问脉有下指浮大。按久索然者。有下指濡软。按久搏指者。有下指微弦。按久和缓者
。何也。答曰。夫诊客邪暴病。应指浮象可证。若切虚羸久病。当以根气为本。如下指浮大。按久索然者。正
气大虚之象。无问暴病久病。虽证显灼热烦扰。皆正衰不能自主。随虚阳发露于外也。下指濡软。久按搏指者
。里病表和之象。非脏气受伤。则坚积内伏。不可以脉沉误认为虚寒也。下指微弦。按久和缓者。久病向安
之象。气血虽殆。而脏气未败也。然多有证变多端。而脉渐小弱。指下微和。似有可愈之机者。此元气与病气
俱脱。反无病象发现。乃脉不应病之候。非小则病退之比。大抵病患之脉。初下指虽见乏力。或弦细不和。按
至十余至渐和者。必能收功。若下指似和。按久微涩不能应指。或渐觉弦硬者。必难取效。设病虽牵缠。而饮
食渐进。便溺自调。又为胃气渐复之兆。经云。安谷者胃。浆粥入胃。则虚者活。此其候也。
问有病同而脉异。病异而脉同。病同而治异。病异而治同。何也。答曰。夫所谓病
同而脉异者。人在气交之中。所感六淫七情。八风九气。一时之病。大率相类。故所见之证。亦多相类。而人之
所禀。各有偏旺偏衰之不同。且有内戕神志。外役肢体。种种悬殊。脉象岂能如一。如失血证。脉有浮大而芤
者。有小弱而数者。伤胃及脏之不同也。气虚证有气口虚大而涩者。有气口细小而弱者。劳伤脱泄之不同也。
病异而脉同者。内伤夹外感。阳证夹阴寒。虚中有实结。新邪挟旧邪。表里交错。为患不一。而脉之所现。不
离阴阳寒热虚实之
机。其细微见证。安得尽显于指下哉。如太阳中风。瘫痪不仁。脉皆浮缓。一为暴感之邪。一为久虚之病。虚
劳骨蒸。病疟寒热。关尺皆弦紧。一为肾脏阳虚。一为少阳邪盛。可不互参脉证。一概混治乎。病同而治异者
。风气之病。时气之病。疟利之病。内伤虚劳之病。初起见证。往往相似。而人之所禀。各有贞脆。且有多火
多痰多气。平时之资质既殊。病中之调治自异。如金匮之短气有微饮者。从小便去之。苓桂术甘汤主之。肾气
丸亦主之。消渴小便不利。蒲灰散主之。滑石白鱼散茯苓戎盐汤并主之。若治病不求其本。不问脉证之真象假
象。但见病医病。殊失逆从反正之旨矣。病异而治同者。所见之证虽异。总不外乎邪正之虚实。如伤寒尺中脉
迟之营气不足。阳邪内陷之腹中痛。虚劳里急之悸衄失精。并宜小建中汤。伏气郁发之热病。太阳中热之 病
。并宜白虎汤。寒疝之腹急胁急。产后之腹中 痛。并宜当归生姜羊肉汤。岂以一方主治一病。而不达权变之
用哉。
问：脉象在手指初下时表现为浮大，但久按却空虚无力的；有的初下指时感觉濡软，但久按时却搏动有力、冲击手指的；有的初下指时微带弦象，但久按时却和缓从容的。这是什么原因呢？
答：诊治外感客邪引起的急性暴病，脉象应指浮大是可以证实的。但如果切诊身体虚弱消瘦的慢性久病，则应当以根本之气为本。如下指浮大，久按却空虚无力的，这是正气极度虚弱的征象。无论是急性暴病还是慢性久病，即使症状表现为明显的灼热烦扰，也都是正气衰败不能自主，导致虚阳暴露于外的表现。下指感觉濡软，久按却搏动有力的，这是里病而表气和顺的征象。如果不是脏气受伤，就是坚硬的积滞内伏，不可以因为脉沉就误认为是虚寒证。下指微弦，久按却和缓的，这是久病趋向安宁的征象。虽然气血已经危殆，但脏气尚未败坏。然而，临床上常有症状变化多端，而脉象逐渐变小变弱，指下感觉微微和缓，看似有痊愈机会的情况。这其实是元气与病气都脱绝了，反而没有表现出病症的迹象，这是脉象与病情不相符的征候，并不是脉小就意味着病退。大致来说，病人的脉象，初下指时虽然显得乏力，或者弦细不和，但按至十余次跳动后逐渐变得和缓的，必定能够取得疗效。如果初下指时似乎和缓，但久按却微涩不能应指，或者逐渐觉得弦硬，必定难以取效。假设病情虽然缠绵，但饮食逐渐增加，大小便自然调畅，这也是胃气逐渐恢复的征兆。《内经》说：“能进食者胃气存。”浆粥进入胃中，那么虚弱的人就能存活。这就是这种征候。
问：有病名相同而脉象不同，病名不同而脉象相同，病名相同而治法不同，病名不同而治法相同的，这是什么原因呢？
答：所谓病同而脉异，是因为人生活在天地气交之中，所感受的六淫（风、寒、暑、湿、燥、火）七情（喜、怒、忧、思、悲、恐、惊），以及八风九气，一时之间的发病，大体上相似。所以所见到的症状，也多相类似。但是每个人的禀赋，各有偏旺偏衰的不同，而且有内在损伤神志、外在役使肢体的种种悬殊，脉象怎么能完全一样呢？例如失血证，脉象有浮大而芤的，也有细小弱数的，这是由于伤及胃或伤及脏的不同所致。气虚证，脉象有气口部虚大而涩的，也有气口部细小而弱的，这是由于劳伤脱泄的不同所致。
病异而脉同，是指内伤夹杂外感，阳证夹杂阴寒，虚证中有实结，新邪挟带旧邪，表里交错，为患不一，但脉象所显现的，不离阴阳、寒热、虚实之机。那些细微的症状表现，怎么可能完全显露在指下呢？例如太阳中风，出现瘫痪不仁，脉象都是浮缓，一个是暴感之邪，一个是久虚之病；虚劳骨蒸，疟疾寒热，关尺脉皆弦紧，一个是肾脏阳虚，一个是少阳邪盛。难道可以不互参脉证，一概混治吗？
病同而治异，是指风气病、时气病、疟痢病、内伤虚劳病，初起时的症状往往相似，但人的禀赋各有贞固与脆弱之分，且有多火、多痰、多气的不同，平时的体质既然殊异，病中的调治自然不同。例如《金匮要略》中短气伴有轻微饮邪的，通过小便去除，用苓桂术甘汤主治；肾气丸也主治此证。消渴伴小便不利的，蒲灰散主治；滑石白鱼散、茯苓戎盐汤并主治此证。如果治病不求其根本，不问脉证的真实或假象，只是见病医病，就严重违背了逆从反正的宗旨了。
病异而治同，是指所见症状虽然不同，总不外乎邪正虚实的道理。例如伤寒尺中脉迟导致的营气不足，阳邪内陷导致的腹中痛，虚劳里急导致的悸动、衄血、失精，都适宜用小建中汤。伏气郁发导致的热病，太阳中热导致的暍病，都适宜用白虎汤。寒疝导致的腹急胁急，产后导致的腹中痛，都适宜用当归生姜羊肉汤。怎么能认为一方只主治一病，而不通达权变的作用呢？
Question: Regarding the pulse, when the fingers first press down, it appears floating and large, but after prolonged pressing, it feels empty and lacking substance; or when the fingers first press down, it feels soft and soggy, but after prolonged pressing, it beats forcefully against the fingers; or when the fingers first press down, it is slightly wiry, but after prolonged pressing, it feels harmonious and moderate. What is the reason for this?
Answer: When diagnosing external pathogenic factors causing acute sudden diseases, a floating pulse upon initial palpation can confirm the condition. However, when palpating patients with deficiency and emaciation suffering from chronic long-term diseases, one must take the root qi (fundamental energy) as the basis. For instance, a pulse that is floating and large upon initial touch but empty and lacking substance upon prolonged pressing indicates a severe deficiency of righteous qi (vital energy). Regardless of whether it is an acute sudden disease or a chronic long-term disease, even if symptoms manifest as obvious burning heat and restlessness, these are all signs of righteous qi failing to maintain autonomy, leading to deficient yang revealing itself externally. A pulse that feels soft and soggy upon initial touch but beats forcefully against the fingers upon prolonged pressing indicates internal pathology with harmonious exterior qi. This is not due to injury to zang-organ qi, but rather implies hidden firm accumulations internally; one should not mistake a deep pulse for deficiency-cold. A pulse that is slightly wiry upon initial touch but becomes harmonious and moderate upon prolonged pressing indicates a long-term disease tending towards recovery. Although qi and blood may be critically depleted, the zang-organ qi has not yet failed. However, clinically, there are often cases where symptoms change in various ways, while the pulse gradually becomes smaller and weaker, feeling slightly harmonious under the fingers, seemingly indicating a chance of recovery. This actually signifies that both yuan qi (original qi) and pathogenic qi have detached, resulting in no pathological manifestations appearing; this is a sign where the pulse does not correspond to the disease, rather than indicating that a small pulse means the disease is receding. Generally speaking, for a patient's pulse, if it initially feels weak or wiry and irregular under the fingers, but gradually becomes harmonious after about ten beats, treatment will likely succeed. If the pulse seems harmonious initially but becomes slightly choppy and fails to respond upon prolonged pressing, or gradually feels wiry and stiff, treatment will likely fail. Assuming the disease is lingering, but diet gradually increases and urination/defecation naturally regulate, this is also a sign of gradual recovery of stomach qi. The Classics state: "Those who can eat have stomach qi." When gruel and porridge enter the stomach, the deficient person survives. This is such a manifestation.
Question: There are cases where diseases are the same but pulses differ, diseases differ but pulses are the same, diseases are the same but treatments differ, and diseases differ but treatments are the same. What is the reason?
Answer: Regarding "same disease, different pulse," humans live within the intersection of heaven and earth qi, contracting the six excesses (wind, cold, summerheat, dampness, dryness, fire) and seven emotions, as well as eight winds and nine qi variations. Sudden illnesses at any given time are generally similar. Thus, observed symptoms are also mostly similar. However, each person's constitution varies in excess and deficiency, and there are differences in internal damage to spirit/mind and external strain on limbs. How can pulses be identical? For example, in blood-loss syndromes, pulses may be floating, large, and hollow (Kou pulse), or small, weak, and rapid, differing based on whether the stomach or zang-organs are injured. In qi-deficiency syndromes, pulses at the Qi Kou position may be deficient, large, and choppy, or small, thin, and weak, differing based on the nature of labor injury or depletion.
Regarding "different diseases, same pulse," this refers to internal injuries complicated by external contractions, yang syndromes complicated by yin-cold, deficiency with solid knots, new pathogens carrying old pathogens, and interlaced interior-exterior issues. Pathologies vary, but the manifested pulse always revolves around the mechanisms of yin-yang, cold-heat, and deficiency-excess. How can subtle symptom details fully reveal themselves under the fingers? For instance, Taiyang wind-strike presenting with paralysis and numbness shows a floating-slow pulse; one is an acute external contraction, the other a chronic deficiency disease. Consumption with bone-steaming fever and malaria chills/fevers show wiry-tight pulses at Guan and Chi positions; one is kidney yang deficiency, the other Shaoyang pathogen excess. Can one ignore correlating pulse and symptoms and treat indiscriminately?
Regarding "same disease, different treatment," conditions like wind-pathogen diseases, seasonal epidemic diseases, malaria/dysentery diseases, and internal injury consumption diseases often present with similar initial symptoms. However, constitutions vary in resilience and fragility, and individuals may have tendencies toward excessive fire, phlegm, or qi. Since baseline constitutions differ, treatments during illness must differ. For example, in *Jin Gui Yao Lue*, shortness of breath with slight fluid retention is treated by promoting urination using Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction); Shen Qi Wan (Kidney Qi Pill) is also used. For thirst with difficult urination, Pu Hui San (Cattail Pollen Powder) is used; Hua Shi Bai Yu San (Talcum, White Fish, and Powder Decoction) and Fu Ling Rong Yan Tang (Poria, Tallow Tree Salt, and Decoction) are also used. If treating disease without seeking its root, ignoring the true or false appearance of pulse and symptoms, and merely treating the disease name, one severely deviates from the principles of counteracting and correcting deviations.
Regarding "different diseases, same treatment," although observed symptoms differ, they ultimately revolve around the deficiency and excess of pathogens and righteous qi. For example, Ying qi insufficiency due to slow pulse at Chi position in Shang Han (Cold Damage), abdominal pain due to inward collapse of yang pathogen, palpitations, epistaxis, and seminal emission due to internal tension in Xiao Lao (Consumption) are all suitable for Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). Febrile diseases due to latent pathogen郁发 (stagnation and eruption), and Yue Bing (Heatstroke) due to Taiyang heat are all suitable for Bai Hu Tang (White Tiger Decoction). Abdominal and hypochondriac urgency due to Han Shan (Cold Colic), and abdominal pain postpartum are all suitable for Dang Gui Sheng Jiang Yang Rou Tang (Angelica Sinensis, Fresh Ginger, and Mutton Decoction). How can one assume one formula treats only one disease, failing to understand the application of flexibility and adaptation?