痧之重者，形之于脉，前言已概之矣。至如杂病兼痧，始发甚微，疑似莫辨，所谓审脉之道，则又吾笔所难书，吾
言所难罄。惟在医者临症之际，神明其意于切脉之中，斩截其痧于方发之始。盖痧之慢者，讵云日久必坏脏腑，损经络，
溃肌表乎。即其轻而又轻者，虽不至骤伤其命，而于杂病之中，一有兼痧，不能审治，其病将缠绵难愈，即愈亦必数数
复发，疾苦相连，此痧之所以可畏，当预审之于几先也。
脉微细者，生；脉实大急数者，重；脉洪大无伦者，凶。一部无脉者，轻；一手无脉者，重；两手无脉者，死。六
脉无根，放痧服药不应者，不治；诸怪脉现，放痧服药不应者，死。
凡属暗痧之类，人多不识，误中其祸，故悉列之于前，庶令人一开帙而注目焉。下卷痧症，人所易明，故姑置之于
后。
心中闷闷不已，欲食不食，行坐如常。即饮温热，不见凶处，更无心腹腰背疼痛之苦，但渐渐憔悴，日甚一日，若
不知治，亦成大害，此痧之慢而轻者也，放之即愈。亦有头痛发热，心中作胀，类于伤寒，亦有寒热往来，似疟非疟，
闷闷不已，亦有咳嗽烦闷，有似伤风，亦有头面肿胀，两目如火，亦有四肢红肿，身体重滞，不能转侧，此痧之慢而重
者也。误吃热汤，热酒、热物，遂乃沉重，或昏迷不醒，或痰喘气急，狂乱见凶。如遇是症，必先审脉辨症的确，果系
何因，在表者刮；在中者放；在里者或丸或散或煎剂，必须连进数服，俟其少安，渐为调理。
治验∶
一余三婶母寡居，四月间忽然昏迷沉重，不省人事，颜色具变，渐渐黑色。二弟骧武次衡延他医治之，莫识其病。
适余至视疾，诊之左脉洪大，右脉沉微，余曰此暗痧也。审其腿弯有青筋三条，刺之，紫黑血流如注，不醒；刮痧亦不
醒；用沉香郁金散加砂仁，并荆芥汤稍冷服之，不醒；次日用宝花散、薄荷汤加大黄丸，微冷服亦不醒；至五日，复刮
痧，用三香散加砂仁汤温下，而后醒，渐调理乃痊。
一余友朱其章一老仆，六月发热沉重，昏迷不醒，黑苔芒刺，舌短狂骂，不避亲疏。其章延余往视，诊其脉，六部
具伏。余曰∶“此痧之重极者也”。彼亲中有厉姓，善放痧。使二人极力扶起，从腿弯有青筋处刺之，但微有紫黑血点而
已，痧血不流，将入死地。余用宝花散蒺藜散稍冷汤饮之，又用紫苏浓朴汤微冷服，次日痧退少苏。但身重如石，不能
转侧，舌上黑苔芒刺不退，用红花汤合清凉至宝饮治之，以渐而愈。
一麓庵朱兄一婢，十二岁，六日不食，头面微肿。余适与于茂生至麓庵宅，即令婢出诊脉，冀立一消食方。余曰∶
“脉微面肿，殆其痧乎”。刺腿弯上一针，紫黑血流不愈，用宝花散稍冷汤饮之，一服而痊。
痧症严重的，在脉象上会有表现，前面已经概括说明了。至于杂病兼夹痧症，刚开始发病时症状很轻微，难以辨别，所谓诊察脉道的要领，又是我的笔墨难以写尽、言语难以说清的。只有在医生临症之时，在切脉的过程中神机妙用、心领神会，才能在痧症刚发作之初就果断地祛除它。大概痧症缓慢的，难道说日子久了必然损害脏腑、损伤经络、溃烂肌肤表面吗？即使是轻之又轻的，虽然不至于突然危及生命，但在杂病之中，一旦兼夹了痧症而不能审察治疗，病情将会缠绵难愈，即使痊愈也必定多次复发，疾苦相连，这就是痧症之所以令人畏惧的原因，应当在细微征兆出现之前就预先审察处理。
脉象微细的，主生；脉象实大急数的，病重；脉象洪大无比的，凶险。一部（一个部位）无脉的，病轻；一手无脉的，病重；两手均无脉的，主死。六部脉均无根底，放痧和服药后无效的，不治；各种怪脉出现，放痧和服药后无效的，主死。
凡是属于暗痧之类的病症，人们大多不认识，误中其祸害，所以全部列在前面，希望让人一打开书卷就能注意看。下卷的痧症，人们容易明白，所以暂时放在后面。
心中烦闷不止，想吃东西却吃不下，行走坐卧如常。即使饮用温热的水，也不见凶险之处，更没有心腹腰背疼痛的痛苦，只是渐渐憔悴，一天比一天严重，如果不知道治疗，也会造成大害，这是痧症缓慢而轻浅的，放痧即可痊愈。也有头痛发热，心中胀满，类似于伤寒的；也有寒热往来，像疟疾又不是疟疾的，烦闷不止的；也有咳嗽烦闷，类似伤风的；也有头面肿胀，两眼如火烧般的；也有四肢红肿，身体沉重滞涩，不能转侧的，这是痧症缓慢而沉重的。误吃热汤、热酒、热物，于是病情加重，或者昏迷不醒，或者痰喘气急，狂乱出现凶兆。如果遇到这种病症，必须先审察脉象、辨明症状的确切情况，果真是由于什么原因，在表位的刮痧；在中焦的放痧；在里位的或用丸药、或散剂、或煎剂，必须连续服用几副，等到病情稍微安定，再逐渐调理。
治验案例：
其一，我三婶母寡居，四月间忽然昏迷沉重，不省人事，脸色全部改变，渐渐变黑。二弟骧武、次衡请其他医生医治，无法识别这是什么病。恰逢我前去诊治，诊察发现左脉洪大，右脉沉微，我说这是暗痧。审察她腿弯处有三条青筋，刺破后，紫黑色的血如注般流出，但病人未醒；刮痧也未醒；用沉香郁金散加砂仁，并用荆芥汤稍冷服下，未醒；第二天用宝花散、薄荷汤加大黄丸，微冷服下也未醒；到了第五天，再次刮痧，用三香散加砂仁汤温服，之后才醒来，逐渐调理后痊愈。
其二，我的朋友朱其章的一位老仆人，六月发热沉重，昏迷不醒，舌苔黑且有芒刺，舌头短缩，狂骂人，不分亲疏。朱其章请我去诊治，诊察他的脉象，六部脉都伏匿不见。我说：“这是痧症极重的。”他亲戚中有个姓厉的，擅长放痧。让两人极力扶起病人，从腿弯有青筋的地方刺破，只有微量的紫黑色血点而已，痧血不流，病人将入死地。我用宝花散、蒺藜散稍冷的汤水饮下，又用紫苏浓朴汤微冷服下，第二天痧退少苏。但身体沉重如石，不能转侧，舌上黑苔芒刺不退，用红花汤合清凉至宝饮治疗，逐渐痊愈。
其三，麓庵朱兄的一个婢女，十二岁，六天没吃东西，头面微肿。我恰好与于茂生到麓庵宅邸，就让婢女出来诊脉，希望能立刻开一个消食的方子。我说：“脉微面肿，大概是痧症吧。”刺腿弯上一针，紫黑色的血流出不止，用宝花散稍冷的汤水饮下，一副药后痊愈。
Severe Sha (Sha disease, a condition characterized by sudden onset of symptoms due to pathogenic factors) manifests in the pulse, as previously summarized. Regarding miscellaneous diseases complicated by Sha, the initial onset is very subtle and difficult to distinguish, making the method of pulse diagnosis hard to fully capture with words or writing. It relies on the physician's intuitive insight during pulse taking to decisively eliminate Sha at its earliest stage. Generally, slow-onset Sha does not necessarily damage the Zang-Fu organs (internal organs), meridians, or skin surface over time. Even mild cases, while not immediately fatal, if complicated by Sha and misdiagnosed, will lead to chronic, lingering illness with frequent relapses and continuous suffering. This is why Sha is feared and must be anticipated and treated before obvious signs appear.
A fine and thin pulse indicates survival; a full, large, rapid, and forceful pulse indicates severity; an excessively surging and large pulse indicates peril. Absence of pulse in one region suggests mildness; absence in one hand suggests severity; absence in both hands indicates death. If all six pulses lack root and respond neither to bloodletting nor medication, the case is incurable; if strange pulses appear and fail to respond to treatment, it indicates death.
Since "Hidden Sha" (a type of Sha with subtle symptoms often mistaken for other diseases) is unrecognized by many, leading to mishandling, it is listed first to draw attention. The Sha syndromes in the lower volume are easier to understand, so they are placed later.
Symptoms include persistent mental oppression, loss of appetite despite desire to eat, yet normal mobility. Drinking warm fluids shows no immediate danger, and there is no pain in the chest, abdomen, waist, or back. However, the patient gradually becomes emaciated and worse day by day. Without proper treatment, this can become severe. This represents slow and mild Sha, which resolves after bloodletting. Other presentations include headache and fever with abdominal distension, resembling Taiyang syndrome (Exterior Syndrome); alternating chills and fever, resembling malaria but not quite; persistent mental oppression; coughing with irritability, resembling wind-cold invasion; swelling of the head and face with burning eyes; redness and swelling of limbs with heavy body stiffness preventing movement. These represent slow and severe Sha. Ingestion of hot soups, wine, or food exacerbates the condition, leading to coma, phlegm-wheezing,急促 breathing, madness, and ominous signs. In such cases, the physician must accurately diagnose the pulse and symptoms. For exterior involvement, scraping therapy is used; for middle-jiao involvement, bloodletting is applied; for interior involvement, pills, powders, or decoctions are administered continuously until stabilization, followed by gradual regulation.
Case 1: My third aunt, widowed, suddenly fell into deep coma in April, unconscious, with complexion changing to black. My second brothers, Xiangwu and Ciheng, sought other doctors who could not identify the disease. Upon my examination, the left pulse was surging and large, while the right pulse was deep and faint. I diagnosed Hidden Sha. Three green veins were found behind the knees; puncturing them released dark purple-black blood profusely, but she remained unconscious. Scraping also failed. Shenxiang Yujin San (Agarwood and Curcuma Powder) with Amomum fruit, taken cool with Jingjie Decoction, did not work. The next day, Baohua San (Treasure Flower Powder) with Bohe Decoction and Dahuang Pills, taken slightly cool, also failed. On the fifth day, scraping was repeated, and Sanxiang San (Three Fragrances Powder) with Amomum decoction was given warm, after which she woke up and recovered through gradual调理 (regulation).
Case 2: An old servant of my friend Zhu Qizhang suffered from fever and heaviness in June, falling into coma with black tongue coating with prickles, short tongue, cursing madly without recognizing relatives. Pulse diagnosis revealed all six positions were hidden/deep. I stated this was extreme severe Sha. A relative surnamed Li, skilled in bloodletting, was summoned. After being held upright, puncture behind the knee yielded only minor dark blood spots, failing to release Sha blood, pushing the patient toward death. I administered Baohua San and Jili San (Tribulus Powder) with cool water, followed by Zisu Nongpo Tang (Perilla and Magnolia Bark Decoction) slightly cool. The next day, Sha receded slightly, but the body remained heavy as stone, unable to move, and the black tongue coating persisted. Honghua Tang (Safflower Decoction) combined with Qingliang Zhibao Yin (Cooling Precious Treasure Drink) led to gradual recovery.
Case 3: A maid of Brother Zhu Lu'an, aged twelve, had not eaten for six days and had slight facial swelling. Visiting his residence, I examined her pulse to prescribe a digestive remedy. Noting the fine pulse and swollen face, I suspected Sha. Puncturing the leg released dark purple-black blood. Baohua San with cool water cured her after one dose.