咽喉肿痛，轻按之痛，重按之快，食饮如故，曰腑实也。诊其脉，浮而实大者是也。皮肤瘙
痒，肌肉 胀，食饮不化，大便滑而不止诊其脉，轻手按之得滑，重手按之得平，此乃腑虚
也。看在何经，而正其时也。胸膈痞满，头目碎痛，饮食不下，脑项昏重，咽喉不利，涕唾
稠粘。诊其脉，左右寸口沉、结、实、大者，上实也。颊赤心忪，举动颤栗，语声嘶嗄，唇
焦口干，喘乏无力，面少颜色，颐颔肿满；诊其左右寸脉弱而微者，上虚也。大小便难，饮
食如故，腰脚沉重，脐腹疼痛；诊其左右手脉，尺中脉伏而涩者，下实也。大小便难，饮食
进退，腰脚沉重，如坐水中，行步艰难，气上奔冲，梦寐危险；诊其左右尺中，脉滑而涩者
，下虚也。病患脉微涩短小，俱属下虚也。
张景岳曰∶通评虚实论曰，邪气盛则实，精气夺则虚，此虚实之大法也。设有人焉，正
已夺
而邪方盛者，将顾其虚而补之乎?抑先其邪而攻之乎?见有不的，则死生系之，此其所以宜慎
也。夫正者，本也；邪者，标也。若正气既虚，则邪气虽盛，亦不可攻，盖恐邪未去而正先
脱，呼吸变生，则措手无及。故治虚邪者，当先顾正气，正气存则不致于害，且补中自有攻
意，盖补阴即所以攻热，补阳即所以攻寒。世未有正气复而邪不退者，亦未有正气竭而命不
倾者。如必不得已，亦当酌量缓急，暂从权宜，从少从多，寓战于守，斯可矣。此治虚之道
也。若正气无损者，邪气虽微，自不宜补。盖补之，则正无与，而邪反盛，适足以借寇兵而
资盗粮。故治实证者，当直攻其邪，邪去则身安。但法贵精专，便臻速效。此治实之道也。
要之能胜攻者，方是实证，实者可攻，何虑之有?不能胜攻者，便是虚证，气去不返，可不
寒心?此邪正之本末，不可不知也。
日本元坚，字廉夫者，尝论列虚实夹杂之证治，甚为明备。其文曰∶为医之要，不过辨
病之
虚实也已。虚实之不明，妄下汤药，则冰炭相反，坐误性命，是以临处之际，不容毫有率略
矣。盖尝考之，厥冷、下利，人皆知大虚宜补；潮热、谵语，人皆知大实宜泻。此则其病虽
重，而诊疗之法，莫甚难者矣。如夫至虚有盛候，大实有羸状者，诚医之所难也。虽然，此
犹难乎辨证，而不难乎处治。何者?假证发露，抑遏真情，自非至心体察，则不能辨其疑似
而认其真；然既认其真也，纯补纯泻，一意直到而病可愈矣，岂有他策耶?唯医之所最难者
，在真实真虚，混淆糅杂者而已。何者?其病视为虚乎，挟有实证；视为实乎，兼有虚候，
必也精虑熟思，能析毫厘，而其情其机，始可辨认。及其施治，欲以补之，则恐妨其实；欲
以泻之，则恐妨其虚。补泻掣肘，不易下手，必也审之又审，奇正攻守，着着中法，而后病
可起矣。此岂非辨认难而处治亦难者乎?岐伯有五有余、二不足之说，而仲景之经，所云难
治者，概此之谓也。盖虚实之相错，其证不能一定，其治不能各无其别也。区而论之，有虚
实相兼者焉。病本邪实，当汗如下，而医失其法；或用药过剂，以伤真气，病实未除，又见
虚候者，此实中兼虚也。治之之法，宜泻中兼补，倘虚甚者，或不得已，姑从于补，虚复而
后宜议泻矣。其人素虚，阴衰阳盛，一旦感邪，两阳相搏，遂变为实者，此虚中兼实也。治
之之法，不清凉无由解热，不转刷无由逐结，然从前之虚不得罔顾，故或从缓下，或一下止
服。前哲于此证，以为须先治其虚，后治其实，此殆未是也。大抵邪不解则不受补，有邪而
补，徒增壅住；且积日之虚，岂暂补所能挽回乎?考之经文，如附子泻心、调胃承气，即泻
中兼补之治也。阳明病至，循衣摸床，微喘直视，则既属虚惫，而犹用承气者，以实去而阴
可回；纵下后顿见虚候，其实既去，则调养易施也。扩充触长，无适而不可矣。此虚实之相
兼，大较如此。如夫虚实之相因而生，是亦不可不辨也。有人于此焉，脾气亏损，或久吐，
或久利，中气不行，驯至腹满、溺闭，此自虚而生实也。至其满极，则姑治其标，主以疏导
，然不以扶阳为念，则土崩可待也。又有人焉，肾阴不足，下亏上盈，或潮热、心烦，或血
溢、痰涌，亦是虚生实者也。至其火亢，则姑治其标，专主清凉，然不以润养为念，则真元
竭绝矣。有人于此焉，肠 赤 ，腹痛后重，如其失下，则病积依然，而津汁日泄，羸劣日
加，此自实而生虚也。治法或姑从扶阳，然不以磨积为先，则邪胜其正，立至危殆。又有人
焉，肝气壅实，妄言妄怒，既而脾气受制，饮食减损，日就委顿，亦是实生虚者也。治法或
姑从补中，然不兼以清膈，则必格拒不纳矣。在仲景法，则汗后胀满，是自虚而实，故用且
疏且补之剂。五劳虚极，因内有干血，是自实而虚，宿食脉涩，亦自实而虚，故一用大黄
虫丸，一用大承气汤。盖干血下而虚自复，宿食去而胃必和也。此虚实相因而生之大略也。
要之，相兼者与相因者，病之新久，胃之强弱，尤宜参伍加思，亦是诊处之大关钥也。更论
虚实之兼挟，则表里上下之分，又不可不知也。实在表而里虚者，补其中而病自愈，以病之
在
外，胃气充盛，则宜托出，且里弱可以受补，如发背、痘疮之类是也。实在里而兼虚者，除
其实而病自愈，以病之属热，倘拦补之，必助其壅，如彼虚人，得胃实与瘀血、宿食之类是
也。病上实素下寒者，必揣其脐腹，而后吐、下可用；病下虚素上热者，必察其心胸，而后
滋补可施。此表里上下之例也。虽然，今此所论，大概就病之属热者而立言已。如病寒之证
，亦不可不辨焉。经云∶气实者热也，气虚者寒也。盖胃强则热，胃弱则寒，此必然之理也
，故寒病多属虚者。然有如厥阴病之上热下寒，此其上热虽未必为实，而未得不言之犹有阳
存，故凉温并用，方为合辙矣。寒病又有阳虽虚而病则实者，固是胃气本弱，然关门犹有权
，而痼寒宿冷僻在一处，或与邪相并，或触时气而动，以为内实也。倘其初起满闭未甚者，
须
温利之；满闭殊剧者，攻下反在所禁，唯当温散之。盖以寒固胃之所畏，其实之极，必伤胃
气，遂变纯虚耳!观仲景太阴病及腹满、寒疝之治，而其理可见也。然则病寒之实，必要温
补，固不可与病热之虚，犹宜清涤者一例而论矣。《玉函经》曰∶寒则散之，热则去之。可
谓一言蔽之已。是寒热之分，诚虚实证治之最吃紧也。病之虚实，药之补泻，各有条例，其
略如此，而微甚多少之际，犹有不可计较者，实如张景岳氏之言焉。夫虚实之不明，补泻之
不当，而栩栩然欲疗极重极险之病者，岂足与语医哉!
要之，病之实，实有百也；病之虚，虚有百也。实之泻，泻有百也；虚之补，补有百也
。而
大旨总视胃气之盛衰有无，以为吉凶之主。《内经》曰∶五实死，五虚死。脉盛，(心也。)
皮热，(肺也。)腹胀，（脾也。）前后不通，(肾也。)闷瞀，(肝也。)此谓五实。脉细，(心也
。)皮寒，(肺
也。)气少，(脾也。)泄利前后，(肾也。)饮食不入，(肝也。)此谓五虚。其时有生者，何
也?曰∶浆粥入胃，泄注止，则虚者活；身汗得后利，则实者活。全注云∶此皆胃气之得调
和也。韪哉言乎!缪仲淳曰∶谷气者，譬国家之饷道也。饷道一绝，则万众立散；胃气一败
，则百药难施。若阴虚，若阳虚，或中风，或中暑，乃至泻利、滞下、胎前、产后，疔肿、
痈疽、痘疮，痧疹、惊疳，靡不以保护胃气、补养脾气为先，务本所当急也。故益阴宜远苦
寒，益阳宜防增气，祛风勿过燥散，消暑毋轻下通，泻利勿加消导，滞下之忌芒硝、巴豆、
牵牛，胎前泄泻之忌当归，产后寒热之忌黄连、栀子，疔肿痈疽之未溃忌当归，痘疹之不可
妄下。其他内外诸病应投药物之中，凡与胃气相违者，概勿施用。夫治实者，急去其邪；治
虚者，治专于补。其顾胃气，人所易知也，独此邪盛正虚，攻补两难之际，只有力保胃气，
加以攻邪，战守具备，敌乃可克。昔人谓孕妇患病，统以四物，加对治之药。此固不足为训
，然其意可师，推而行之，保胃气以攻邪，其理正如是也。
咽喉肿痛，轻按时疼痛，重按时反而舒适，饮食正常，这称为腑实。诊察其脉象，浮取而坚实洪大的是这种情况。皮肤瘙痒，肌肉胀满，饮食不消化，大便滑泄不止，诊察其脉象，轻手按之得滑脉，重手按之脉象平和，这是腑虚。需根据病变所在的经络，来调整治疗时机。胸膈痞闷胀满，头目刺痛，饮食难以下咽，头脑和项部昏沉沉重，咽喉不利，鼻涕和唾液稠粘。诊察其脉象，左右寸口脉沉、结、实、大的，是上实。面颊发红，心悸心慌，动作颤抖战栗，声音嘶哑，嘴唇焦裂口干，气喘乏力，面色无华，下巴肿胀；诊察左右寸脉弱而微的，是上虚。大小便困难，饮食如常，腰脚沉重，脐腹疼痛；诊察左右手脉，尺中脉伏而涩的，是下实。大小便困难，饮食时进时退，腰脚沉重，如同坐在水中，行走艰难，气向上冲逆，梦中感到危险；诊察左右尺中脉滑而涩的，是下虚。患者脉象微涩短小，都属于下虚。
张景岳说：《通评虚实论》指出，邪气盛则表现为实证，精气亏损则表现为虚证，这是辨别虚实的大法。假设有一个人，正气已经亏损而邪气正盛，是应当顾护其虚证而补益呢？还是应当先祛除邪气而攻伐呢？如果见解不确切，生死就系于此，这就是之所以需要谨慎的原因。正气是本，邪气是标。如果正气既已虚弱，那么即使邪气很盛，也不可以攻伐，因为恐怕邪气未去而正气先脱失，呼吸之间发生变故，就来不及措手了。所以治疗虚邪（正气虚而邪气盛的病证），应当先顾护正气，正气存在就不会致害，而且补益之中自有攻邪之意，补阴就是用来清热，补阳就是用来散寒。世间没有正气恢复而邪气不退的，也没有正气枯竭而生命不倾覆的。如果实在不得已，也应当斟酌缓急，暂时权宜行事，根据情况决定用药多少，在防守中寓含攻战之意，这样就可以了。这是治疗虚证的方法。如果正气没有损伤，邪气即使轻微，自然也不宜补益。因为补益的话，正气得不到帮助，而邪气反而更盛，这恰恰是借给敌人兵器、资助盗贼粮食。所以治疗实证，应当直接攻伐邪气，邪气去除身体就安康了。但治法贵在精专，才能迅速见效。这是治疗实证的方法。总之，能够承受攻伐治疗的，才是实证，实证可以攻伐，有什么可忧虑的呢？不能承受攻伐治疗的，便是虚证，气机耗散不再返回，能不让人寒心吗？这是邪正的本末关系，不可不知道。
日本学者元坚，字廉夫，曾经论述列举虚实夹杂证候的治疗，非常明白完备。他的文章说：做医生的关键，不过是辨别疾病的虚实罢了。虚实如果不明确，妄自使用汤药，就会像冰炭一样相反，白白耽误性命，所以在临证处方之际，不容许有一丝一毫的草率。我曾经考察过，四肢厥冷、下利，人们都知道是大虚应当补益；潮热、谵语，人们都知道是大实应当泻下。这虽然病情严重，但诊疗的方法，没有比这更难的了。至于那种“至虚有盛候，大实有羸状”的情况，确实是医生难以处理的。虽然如此，这还是在辨证上难，而在处方治疗上不难。为什么呢？假象显露，压抑遏止了真情，如果不是尽心体察，就不能辨别疑似而认清真相；然而既然认清了真相，纯用补法或纯用泻法，一意到底，病就可以痊愈了，还有什么别的策略呢？只有医生最难处理的，在于真实与真虚混淆掺杂的情况。为什么呢？把病看作虚证，却夹杂有实证；看作实证，又兼有虚候，必须精密思虑，能分析到毫厘之间，其病情和机理才可以辨认。等到施治时，想要补益，恐怕妨碍其实证；想要泻下，恐怕妨碍其虚证。补泻互相牵制，不易下手，必须审慎再审慎，奇正攻守，招招符合法度，然后病才可以好转。这难道不是辨认难而治疗也难的情况吗？岐伯有五有余、二不足的学说，而张仲景的经文中所说的难治之症，大概就是指这种情况。虚实相互错杂，其证候不能固定不变，其治法也不能没有区别。分类而论，有虚实相兼的情况。病本是邪实，应当发汗或泻下，但医生失法；或者用药过量，损伤真气，病实未除，又出现虚候的，这是实中兼虚。治疗的方法，应当在泻下中兼用补益，如果虚得很严重，或者不得已，暂且从补益入手，虚证恢复后再议泻下。这个人素来体虚，阴衰阳盛，一旦感受邪气，两阳相搏，于是变为实证，这是虚中兼实。治疗的方法，不清凉无法解热，不转刷（通导）无法逐结，然而之前的虚损不能不顾及，所以或者缓缓泻下，或者一次泻下后停止服药。前代名医对此证，认为必须先治其虚，后治其实，这大概是不对的。大抵邪气不解则不能受补，有邪气而补益，徒然增加壅滞；况且积久之虚，岂是暂时补益所能挽回的？考证经文，如附子泻心汤、调胃承气汤，就是泻中兼补的治疗方法。阳明病发展到循衣摸床、微喘直视的程度，既属于虚惫，仍然使用承气汤，是因为实邪去除后阴液可以回复；纵然泻下后立刻见到虚候，其实邪既去，调养就容易施行了。扩充引申，无处不可应用了。这就是虚实相兼的大概情况。至于虚实因相生而成，这也是不可不辨别的。有人在这里，脾气亏损，或者久吐，或者久利，中气不行，逐渐导致腹满、小便闭塞，这是由虚而生实。到了胀满极点，暂且治其标，主以疏导，但如果不以扶阳为念，土崩瓦解就在等待了。又有人，肾阴不足，下亏上盈，或者潮热、心烦，或者血溢、痰涌，也是由虚生实。到了火气亢盛，暂且治其标，专主清凉，但如果不以润养为念，真元就会竭绝了。有人在这里，肠红（便血），腹痛后重，如果失于泻下，病积依然存在，而津液日渐泄漏，身体日益消瘦衰弱，这是由实而生虚。治疗方法或者暂从扶阳，但如果不以磨积为先，邪胜正衰，立即危及生命。又有人，肝气壅实，胡言乱语易怒，继而脾气受制，饮食减少，日渐委顿，也是由实生虚。治疗方法或者暂从补中，但不兼清膈热，必然格拒不纳食。在张仲景的法度中，发汗后胀满，是自虚而实，所以用既疏又补的方剂。五劳虚极，因内有干血，是自实而虚，宿食脉涩，也是自实而虚，所以一个用大黄䗪虫丸，一个用大承气汤。大概干血下行而虚自复，宿食去除而胃气和顺。这就是虚实相因而生的大概情况。总之，相兼者与相因者，疾病的新久，胃气的强弱，尤其应该参伍加思，这也是诊断处方的关键所在。再论虚实之兼挟，表里上下之分，又不可不知道。实邪在表而里虚的，补其中气而病自愈，因为病在外，胃气充盛，则宜托出，且里弱可以受补，如发背、痘疮之类就是这样。实邪在里而兼虚的，除去其实邪而病自愈，因为病属热，如果拦阻补益，必助其壅滞，如那些虚人，得了胃实与瘀血、宿食之类就是这样。病上实素来下寒的，必须揣测其脐腹，然后吐法、下法可用；病下虚素来上热的，必须察视其心胸，然后滋补可施。这是表里上下的例子。虽然如此，现在所讨论的，大概就属于热病的方面立论罢了。如寒病的证候，也不可不知。经文说：气实则是热，气虚则是寒。大概胃强则热，胃弱则寒，这是必然的道理，所以寒病多属于虚。然而有如厥阴病之上热下寒，其上热虽未必为实，但未尝不能说仍有阳气存在，所以凉温并用，才合乎法度。寒病又有阳气虽虚而病则实的，固然是胃气本弱，但关门还有权变，而痼寒宿冷僻在一处，或与邪气相并，或触动时气而动，成为内实。如果初起满闭不严重的，须温利之；满闭特别严重的，攻下反在所禁忌，只当温散之。因为寒是胃所畏惧的，其实邪至极，必伤胃气，遂变成纯虚！观察张仲景太阴病及腹满、寒疝的治疗，其道理可见。然而病寒之实，必要温补，固然不可与病热之虚，犹宜清涤者一例而论。《玉函经》说：寒则散之，热则去之。可以说是一言蔽之了。寒热之分，确实是虚实证治中最紧要的。病的虚实，药的补泻，各有条例，大致如此，而轻重多少之间，还有不可计较的地方，确实如张景岳氏所言。虚实不明，补泻不当，却洋洋自得地想要治疗极重极险的病，哪里值得与之谈论医学呢！
总之，病的实，实有百种；病的虚，虚有百种。实的泻，泻有百种；虚的补，补有百种。而大旨总视胃气的盛衰有无，作为判断吉凶的主宰。《内经》说：五实死，五虚死。脉盛（心），皮热（肺），腹胀（脾），前后不通（肾），闷瞀（肝），这叫五实。脉细（心），皮寒（肺），气少（脾），泄利前后（肾），饮食不入（肝），这叫五虚。其中有活的，为什么呢？回答说：浆粥入胃，泄注止，则虚者活；身汗得后利，则实者活。全注云：这都是胃气得调和的缘故。说得真好啊！缪仲淳说：谷气，好比国家的粮道。粮道一断，则万众立散；胃气一败，则百药难施。无论是阴虚，还是阳虚，或是中风，或是中暑，乃至泻利、痢疾、胎前、产后，疔肿、痈疽、痘疮，痧疹、惊疳，无不以保护胃气、补养脾气为先，这是务本所当急的事。所以益阴宜远离苦寒，益阳宜防增气，祛风勿过燥散，消暑毋轻下通，泻利勿加消导，痢疾忌芒硝、巴豆、牵牛，胎前泄泻忌当归，产后寒热忌黄连、栀子，疔肿痈疽未溃忌当归，痘疹不可妄下。其他内外诸病应投药物之中，凡与胃气相违背的，一概不要施用。治疗实证，急去其邪；治疗虚证，治专于补。顾护胃气，是人人都容易知道的，唯独在此邪盛正虚，攻补两难之际，只有力保胃气，加以攻邪，战守具备，敌方可克。古人说孕妇患病，统用四物汤，加上对治的药物。这固然不足以作为典范，但其意可效法，推而行之，保胃气以攻邪，其理正是如此。
Throat swelling and pain, where light pressure causes pain but heavy pressure brings relief, with normal eating and drinking, is termed Fu-organ Excess (Fu-organ Excess: a pattern of excess in the fu organs). The pulse is floating and solid and large. Skin itching, muscle distension, undigested food, and slippery, unceasing diarrhea; the pulse, when lightly pressed, feels slippery, and when heavily pressed, feels level, indicates Fu-organ Deficiency (Fu-organ Deficiency: a pattern of deficiency in the fu organs). One must observe which meridian is involved to correct the timing. Chest and diaphragm stuffiness and fullness, fragmented pain in the head and eyes, inability to swallow food, dizziness and heaviness in the brain and neck, throat discomfort, and thick, sticky sputum and nasal discharge; the pulse at the Cun position of both left and right wrists being deep, knotted, solid, and large indicates Upper Excess (Upper Excess: excess pattern in the upper jiao). Red cheeks, palpitations, trembling and shivering movements, hoarse voice, cracked lips and dry mouth, panting and weakness, lack of luster in the face, and swelling of the chin and jaw; the pulse at the Cun position of both wrists being weak and faint indicates Upper Deficiency (Upper Deficiency: deficiency pattern in the upper jiao). Difficulty in urination and defecation, normal diet, heavy sensation in the waist and legs, and pain in the umbilical and abdominal region; the pulse at the Chi position of both hands being hidden and choppy indicates Lower Excess (Lower Excess: excess pattern in the lower jiao). Difficulty in urination and defecation, intermittent appetite, heavy sensation in the waist and legs as if sitting in water, difficulty walking, Qi rushing upward, and dangerous dreams; the pulse at the Chi position of both wrists being slippery and choppy indicates Lower Deficiency (Lower Deficiency: deficiency pattern in the lower jiao). If the patient's pulse is faint, choppy, short, and small, it all belongs to Lower Deficiency.
Zhang Jingyue said: "Tong Ping Xu Shi Lun" states that 'when pathogenic factors are flourishing, it is Excess; when vital essence is depleted, it is Deficiency.' This is the general principle of distinguishing Excess and Deficiency. Suppose there is a person whose Zheng Qi (Vital Qi) has been depleted while Xie Qi (Pathogenic Factors) is flourishing. Should one attend to the Deficiency and tonify it? Or should one first attack the Pathogenic Factors? If the judgment is not accurate, life and death depend on it; this is why caution is required. Zheng Qi is the root; Xie Qi is the branch. If Zheng Qi is already deficient, even if Xie Qi is strong, one must not attack, for fear that the pathogens will not be expelled while the Zheng Qi collapses first, leading to sudden changes in respiration and life, making it impossible to handle. Therefore, when treating Deficient-Xie patterns, one must first protect the Zheng Qi. If Zheng Qi is preserved, harm will not occur. Moreover, within tonification lies the intent to attack; tonifying Yin clears Heat, and tonifying Yang disperses Cold. There is no case in the world where Zheng Qi recovers while pathogens remain, nor is there a case where Zheng Qi is exhausted while life is preserved. If absolutely necessary, one must weigh urgency and delay, act temporarily by expediency, decide whether to use more or less dosage, and embed offensive strategies within defensive ones. This is the way to treat Deficiency. If Zheng Qi is undamaged, even if Xie Qi is slight, tonification is inappropriate. Tonifying would not help the Zheng Qi but would instead strengthen the Xie Qi, effectively lending weapons to bandits and providing grain to thieves. Therefore, when treating Excess patterns, one should directly attack the Xie Qi; once the Xie Qi is gone, the body is safe. However, the method must be precise and dedicated to achieve rapid results. This is the way to treat Excess. In summary, only those who can withstand attack are true Excess patterns; Excess can be attacked, so what is there to worry about? Those who cannot withstand attack are Deficiency patterns; if Qi departs and does not return, how can one not feel chilled? This is the fundamental relationship between Xie and Zheng, which must not be ignored.
Yuan Jian, courtesy name Lianfu, from Japan, once discussed and listed the treatment of mixed Excess-Deficiency patterns, which was very clear and comprehensive. His text says: The key to medicine lies merely in distinguishing the Excess and Deficiency of the disease. If Excess and Deficiency are not clarified, and decoctions are administered recklessly, it is like mixing ice and charcoal, leading to fatal errors. Thus, in clinical practice, one cannot afford any negligence. I have examined that cold limbs and diarrhea are known by everyone to require tonification for severe Deficiency; tidal fever and delirious speech are known by everyone to require purgation for severe Excess. Although these conditions are serious, their diagnostic and therapeutic methods are not the most difficult. However, situations where 'extreme Deficiency presents with Excess symptoms' and 'severe Excess presents with Deficiency signs' are indeed difficult for physicians. Nevertheless, this is difficult in differentiation but not in treatment. Why? Because false symptoms reveal themselves, suppressing the true condition. Unless one investigates with utmost care, one cannot distinguish the similar from the true. Once the truth is recognized, pure tonification or pure purgation, applied consistently until the end, can cure the disease. What other strategy is needed? The greatest difficulty for physicians lies in cases where true Excess and true Deficiency are confused and mixed. Why? When viewing the disease as Deficiency, it harbors Excess; when viewing it as Excess, it includes Deficiency symptoms. One must think carefully and analyze minutely to identify the nature and mechanism. When treating, if one wishes to tonify, one fears hindering the Excess; if one wishes to purge, one fears harming the Deficiency. Tonification and purgation constrain each other, making it hard to start. One must examine repeatedly, employing odd and regular, offensive and defensive strategies, ensuring every move follows the law, before the disease can improve. Is this not a case where both identification and treatment are difficult? Qibo's theory of 'five Excesses and two Deficiencies,' and Zhang Zhongjing's mention of difficult-to-treat conditions in his classics, generally refer to this. The interweaving of Excess and Deficiency means the symptoms are not fixed, and treatments must vary. Categorizing them, there are cases of simultaneous Excess and Deficiency. If the disease originates from pathogenic Excess, requiring sweating or purging, but the doctor errs in method, or uses excessive medication damaging True Qi, leaving the Excess unresolved while Deficiency symptoms appear, this is Excess accompanied by Deficiency. The treatment should combine purging with tonification. If Deficiency is severe, or out of necessity, one may temporarily focus on tonification; once Deficiency recovers, purging can be considered. If a person is constitutionally deficient, with Yin decline and Yang hyperactivity, and suddenly contracts pathogens, causing two Yangs to clash and transform into Excess, this is Deficiency accompanied by Excess. The treatment requires cooling to resolve heat and purging to remove accumulation, yet the prior Deficiency cannot be ignored. Thus, one may purge slowly or stop after one dose. Ancient masters believed one must first treat Deficiency then Excess, which is likely incorrect. Generally, if pathogens are not resolved, tonification cannot be accepted; tonifying with pathogens present only increases stagnation. Moreover, chronic Deficiency cannot be reversed by temporary tonification. Examining the classics, such as Fuzi Xiexin Tang and Tiaowei Chengqi Tang, represent treatment combining purging with tonification. In Yangming disease, progressing to grasping at empty air, twitching, slight panting, and fixed gaze, indicating extreme Deficiency and exhaustion, Chengqi Tang is still used because removing Excess allows Yin to recover; even if Deficiency symptoms appear immediately after purging, since Excess is gone, recovery measures are easier to apply. Expanding on this, the application is universal. This is the general situation of simultaneous Excess and Deficiency. Furthermore, Excess and Deficiency arising from causality must also be distinguished. Consider a person with Spleen Qi damage, prolonged vomiting or diarrhea, leading to stagnant Middle Qi, eventually resulting in abdominal fullness and urinary retention; this is Excess arising from Deficiency. When fullness reaches its peak, treat the branch symptom with dredging, but without focusing on supporting Yang, collapse is imminent. Another person with Kidney Yin insufficiency, deficiency below and excess above, presenting with tidal fever, irritability, bleeding, or phlegm surging, is also Excess arising from Deficiency. When Fire is hyperactive, treat the branch with cooling, but without nourishing, True Yuan will be exhausted. Consider a person with intestinal bleeding, abdominal pain, and tenesmus. If purging is delayed, the pathogenic accumulation remains, fluids leak daily, and emaciation worsens; this is Deficiency arising from Excess. Treatment may temporarily support Yang, but without grinding away accumulation, Pathogens will overcome Zheng Qi, leading to immediate danger. Another person with Liver Qi stagnation and Excess, speaking nonsense and angering easily, subsequently affecting Spleen Qi, reducing appetite, and becoming increasingly lethargic, is also Excess generating Deficiency. Treatment may temporarily tonify the Middle, but without clearing the Diaphragm, rejection of food will occur. According to Zhang Zhongjing's methods, bloating after sweating is Deficiency turning into Excess, so formulas that both disperse and tonify are used. Extreme deficiency from five labors due to internal dried blood is Excess turning into Deficiency; pulse sluggishness due to retained food is also Excess turning into Deficiency. Hence, Dahuang Zhechong Wan is used in one case, and Dachengqi Tang in the other. Dried blood descending restores Deficiency; retained food removed harmonizes the Stomach. This is the general principle of Excess and Deficiency arising from causality. In summary, regarding simultaneous and causal Excess-Deficiency, one must consider the newness or chronicity of the disease and the strength of Stomach Qi, which is the key to diagnosis and treatment. Further discussing mixed Excess-Deficiency, the distinction between exterior-interior and upper-lower must be known. If Excess is in the exterior and Deficiency in the interior, tonifying the Middle cures the disease because the pathology is external, Stomach Qi is robust, allowing expulsion, and the interior can accept tonification, as seen in carbuncles and smallpox. If Excess is in the interior accompanied by Deficiency, removing Excess cures the disease because the pathology is Heat; blocking tonification prevents aiding stagnation, as seen in deficient patients with Stomach Excess, blood stasis, or retained food. If the disease involves Upper Excess and underlying Lower Cold, palpate the abdomen before using emesis or purgation. If the disease involves Lower Deficiency and underlying Upper Heat, inspect the chest and heart before applying tonification. These are examples of exterior-interior and upper-lower distinctions. Although the above discussion focuses on Heat patterns, Cold patterns must also be distinguished. The classic states: 'Qi Excess is Heat; Qi Deficiency is Cold.' Strong Stomach generates Heat; weak Stomach generates Cold. Thus, Cold diseases often belong to Deficiency. However, in Jueyin disease with Upper Heat and Lower Cold, although the Upper Heat may not be true Excess, it indicates remaining Yang, so combining cooling and warming is appropriate. Cold diseases may also involve Yang Deficiency but Excess pathology. Although Stomach Qi is inherently weak, the 'gate' retains function, and entrenched Cold may localize, combine with pathogens, or be triggered by seasonal Qi, creating internal Excess. If initial fullness and obstruction are mild, warm purgation is needed; if severe, direct purgation is contraindicated, and warm dispersal is preferred. Cold is feared by the Stomach; extreme Excess damages Stomach Qi, transforming into pure Deficiency. Observing Zhang Zhongjing's treatment of Taiyin disease, abdominal fullness, and cold hernias reveals this logic. Therefore, Excess in Cold diseases requires warm tonification, which cannot be treated similarly to Deficiency in Heat diseases requiring clearing. The "Yuhan Jing" states: 'Disperse Cold, Remove Heat.' This summarizes it well. The distinction between Cold and Heat is crucial in treating Excess and Deficiency. Patterns of Excess/Deficiency and methods of Tonification/Purgation have specific rules, as outlined above. However, nuances of severity and quantity are immeasurable, as Zhang Jingyue noted. If Excess/Deficiency is unclear and Tonification/Purgation is improper, yet one arrogantly attempts to treat critical illnesses, such a person is unworthy of discussing medicine.
In summary, Excess diseases have hundreds of types; Deficiency diseases have hundreds of types. Methods of purging Excess have hundreds; methods of tonifying Deficiency have hundreds. The general principle always depends on the presence and strength of Stomach Qi to determine prognosis. The "Neijing" states: 'Five Excesses lead to death; Five Deficiencies lead to death.' Pulse surging (Heart), skin hot (Lung), abdominal fullness (Spleen), blockage of front and back (Kidney), oppression and dizziness (Liver) — these are Five Excesses. Pulse fine (Heart), skin cold (Lung), shortness of breath (Spleen), diarrhea and urinary incontinence (Kidney), inability to eat (Liver) — these are Five Deficiencies. How can some survive? It is said: If porridge enters the Stomach and diarrhea stops, the Deficient patient lives; if sweat occurs and bowels/bladder open, the Excess patient lives. Quan Zhu notes: This is because Stomach Qi becomes harmonized. How true! Miao Zhongchun said: Grain Qi is like the supply line of an army. If the supply line is cut, the army scatters; if Stomach Qi fails, medicines are useless. Whether Yin Deficiency, Yang Deficiency, Wind-stroke, Summerheat, diarrhea, dysentery, pregnancy, postpartum, carbuncles, ulcers, smallpox, measles, convulsions, or malnutrition, protecting Stomach Qi and nourishing Spleen Qi must be the priority, as it is the urgent task of addressing the root. Therefore, tonifying Yin should avoid bitter-cold herbs; tonifying Yang should prevent increasing Qi stagnation; dispelling wind should not overuse drying-dispersing herbs; clearing summerheat should not lightly use purgatives; treating diarrhea should not add digestive-promoting herbs; dysentery contraindicates Mangxiao, Badou, and Qianniu; pregnancy diarrhea contraindicates Danggui; postpartum chills and fever contraindicate Huanglian and Zhizi; unruptured carbuncles and ulcers contraindicate Danggui; measles and rashes contraindicate reckless purgation. Among all internal and external diseases, any medication conflicting with Stomach Qi should not be used. Treating Excess requires urgently removing pathogens; treating Deficiency requires focusing on tonification. Protecting Stomach Qi is commonly known. However, in the dilemma of Excess pathogens and Deficient Zheng Qi, where attack and tonification are both difficult, one must vigorously protect Stomach Qi while attacking pathogens, combining offense and defense to defeat the enemy. Ancients said that for pregnant women with illness, Siwu Tang is universally used with对症 medications. While this is not a strict model, its intent is worth learning. Extending this principle, protecting Stomach Qi while attacking pathogens follows the same logic.