；滑，是不涩；涩，是不滑；长，是不短；短，是不长；大，是不小；小，是不大；缓，是不逮（不及）；弱，是不盛；伏，是不见；软，是无力量；微，是不显；散，是不聚；洪，是洪大；细，是微细；代，是更代（间歇）；牢，是坚牢；动，是滑大于关部之上；弦，是状如弓弦，按之不移；紧，是如转索无常；芤，是浮大而按之中空；革，是中空而外坚；结，是缓而有止息；促，是数而有止息。用对待的方法来识别，在指下还容易分别。所谓审脉，是要体认所见之脉是什么原因所致，所主的病症是什么证候，用心印证后才能得到。仲景《平脉篇》说：浮脉表示病在表，沉脉表示病在里，数脉表示病在腑，迟脉表示病在脏。又说：浮则为风，浮则为热，浮为气实，浮为气虚，浮则无血，浮则为虚。这究竟是外感呢，还是内伤？是气病呢，还是血病？是实证呢，还是虚证？必须审察症状的表里、阴阳、寒热、虚实，病的久病新病，脉的有力无力，然后用意念判断，再参考望、闻、问三诊，必须四诊齐全，才可以保证万无一失。所以说：审脉更难，能不谨慎吗？
医经说，从外部征象知晓病情叫“圣”，从内部机理知晓病情叫“神”，说的就是这个意思。
观察面色、听取声音，是从外部知晓，所以叫“圣”。询问病因、切按脉搏，是从内部知晓，所以叫“神”。这是对上文四诊意义的总结。
以上第四卷，从第四十八难到第六十一难，论述疾病。
Difficulty 61 states: The medical classics say, "Diagnosing through observation is called 'Shen' (Divine), diagnosing through hearing is called 'Sheng' (Sage), diagnosing through questioning is called 'Gong' (Skilled), and diagnosing through pulse palpation is called 'Qiao' (Skillful). What does this mean?"
Observation (Wang) refers to observing the colors of the Five Zang organs manifested on the patient's face. Each area of the face corresponds to specific organ divisions, allowing one to assess patterns of mutual generation and restriction (Xiang Sheng Xiang Ke). Hearing (Wen) refers to listening to the patient's voice to investigate the location of the disease. Questioning (Wen) refers to asking about the patient's complaints, as well as their preferences, aversions, joy, and anger, to seek the origin of the disease. Pulse palpation (Qie) refers to feeling the patient's pulse to determine which Zang or Fu organ is affected. "Shen" refers to a state of divine transformation that is unfathomable. "Sheng" refers to reaching the utmost perfection. "Gong" refers to specialized expertise. "Qiao" refers to mental agility and flexibility. This differs slightly from the statement in *Ling Shu: Pathogenic Factors, Zang-Fu Organs, and Disease Manifestations Chapter*; perhaps the classic has a different source.
However, "diagnosing through observation" means knowing the disease by observing the five complexions.
To diagnose through observation is to perceive the Shen Qi (Spiritual Energy) within the patient's constitution and complexion luster. This is what *Ling Shu* refers to when it says, "Crude physicians guard the form; superior physicians guard the Shen." Human Shen Qi reveals itself most authentically between intention and non-intention. The physician must clear the mind and concentrate spirit, perceiving it immediately upon contact. One should not be overly rigid; rigidity introduces subjective bias, causing the physician's and patient's Shen Qi to mix, leading to ambiguity and difficulty in grasping the true nature of the condition. This illustrates the subtle principle of comprehending Shen with Shen. What is Shen Qi? It consists of Guang (Light/Luster) and Ti (Body/Substance). Guang refers to external brightness; Ti refers to internal moistness/luster. Guang is formless and governs Yang and Qi; Ti has form and governs Yin and Blood. When Qi and Blood are harmonious and Yin and Yang do not conflict, both Guang and Ti are naturally present. *Su Wen: Generation of Colors of the Five Zang Chapter* states: "The Qi of the Five Zang organs manifests in color. If the color appears like dead grass (greenish-black), death ensues; if like orange peel (dull yellow), death ensues; if like dried bone (pale white), death ensues; if like congealed blood (dark red/black), death ensues; if like leaking roof water (dull black), death ensues. These are the signs of death in the five colors." Dry and withered colors indicate the exhaustion of both Qi and Blood, lacking both Guang and Ti, meaning Shen Qi has departed, hence indicating death. Conversely, green like a kingfisher feather indicates life; red like a rooster comb indicates life; yellow like a crab's belly indicates life; white like pig fat indicates life; black like a crow's feather indicates life. These are signs of life in the five colors. This is because Qi and Blood are undamaged, possessing both Guang and Ti, neither overly internalized nor excessively exposed. Thus, although ill, life is preserved. Furthermore, the healthy appearance of the Heart is like cinnabar wrapped in silk; the Lung is like red wrapped in silk; the Liver is like cyan-purple wrapped in silk; the Spleen is like a trichosanthes fruit wrapped in silk; the Kidney is like purple wrapped in silk. These are the external manifestations of the Five Zang organs. In a healthy person, with harmonious Zang organs, the complexion derives from Stomach Qi and emerges between the skin and hair. Stomach Qi yields a yellow hue, while skin/hair yields a white hue. Essence and Qi are contained internally, and precious luster radiates externally, neither floating/exposed nor muddy/obscure. Hence, it is described as "wrapped in silk." Observing the discussion on colors in *Nei Jing*, it divides into three grades: death, illness, and normalcy. Although "Shen Qi" is not explicitly stated, it is implied within. However, while the five colors correspond internally to the five Zang organs as a norm, diseases involve variations, and sometimes colors do not correspond to the Zang organs, representing variation within variation. If one can observe Shen Qi, using the norm to identify variations, then one grasps the essentials of color diagnosis.
"Diagnosing through hearing" means distinguishing disease by listening to the five tones.
To diagnose through hearing is to listen to the voice, distinguish between clear and turbid sounds, and thereby investigate the disease. Earth corresponds to the number five, and five corresponds to tone. Thus, sound originates from the Spleen-Earth and resonates in the Lung-Metal. The Heart governs speech; the Heart opens into the tongue, which is the mechanism of sound production. The Liver governs language; the Liver meridian circulates along the throat and enters the Ying-Sang (the upper part of the pharynx behind the soft palate). The throat is the pathway for Qi to ascend and descend. The Ying-Sang is where Qi is distributed. When Liver and Heart Qi are harmonious, speech becomes clear and bright. However, sound also emanates from the Moving Qi (Dong Qi) in the Kidneys. Therefore, if Kidney Qi is short, Upper Qi cannot connect with Lower Qi. Vocalization and singing arise from the Five Spirits and Five Emotions of the Zang organs, producing sound. Unclear speech should be attributed to the Heart and Liver; the ability to speak without sound should be attributed to the Spleen and Lungs; the ability to speak with sound but with disconnected breath should be attributed to the two Kidneys. This is the origin and course of sound. If one follows the classic method of matching the five tones to the five Zang organs: Liver corresponds to Jue (Wood), its sound is shouting; Heart corresponds to Zhi (Fire), its sound is laughing; Spleen corresponds to Gong (Earth), its sound is singing; Lung corresponds to Shang (Metal), its sound is weeping; Kidney corresponds to Yu (Water), its sound is groaning. If one understands the origin, distinguishes clarity from turbidity, separates Yin from Yang, and examines deficiency and excess, one can investigate the disease condition. In the method of hearing sounds, one would then be close to mastery.
"Diagnosing through questioning" means asking about desires for the five flavors (sour, bitter, sweet, pungent, salty) to know where the disease originated and is located.
To diagnose through questioning is to inquire and investigate the origin and details. A skilled questioner does not merely ask about symptoms but seeks the etiology based on those symptoms. Conditions such as Tuoying (Depletion of Camp Qi) and Shijing (Loss of Essence) can be understood by asking about the patient's social status (noble/poor) and wealth. One must ask systematically: Does the patient have chronic diseases? Have they experienced anger, worry, or sorrow? Do they prefer light or heavy tastes? Do they prefer dry or moist foods? Are they addicted to tea or alcohol? Further, ask the cause of the initial onset, previous symptoms, and subsequent changes. Which is heavier, aversion to cold or aversion to heat? Is there sweat or no sweat? Is the sweat profuse or slight? Where does the sweat start and stop? Regarding headache or body pain, when does it occur and where is the location? Is the taste bland or bitter? Is there thirst or no thirst? Do they desire to drink or not? Do they drink much or little? Do they prefer hot or cold drinks? Do they desire food or not? Can they eat or not? Do they eat much or little? Is digestion fast or slow? Is there distension or pain in the chest, heart, hypochondrium, or abdomen? Is urination and defecation unobstructed or obstructed? Is stool dry or loose? Is urine clear or turbid? Is the color yellow or pale? For women, ask about pregnancy and childbirth, whether menstruation occurs early or late, presence of distension/pain, presence of leukorrhea (Daixia), whether it is red or white, and the volume. Through such detailed inquiry, correlating observed symptoms with etiology, one achieves the principle of treating the disease by seeking its root.
"Diagnosing through pulse palpation" means examining the Cun-Kou (Radial) pulse, observing deficiency and excess, to know which Zang-Fu organ is diseased.
To diagnose through palpation is to examine the Cun-Kou pulse to identify the disease, which is not the comprehensive pulse diagnosis method of all arteries found in *Nei Jing*. Some may ask: *Nei Jing* lists only eight pulse types for comprehensive diagnosis: Floating (Fu), Deep (Chen), Slow (Huan), Urgent (Ji), Large (Da), Small (Xiao), Slippery (Hua), and Choppy (Se). It emphasizes comparing their intensity and extremes, marking differences of three degrees, making the variations precise. Why did later generations complicate this into twenty-nine pulses, becoming more obscure in pursuit of precision? Is this due to the error of taking only the Cun-Kou pulse? The answer is: No. Zhang [Zhongjing] said: Later generations find identifying pulses difficult, but they do not realize that ancient physicians found examining pulses even more difficult. "Identifying" the pulse means knowing: Floating is not Deep; Deep is not Floating; Slow is not rapid (not reaching); Rapid is excessive; Deficient is not Excess; Excess is not Deficient; Slippery is not Choppy; Choppy is not Slippery; Long is not Short; Short is not Long; Large is not Small; Small is not Large; Slow (Huan) is not deficient (not reaching strength); Weak is not vigorous; Hidden (Fu) is not visible; Soft is without strength; Minute (Wei) is not manifest; Scattered (San) is not gathered; Surging (Hong) is large and expansive; Fine (Xi) is minute and thin; Intermittent (Dai) involves replacement/interruption; Firm (Lao) is solid and fixed; Moving (Dong) is slippery and larger above the Guan position; Wiry (Xian) feels like a bowstring, firm under pressure; Tight (Jin) feels like a twisting rope; Hollow (Kou) is floating and large but empty upon pressure; Leathery (Ge) is empty inside and hard outside; Knotted (Jie) is slow with interruptions; Rapid-Cessation (Cu) is rapid with interruptions. Using comparative methods, these are relatively easy to distinguish under the fingers. "Examining" the pulse requires recognizing the cause of the felt pulse and the syndrome it governs, confirming it with the mind. Zhongjing's *Ping Mai Pian* states: Floating indicates exterior; Deep indicates interior; Rapid indicates Fu organs; Slow indicates Zang organs. It also states: Floating indicates Wind, Heat, Qi excess, Qi deficiency, lack of Blood, or Deficiency. Is it an external contraction or internal injury? Is it a Qi disorder or Blood disorder? Is it Excess or Deficiency? One must examine the symptoms for exterior/interior, Yin/Yang, Cold/Heat, Deficiency/Excess, and the duration of the disease (old vs. new), as well as the strength of the pulse (strong vs. weak), and make a judgment based on reasoning. Then, refer to Observation, Hearing, and Questioning. Only when all four diagnostic methods are complete can one ensure safety and accuracy. Thus, it is said that examining the pulse is even more difficult. How can one not be cautious?
The classics state: Knowing from external signs is called 'Sheng'; knowing from internal mechanisms is called 'Shen'. This is what is meant.
Observing color and hearing sound constitutes knowing from the exterior, hence called 'Sheng'. Asking for causes and palpating the pulse constitutes knowing from the interior, hence called 'Shen'. This summarizes the meaning of the Four Diagnostic Methods discussed above.
Above, Volume IV, Difficulties 48 to 61, discuss diseases.