喻昌曰∶息出于鼻，其气布于膻中。膻中宗气，主上焦息道，恒与肺胃关通，或清而徐，或短而促，咸足以占宗气
之盛衰。所以《经》云∶乳之下，其动应衣，宗气泄也。人顾可奔迫无度，令宗气盛喘数急，有余反成不足耶？此指呼
出为息之一端也。其谓起居如故而息有音，此肺之络脉逆也。不得卧而息有音者，是阳明之逆也。益见布息之气，关通
肺胃，又指呼出为息之一端也。呼出心肺主之；吸入肾肝主之；呼吸之中，脾胃主之。故惟脾胃所主中焦，为呼吸之总
持。设气积贲门不散，而阻其出入，则危急存亡非常之候。善养生者，俾贲门之气，传入幽门，幽门之气，传二阴之窍
而出，乃不为害。其上焦下焦，各分呼出吸入，未可以息之一字，统言其病矣。此义惟仲景知之，谓息摇肩者心中坚，
息引胸中上气者咳，息张口短气者，肺痿唾沫。分其息颛主乎呼，而不与吸并言，似乎创说。不知仲景以述为作，无不
本之《内经》，昌前所拟呼出为息二端，不足尽之。盖心火乘肺，呼气奔促，势有必至。呼出为心肺之阳，自不得以肝
肾
之阴混之耳。息摇肩者，肩随息动，惟火故动也。息引胸中上气咳者，肺金收降之令不行，上逆而咳，惟火故咳也。张
口短气，肺痿唾沫，又金受火形不治之证，均以出气之粗，名为息耳。然则曷不径以呼名之耶？曰∶呼中有吸，吸中有
呼，剖而中分，圣神所不出也。但以息之出者主呼之病，而息之入者主吸之病，不待言矣。《经》谓乳子中风热，喘鸣肩
息，以及息有音者，不一而足。惟其不与吸并言，而吸之病转易识别，然尚恐后人未悉，复补其义云∶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，在下焦者其吸迟，此皆难治。呼吸动摇振振者不治，见吸微且
数，吸气之往返于中焦者速，此必实者下之，通其中焦之壅而即愈。若虚则肝肾之本不固，其气轻浮脱之于阳，不可治
矣。昌前所指贲门幽门不下通，为危急存亡非常之候者此也。在上焦者其吸促，以心肺之道近其真阴之虚者，则从阳火
而升，不入于下。故吸促，是上焦未尝不可候其吸也。下焦者其吸迟，肝肾之道远其元阳之衰者，则困于阴邪所伏，卒
难升上，故吸迟。此真阴元阳受病，故皆难治。若呼吸往来，振振动摇，则营卫往返之气已索，所存呼吸一线耳，尚可
为哉？学人先分息之出入，以求病情，既得其情，合之愈益不爽。若但统论呼吸，其何以分上中下三焦所主乎？噫！微
矣。
【律一条】
凡辨息，不分呼出吸入以求病情，毫厘千里，医之过也。
喻昌说：呼吸之气从鼻孔出入，其气运行于膻中穴所在区域。膻中处的宗气（积聚于胸中的大气），主要主管上焦的呼吸通道，经常与肺、胃的功能相通。呼吸或清长而缓慢，或短促而急迫，都足以用来判断宗气的盛衰情况。所以《黄帝内经》中说：“乳头下方，跳动剧烈到衣服随之颤动，这是宗气外泄的表现。”人怎么能不顾节制地奔忙劳碌，导致宗气旺盛而喘息急促、频率过快，使得原本有余的状态反而变成不足呢？这是指出“呼出”是“息”的一个方面。如果说起居如常但呼吸有声音，这是肺的络脉之气逆乱所致。不能平卧且呼吸有声音的，是阳明胃经之气上逆所致。这更加说明布散呼吸之气的关键在于肺和胃的通畅，这也是指出“呼出”是“息”的另一个方面。呼出由心肺所主；吸入由肾肝所主；在呼吸的中间过程，由脾胃所主。因此，只有脾胃所主的“中焦”，才是呼吸的根本枢纽。如果气积聚在贲门（胃的上口）不散，阻碍了气的出入，那就是危急存亡的非常征候。善于养生的人，会让贲门的气传入幽门（胃的下口），幽门的气再传至二阴（前后二阴户）排出体外，这样才不致为害。上焦和下焦分别主管呼出和吸入，不能简单地用“息”这一个字来统括所有的病症。这个道理只有张仲景深知，他说：“呼吸时肩膀摇动的，是心中痞坚；呼吸牵引胸中气逆上冲的是咳嗽；呼吸张口短气的，是肺痿并伴有唾沫。”他将呼吸分开论述，专门针对呼出的病症，而不与吸入并列提及，似乎是一种创新的说法。不知道张仲景是以阐述经典为本进行创作，无不依据《黄帝内经》，我前面拟定的将“呼出”作为“息”的两个方面，还不足以完全涵盖其中的深意。大概是因为心火侵犯肺金，导致呼气奔促，这是必然的趋势。呼出属于心肺的阳气，自然不能用肝肾的阴气来混淆。呼吸时肩膀摇动，是因为肩随呼吸而动，唯有火邪才会导致这种躁动。呼吸牵引胸中气逆上冲而咳嗽，是因为肺金收敛下降的功能不行，气机上逆而咳，唯有火邪才会导致这种咳嗽。张口短气、肺痿唾沫，又是金受火刑难以治愈的证候，都是因为出气粗重，所以称为“息”。既然如此，为什么不直接称之为“呼”呢？回答说：呼中有吸，吸中有呼，如果强行将其剖开并从中分开，那是圣神境界所不取的做法。只是说，以呼出的气息异常来主治呼相关的病，以吸入的气息异常来主治吸相关的病，这是不言而喻的。《黄帝内经》中提到乳子（哺乳期妇女）中风热，出现喘鸣、肩息（呼吸时耸肩），以及呼吸有声音等情况，不胜枚举。只是因为这些没有与吸气并列提及，所以吸气的病症反而容易识别，然而还是担心后人不能完全理解，所以补充阐述其义理：吸气轻微且快速，病在中焦实证，应当用攻下法治疗即可痊愈，若是虚证则无法治愈。病在上焦的，吸气短促；病在下焦的，吸气迟缓，这些都是难治之症。呼吸时身体动摇振颤的，无法治愈。看到吸气轻微且快，说明吸气往返于中焦的速度很快，这必定是实证，通过攻下法疏通中焦的壅滞即可痊愈。如果是虚证，则是肝肾的根本不稳固，气轻浮脱失于阳分，不可治愈了。我前面所指出的贲门、幽门不通畅，导致危急存亡的非常征候，指的就是这种情况。病在上焦的吸气短促，是因为心肺之道接近真阴，若真阴虚损，则气从阳火而上升，不能下行入下焦。所以吸气短促，说明上焦并非不能通过吸气来诊察病情。病在下焦的吸气迟缓，是因为肝肾之道远离元阳，若元阳衰微，则气困于阴邪潜伏之中，难以迅速升发上来，所以吸气迟缓。这是因为真阴和元阳受到病变，所以都难治愈。如果呼吸往来之间，身体振振动摇，说明营卫往返的气机已经枯竭，仅存一线呼吸之气，还能有什么作为呢？学习中医的人，先要分清呼吸的出入，以求得病情的真相，既然掌握了病情，结合其他诊法会更加准确无误。如果只是笼统地谈论呼吸，又怎能区分上、中、下三焦各自所主的病症呢？唉！道理真是精微啊。
【律一条】
凡是诊察呼吸，如果不分辨呼出和吸入来探求病情，就会差之毫厘谬以千里，这是医者的过错。
Yu Chang stated: Respiration originates from the nose, and its qi distributes to the Shanzhong (Chest Center) region. The Zongqi (Pectoral Qi) at Shanzhong primarily governs the respiratory pathway of the Upper Jiao (Upper Burner), and is constantly connected with the Lung and Stomach. Whether respiration is clear and slow, or short and rapid, all suffice to indicate the abundance or deficiency of Zongqi. Therefore, the *Classic* (Huangdi Neijing) states: "Below the breast, if the pulsation is visible through the clothing, it indicates leakage of Zongqi." How can people run about without restraint, causing Zongqi to become excessive while leading to panting, rapid breathing, and urgency, thereby turning excess into deficiency? This points out that exhalation is one aspect of "respiration" (Xi). When daily activities are normal but there is sound during respiration, this is due to the reversal of the collateral vessels of the Lung. Inability to lie flat accompanied by sound during respiration indicates the reversal of Yangming Stomach channel qi. This further demonstrates that the qi distributing respiration is connected to the Lung and Stomach; this is another aspect pointing out that exhalation is part of "respiration." Exhalation is governed by the Heart and Lung; inhalation is governed by the Kidney and Liver; within the process of breathing, the Spleen and Stomach are in charge. Thus, only the Middle Jiao (Middle Burner) governed by the Spleen and Stomach serves as the master control of respiration. If qi accumulates at the cardia (Bumen, upper opening of the stomach) and does not disperse, obstructing entry and exit, it constitutes a critical state of survival or death. Those skilled in health preservation allow the qi from the cardia to transmit to the pylorus (Youmen, lower opening of the stomach), and the qi from the pylorus to transmit to the two yin openings (anterior and posterior orifices) for discharge, thus avoiding harm. The Upper and Lower Jiaos respectively govern exhalation and inhalation; one cannot simply use the single character "respiration" to generalize all diseases. This principle was known only by Zhang Zhongjing, who stated: "Shoulders moving with respiration indicates firmness in the heart center; respiration drawing qi upward from the chest causes cough; open-mouthed shortness of breath indicates Lung萎 (Fei Wei, Lung Atrophy/Withering) with spittle." He separated respiration, focusing specifically on diseases related to exhalation without mentioning inhalation together, which seems like an innovative theory. However, Zhang Zhongjing's work was based on exposition of classics, rooted in the *Inner Canon*. My previous proposal of two aspects of exhalation as respiration is insufficient to cover everything. Generally, when Heart Fire invades the Lung, exhalation becomes urgent and rapid, which is inevitable. Exhalation belongs to the Yang of the Heart and Lung, and naturally should not be confused with the Yin of the Kidney and Liver. Shoulders moving with respiration occur because the shoulders move with the breath; only Fire causes such movement. Respiration drawing qi upward from the chest causing cough occurs because the Lung Metal's function of contracting and descending fails, leading to rebellious qi and cough; only Fire causes such cough. Open-mouthed shortness of breath, Lung Withering with spittle, are also untreatable conditions where Metal is damaged by Fire, all named "respiration" due to rough exhalation. Then why not simply call it "exhalation"? The answer is: There is inhalation within exhalation, and exhalation within inhalation; separating them strictly is beyond the scope of sage wisdom. It is merely understood that abnormalities in exhaled air govern diseases of exhalation, and abnormalities in inhaled air govern diseases of inhalation, which goes without saying. The *Classic* mentions that infants suffering from wind-heat present with wheezing, shoulder-respiration (panting with shoulder movement), and various sounds during respiration, among many other examples. Because these were not mentioned alongside inhalation, inhalation-related diseases became easier to identify. However, fearing later generations might not fully understand, I supplement the meaning: Mild and rapid inhalation indicates excess in the Middle Jiao, which heals immediately after purgation; deficiency cases are untreatable. Inhalation that is short and rapid indicates disease in the Upper Jiao; inhalation that is slow and delayed indicates disease in the Lower Jiao; both are difficult to treat. Respiration accompanied by whole-body trembling indicates untreatability. Seeing mild and rapid inhalation means the return journey of qi in the Middle Jiao is fast; this must be excess, treated by purgation to unblock the Middle Jiao obstruction, leading to immediate cure. If it is deficiency, the root of the Kidney and Liver is unstable, qi floats and escapes to the Yang level, making it untreatable. This is what I previously referred to as the critical state caused by the blockage between the cardia and pylorus. Inhalation that is short and rapid in the Upper Jiao occurs because the pathways of the Heart and Lung are close to True Yin; if True Yin is deficient, qi rises via Yang Fire and does not enter the Lower Jiao. Thus, short inhalation shows that the Upper Jiao can indeed be diagnosed via inhalation. Inhalation that is slow in the Lower Jiao occurs because the pathways of the Kidney and Liver are distant from Yuan Yang; if Yuan Yang is declining, qi is trapped by latent Yin pathogens and struggles to rise, hence slow inhalation. Since True Yin and Yuan Yang are diseased, both are difficult to treat. If respiration involves whole-body trembling, the qi of Ying and Wei circulating has been exhausted, leaving only a thread of respiration; what can be done? Students should first distinguish the entry and exit of respiration to ascertain the condition; once the condition is known, combining it with other methods yields accurate results. If one only discusses respiration generally, how can one differentiate the governance of the Upper, Middle, and Lower Jiaos? Alas, the principle is subtle.
[Rule One]
In diagnosing respiration, failing to distinguish between exhalation and inhalation to determine the pathology leads to errors of miles for every inch; this is the fault of the physician.