问其所服何药。某药稍效。某药不效者。明其有否药误。以便核前之因。酌己之见
。默为挽救。亦不必吹毛求疵。信口雌黄。有伤雅道。如果病已垂危。无可挽救。慎勿
贪功奏技。而违众处方。以招铄金之谤。而最为吾绍惯习。不究其病之寒热虚实。标本
阴阳。而病家专好议药以责问医者。医家专好议方以伤残同道。酿成一议药不议病之恶俗
。此喻西昌所以定议病式。有先议病后议药之名论也。
【荣斋按】“查旧方”的作用，尚具有其他重要意义。由于过去的治疗，能影响现
在的病状和征候。伤寒病患如果吃过退热药，它的正常热型（稽留热）就要改变。有痛
感的病患如果吃过止痛药，他的痛感会临时减轻。我们要知道那些症状是因为治疗或药
物的关系而加重或减轻的。所以症状与过去接受的治疗的关系，我们须彻底了解。
新病易治。久病难已。暴病无虚。久病无实。夫人而知之。然新病猝中。如中风、
中寒、中暑、中湿、中恶、中毒、及痰中虚中、食厥、色厥之类。何尝易治。亦未尝无
虚症。久病如顽痰蓄饮气滞血瘀。及三痼六郁之类。尽多实症似虚。果能审症详明。投
剂果决。自然病势渐减。逐日见功。亦未必难已。问其病之新久者。欲察其为外感。为
内伤。为外感夹内伤。为内伤夹外感。为实为虚。为实中夹虚。为虚中夹实。以定病之
准的而已。总而言之。在医者博历知病。多诊
识脉。屡用达药。有真学问。肯负责任。而病患又深信不疑。善为调养。二难并。两美合
。何致有世无良医。病多不治之长叹也哉。至于切脉之道。一载六经脉象。一载诊脉举
要。兹不赘述。
【秀按】俞氏诊法。简而得要。固足为后学典型。喻西昌议病式。繁而得当。亦足
为后学模范。试述其式。某年、某月、某地、某人、年纪若干。形之肥瘦长短若何。色
之黑白枯润若何。声之清浊长短若何。人之形志苦乐若何。病始何日。初服何药。次后
再服何药。某药稍效。某药不效。现下昼夜孰重。寒热孰多。饮食喜恶多寡。二便滑涩
有无。脉之三部九候。何候独异。二十四脉中。何脉独见。何脉兼见。其症或内伤。或
外感。或兼内外。或不内外。根据经断为何病。其标本先后何在。汗吐下和。寒温补泻何
施。其药宜用七方中何方。十剂中何剂。五气中何气。五味中何味。以何汤名为加减和
合。其效验定于何时。一一详明。务令纤毫不爽。起众信从。允为医门矜式。不必演文
可也。其自释义云。某年者。年上之干支。治病先明运气也。某月者。治病先明四时也
。某地者。辨高卑燥湿。五方异宜也。某龄某形某声某气者。用之合脉以图万全也。形
志苦乐者。验七情劳逸也。始于何日者。察久近传变也。历问病症药物验否者。以之斟
酌己见也。昼夜寒热者。辨气分血分也。饮食二便者。察肠胃乖和也。三部九候。何候
独异者。推十二经脉受病之所也。二十四脉见何脉者。审阴阳表里无差忒也。根据经断为
何病者。名正则言顺。事成如律度也。标本先后何在者。识轻重次第也。汗、吐、下、
和、寒、温、补、泻何施者。求一定不瘥之法也。七方。大、小、缓、急、奇、偶、复
。乃药之制不敢滥也。十剂。宜、通、补、泻、轻、重、滑、涩、燥、湿。乃药之宜不
敢泛也。五气中何气。五味中何味者。用药最上之法。寒热温凉平。合之酸辛甘苦咸也
。引汤名为加减者。循古不自由也。刻效于何时者。逐款辨之不差。以病之新久定痊期
也。则是则医案之在人者。工拙自定。积之数十年。治千万人而不爽也。
【廉勘】前清国初张石顽老人。于诊法。多所发明。爰为节述其说。以补俞氏之不
逮。（一）辨形。细观肌之滑涩。以征津液之盛衰。理之疏密。以征营卫之强弱。肉之
坚软。以征胃气之虚实。筋之粗细。以征肝血之充馁。骨之大小。以征肾气之勇怯。爪
之刚柔。以征胆液之淳清。指之肥瘦。以征经气之荣枯。掌之浓薄。以征脏气之丰歉。
尺之寒热。以征表里之阴阳。至于深闺窈窕。往往密护屏帏。不能望见颜色。但须验其
手腕色泽之苍白肥瘠。已见一斑。若夫肌之滑涩。理之疏密。肉之坚软。筋之粗细。骨
之大小。爪之刚柔。指之肥瘦。掌之浓薄。尺之寒热。及乎动静之安危。气息之微盛。
更合之以脉。参之以证。则气血之虚实。情性之刚柔。形体之劳逸。服食之精粗。病苦
之逆顺。皆了然心目矣。（二）辨色。色贵明润。不欲沉夭。凡暴感客邪之色。不妨昏
壅滞浊。病久气虚。只宜瘦削清 。若病邪方锐。清白少神。虚羸久困。而妩媚鲜泽。
咸非正色。五色之中。青黑黯惨。无论病之新久。总属阳气不振。惟黄色见于面目。而
不至索泽者。皆为向愈之候。若眼胞上下如烟煤者。寒痰也。眼黑颊赤者。热痰也。眼
黑而行步艰难呻吟者。痰饮入骨。眼黑而面带土色。四肢痿痹。屈伸不便者。风痰也。
病患见黄色光泽者。为有胃气。不死。干黄者。为津液之槁。多凶。目睛黄者。非瘅即
衄。目黄大烦为病进。平人黑气起于口鼻耳目者危。若赤色见于两颧。黑气出于神庭。
乃火气入于心肾。暴亡之兆也。他如黄属脾胃。若黄而肥盛。胃中有痰湿也。黄而枯 。
胃中有火也。黄而色淡。胃气本虚也。黄而色黯。津液久耗也。黄为中央之色。其虚实
寒热之机。又当以饮食便溺消息之。色白属肺。白而淖泽。肺胃之充也。肥白而按之绵
软。气虚有痰也。白而消瘦。爪甲鲜赤。气虚有火也。白而夭然不泽。爪甲色淡。肺胃
虚寒也。白而微青。或臂多青脉。气虚不能统血。若兼爪甲色青。则为阴寒之证矣。白为
气虚之象。纵有失血发热。皆为虚火。断无实热之理。苍黑属肝与肾。苍而理粗。筋骨
劳也。苍而枯槁。营血之涸也。黑而肥泽。骨髓之充也。黑而瘦削。阴火内戕也。苍
黑为下焦气旺。虽犯客寒。亦必蕴为邪热。绝无虚寒之候也。
赤属心。主三焦。深赤色坚。素禀多火也。赤而胭坚。营血之充也。微赤而鲜。气虚有
火也。赤而索泽。血虚火旺也。赤为火炎之色。只虑津枯血竭。亦无虚寒之患。大抵火
形人。从未有肥盛多湿者。即有痰嗽。亦燥气耳。此皆望诊之大要也。（三）辨声。声
虽发于肺。实发自丹田。其轻清重浊。虽由基始。要以不异平时为吉。而声音清朗如常
者。形病气不病也。始病即气壅声浊者。邪乾清道也。病未久而语声不续者。其人中气
本虚也。脉之呻吟者。痛也。言迟者。风也。多言者。火之用事也。声如从室中言者。
中气之湿也。言而微。终日乃复言者。正气夺也。衣被不敛。言语善恶。不避亲疏者。
神明之乱也。出言懒怯。先重后轻者。内伤元气也。出言壮厉。先轻后重者。外感客邪
也。攒眉呻吟者。头痛也。噫气以手抚心者。中脘痛也。呻吟不能转身。坐而下一脚者
。腰痛也。摇头以手扪腮者。齿颊痛也。吟呻不能行步者。腰脚痛也。诊时吁气者。郁
结也。摇头而言者。里痛也。形羸声哑者劳瘵。咽中有肺花疮也。暴哑者。风痰伏火。
或怒喊哀号所致也。语言蹇涩者。风痰也。诊时独言独语。不知首尾者。思虑伤神也。
伤寒坏病。声哑唇口有疮者。狐惑也。平人无寒热。短气不足以息者。痰火也。此皆闻
证之大要也。前清咸同间石芾南先生。于问证颇为扼要。爰为节述其说。以补俞氏之未
备。病、藏于中者也。症、形于外者也。工于问者。非徒问其症。殆欲即其症见。以求
其病因耳。法当先问其人之平昔。有无宿痰。有无恚怒忧思。饮食喜淡喜浓。喜燥喜润
。嗜茶嗜酒。大便为燥为溏。妇人问。其有无胎产。月事先期后期。有无胀痛。再问其
病。初起何因。前见何症。后变何症。恶寒恶热。孰重孰轻。有汗无汗。汗多汗少。汗
起何处。汗止何处。口淡口苦。渴与不渴。思饮不思饮。饮多饮少。喜热喜凉。（喜热
饮不皆属寒、尝有郁遏不通者、亦喜热饮、以热则流通故也。）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。（二便最为紧要、乃病之外见者。）种种详诘。就其见证。审其病因
。方得轩岐治病求本之旨。此皆问诊之大要也。他如寇宗 曰。未
诊先问。最为有准。如看妇人病。尤必先问经期。张子和云。凡看妇病。当先问孕。若
孕在疑似间。不可轻用破气行血药。彭用光曰。凡看产妇病。须问恶露多少有无。及少
腹中有无结块。何西池曰。凡妇人经停四五个月。当问其乳头乳根黑否。乳房升发否。
若系垢胎。必每月行经。须问其经行多少。及腹中果动否。此皆妇科扼要之问法也。至
若景岳十问歌。一问寒热二问汗。三问头身四问便。五问饮食六问胸。七聋八渴俱当辨
。九问旧病十问因。再兼服药参机变。妇人尤必问经期。恶露有无产后验。亦属问法之
要略。惟赵晴初老医。谓诊病虽须详问。又当色脉合参。不可徇病患之言。为其所惑。
【荣斋按】木章俞氏所讲和转载喻西昌等八家对于诊察伤寒的各种方法，是很符合
现代“调查病史”的要求的。本节所谓“察新久”，就是采取“现下病史”和过去病
史”，它不仅能给予诊断上许多佐证，而且在某些特殊条件下它还可以作为诊断的根据
；这就是我们“四诊”中的“问诊”。我认为采取病史的范围，除本章所说各项外，还
应该注意到∶（一）起病的时间和情形──时间要愈准确愈好。可以用各种记时的方法
，如某日几点几分钟或某日清晨、正午、黄昏或半夜，或起床前后，早饭前后，午饭前
后……等。起病情形有骤起的（如大叶肺炎和疟疾），有渐起的（如伤寒），但也有不
知不觉中而起病的（如各种慢性疾病）。（二）症状与时间的关系──各种症状的表现
都有它一定时间的规律。如果忽略了它的时间性，则症状就失掉了它对诊断上的意义。
如疟疾病患的发热，有间日一次的，也有三日一次的。每次发热时间有数十分钟的，也
有几个钟点以上的。伤寒病患是继续不断的高热，而肺结核病患则是每日下午发微热。
因此，要注意它发生的时间。（三）症状与症状之间的关系──各种症状的表现都是互
相关联的，它们之间都有一定的关系。如疟疾病患应该是先发寒、再发热、后出汗，这
三个疟疾的主要症状，有它们时间先后的关系，这种关系是诊断疟疾的标志。又如发热
和头痛的关系，一般急性热病都是热度愈高的时候头痛愈厉害，热度降低头痛也减轻了
。凭着这个关系就
可以知道这个头痛是因为发热而起的，绝不是其他原因。因此，我们的问症状就应注意
它们互相之间的关系，而不应把每一个症状孤立起来，否则，就会造成诊断上的错误。
其他，如症状对生理功能的影响，症状本身的分析，各个系统详细状症的采取，可能致
病的诱因等；都应该加以注意和考虑。至于询问“过去病史”，应根据现下病史的情形
而变化，现下病史中那一个系统是最主要的症状，过去病史也应详细询问那个系统。所
谓“新病引起旧病”如第九章伤寒夹证中的夹痰、夹血、夹疝、夹痨等，这些病史的早
日获得，对诊断和将来的治疗是很有意义的。
问患者服用过什么药物。哪种药稍微有效，哪种药无效，以此明确是否存在用药错误，以便核实之前的病因，斟酌自己的见解，暗中采取挽救措施。也不必吹毛求疵、信口雌黄，有伤医德雅道。如果病情已经垂危，无可挽救，千万不要贪功炫技，而违背众人意见随意处方，以招致“众口铄金”的诽谤，这是绍兴地区医生最惯常的习气。不探究疾病的寒热虚实、标本阴阳，而病家专门喜欢议论药物来责问医者，医者专门喜欢议论方剂来伤残同道，酿成了一种只议药不议病的恶劣风俗。这就是喻嘉言（字西昌）所以制定《议病式》，提出“先议病后议药”这一著名论断的原因。
【荣斋按】“查旧方”的作用，还具有其他重要意义。由于过去的治疗，会影响现在的病状和征候。伤寒病患者如果吃过退热药，它的正常热型（稽留热）就要改变。有痛感的患者如果吃过止痛药，他的痛感会临时减轻。我们要知道那些症状是因为治疗或药物的关系而加重或减轻的。所以症状与过去接受的治疗的关系，我们必须彻底了解。
新病容易治愈，久病难以痊愈。突发疾病没有虚证，久病没有实证，这是人人都知道的道理。然而新病突然发作，如中风、中寒、中暑、中湿、中恶、中毒，以及痰厥、虚厥、食厥、色厥之类，何尝容易治疗？也未尝没有虚证。久病如顽痰、蓄饮、气滞、血瘀，以及三痼六郁之类，尽多实证却表现为虚象。如果能仔细审察症状，详细辨析，投药果断，自然病势逐渐减退，逐日见效，也未必难以痊愈。询问病情的新久，是为了观察它是外感、内伤、外感夹内伤、内伤夹外感，是实是虚，还是实中夹虚、虚中夹实，以此来确定治疗的准确目标罢了。总而言之，在于医者博学阅历、知晓病情、多诊识脉、屡用达药，拥有真学问，肯负责任，而病患又深信不疑，善于调养。两者兼备，两全其美，怎么会导致世间没有良医、疾病大多无法治愈的长叹呢？至于切脉的方法，前面已记载了六经脉象和诊脉举要，这里不再赘述。
【秀按】俞氏的诊法，简洁而抓住要点，足以成为后学的典范。喻西昌的议病式，繁琐但得当，也足以成为后学的模范。试述其格式：某年、某月、某地、某人，年龄多少。体形的肥瘦长短如何？面色的黑白枯润如何？声音的清浊长短如何？人的形体意志的苦乐如何？病始于哪一天？初服什么药？随后再服什么药？哪种药稍效，哪种药无效？现在昼夜哪个时段症状重？寒热哪个更多？饮食喜好及食量多少？二便通畅与否、滑涩有无？脉象的三部九候，哪个部位特别异常？二十四种脉象中，哪种脉独见？哪种脉兼见？其症状或是内伤，或是外感，或是内外兼夹，或不内外因。根据经典判断是什么病？其标本先后在哪里？汗、吐、下、和、寒、温、补、泻如何施用？药物宜用七方中的何方？十剂中的何剂？五气中的何气？五味中的何味？以何种汤名为加减和合？疗效定于何时？一一详明，务必精确无误，使众人信服，确为医门的楷模，不必铺陈文饰即可。其自释义说：某年，指年上的干支，治病先明运气。某月，指治病先明四时。某地，辨别高低燥湿，五方适宜不同。某龄、某形、某声、某气，用来配合脉象以求万全。形志苦乐，验证七情劳逸。始于何日，考察久近传变。历问病症药物是否有效，用来斟酌己见。昼夜寒热，辨别气分血分。饮食二便，察肠胃乖和。三部九候，哪个部位特别异常，推究十二经脉受病之所。二十四脉见何脉，审查阴阳表里无差错。根据经典判断是什么病，名正则言顺，事成如律度。标本先后在哪里，识别轻重次第。汗、吐、下、和、寒、温、补、泻如何施用，寻求一定不愈之法。七方，大、小、缓、急、奇、偶、复，乃制药不敢滥用。十剂，宣、通、补、泻、轻、重、滑、涩、燥、湿，乃用药适宜不敢泛用。五气中何气，五味中何味，是用药最高之法，寒热温凉平，合之酸辛甘苦咸。引汤名为加减，遵循古法不自由。刻效于何时，逐款辨析不差，以病的新久定痊愈期。那么医案在人身上，工拙自定，积累数十年，治千万人而不差。
【廉勘】前清国初张石顽老人，在诊法上多有发明。于是节述其说，以弥补俞氏的不足。（一）辨形。细观肌肤的滑涩，以征验津液的盛衰；纹理的疏密，以征验营卫的强弱；肌肉的坚软，以征验胃气的虚实；筋骨的粗细，以征验肝血的充馁；骨骼的大小，以征验肾气的勇怯；爪甲的刚柔，以征验胆液的淳清；手指的肥瘦，以征验经气的荣枯；手掌的浓薄，以征验脏气的丰歉；尺肤的寒热，以征验表里的阴阳。至于深闺女子，往往严密保护屏风帷帐，不能望见颜色，只需查验其手腕色泽的苍白肥瘠，已可见一斑。至于肌肤的滑涩，纹理的疏密，肌肉的坚软，筋骨的粗细，骨骼的大小，爪甲的刚柔，手指的肥瘦，手掌的浓薄，尺肤的寒热，以及动静安危，气息微盛，更结合脉象，参验证候，则气血的虚实，情性的刚柔，形体的劳逸，饮食的精粗，病苦的逆顺，都了然于心了。（二）辨色。面色贵在明润，不欲沉夭。凡是暴感客邪的面色，不妨昏壅滞浊；病久气虚，只宜瘦削清瘦。若病邪正锐利，清白少神，虚羸久困，而妩媚鲜泽，都不是正色。五色之中，青黑黯惨，无论病的新久，总属阳气不振。惟黄色见于面目，而不至干枯无光泽者，皆为向愈之候。若眼胞上下如烟煤者，是寒痰。眼黑颊赤者，是热痰。眼黑而行步艰难呻吟者，是痰饮入骨。眼黑而面带土色，四肢痿痹，屈伸不便者，是风痰。患者见黄色光泽者，为有胃气，不死。干黄者，为津液枯竭，多凶。目睛黄者，非疸即衄。目黄大烦为病进。平人无寒热，黑气起于口鼻耳目者危。若赤色见于两颧，黑气出于神庭，乃火气入于心肾，暴亡之兆也。他如黄属脾胃，若黄而肥盛，胃中有痰湿也。黄而枯槁，胃中有火也。黄而色淡，胃气本虚也。黄而色黯，津液久耗也。黄为中央之色，其虚实寒热之机，又当以饮食便溺消息之。色白属肺，白而淖泽，肺胃之充也。肥白而按之绵软，气虚有痰也。白而消瘦，爪甲鲜赤，气虚有火也。白而夭然不泽，爪甲色淡，肺胃虚寒也。白而微青，或臂多青脉，气虚不能统血。若兼爪甲色青，则为阴寒之证矣。白为气虚之象，纵有失血发热，皆为虚火，断无实热之理。苍黑属肝与肾，苍而理粗，筋骨劳也。苍而枯槁，营血之涸也。黑而肥泽，骨髓之充也。黑而瘦削，阴火内戕也。苍黑为下焦气旺，虽犯客寒，亦必蕴为邪热，绝无虚寒之候也。赤属心，主三焦，深赤色坚，素禀多火也。赤而腘坚，营血之充也。微赤而鲜，气虚有火也。赤而索泽，血虚火旺也。赤为火炎之色，只虑津枯血竭，亦无虚寒之患。大抵火形人，从未有肥盛多湿者，即有痰嗽，亦燥气耳。此皆望诊之大要也。（三）辨声。声音虽发于肺，实发自丹田。其轻清重浊，虽由基础决定，要以不异平时为吉。而声音清朗如常者，形病气不病也。始病即气壅声浊者，邪干清道也。病未久而语声不续者，其人中气本虚也。脉之呻吟者，痛也。言迟者，风也。多言者，火之用事也。声如从室中言者，中气之湿也。言而微，终日乃复言者，正气夺也。衣被不敛，言语善恶，不避亲疏者，神明之乱也。出言懒怯，先重后轻者，内伤元气也。出言壮厉，先轻后重者，外感客邪也。攒眉呻吟者，头痛也。噫气以手抚心者，中脘痛也。呻吟不能转身，坐而下一脚者，腰痛也。摇头以手扪腮者，齿颊痛也。吟呻不能行步者，腰脚痛也。诊时吁气者，郁结也。摇头而言者，里痛也。形羸声哑者劳瘵，咽中有肺花疮也。暴哑者，风痰伏火，或怒喊哀号所致也。语言蹇涩者，风痰也。诊时独言独语，不知首尾者，思虑伤神也。伤寒坏病，声哑唇口有疮者，狐惑也。平人无寒热，短气不足以息者，痰火也。此皆闻证之大要也。前清咸同间石芾南先生，于问证颇为扼要。于是节述其说，以补俞氏之未备。病，藏于中者也。症，形于外者也。工于问者，非徒问其症，殆欲即其症见，以求其病因耳。法当先问其人之平昔，有无宿痰，有无恚怒忧思，饮食喜淡喜浓，喜燥喜润，嗜茶嗜酒，大便为燥为溏。妇人问，其有无胎产，月事先期后期，有无胀痛。再问其病，初起何因，前见何症，后变何症，恶寒恶热，孰重孰轻，有汗无汗，汗多汗少，汗起何处，汗止何处，口淡口苦，渴与不渴，思饮不思饮，饮多饮少，喜热喜凉。（喜热饮不皆属寒，尝有郁遏不通者，亦喜热饮，以热则流通故也。）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。（二便最为紧要，乃病之外见者。）种种详诘，就其见证，审其病因，方得轩岐治病求本之旨。此皆问诊之大要也。他如寇宗奭曰，未诊先问，最为有准。如看妇人病，尤必先问经期。张子和云，凡看妇病，当先问孕。若孕在疑似间，不可轻用破气行血药。彭用光曰，凡看产妇病，须问恶露多少有无，及少腹中有无结块。何西池曰，凡妇人经停四五个月，当问其乳头乳根黑否，乳房升发否。若系垢胎，必每月行经，须问其经行多少，及腹中果动否。此皆妇科扼要之问法也。至若景岳十问歌，一问寒热二问汗，三问头身四问便，五问饮食六问胸，七聋八渴俱当辨，九问旧病十问因，再兼服药参机变，妇人尤必问经期，恶露有无产后验，亦属问法之要略。惟赵晴初老医，谓诊病虽须详问，又当色脉合参，不可徇病患之言，为其所惑。
【荣斋按】本章俞氏所讲和转载喻西昌等八家对于诊察伤寒的各种方法，是很符合现代“调查病史”的要求的。本节所谓“察新久”，就是采取“现下病史”和“过去病史”，它不仅能给予诊断上许多佐证，而且在某些特殊条件下它还可以作为诊断的根据；这就是我们“四诊”中的“问诊”。我认为采取病史的范围，除本章所说各项外，还应该注意到：（一）起病的时间和情形——时间要愈准确愈好。可以用各种记时的方法，如某日几点几分钟或某日清晨、正午、黄昏或半夜，或起床前后，早饭前后，午饭前后……等。起病情形有骤起的（如大叶肺炎和疟疾），有渐起的（如伤寒），但也有不知不觉中而起病的（如各种慢性疾病）。（二）症状与时间的关系——各种症状的表现都有它一定时间的规律。如果忽略了它的时间性，则症状就失掉了它对诊断上的意义。如疟疾病患的发热，有间日一次的，也有三日一次的。每次发热时间有数十分钟的，也有几个钟点以上的。伤寒病患是继续不断的高热，而肺结核病患则是每日下午发微热。因此，要注意它发生的时间。（三）症状与症状之间的关系——各种症状的表现都是互相关联的，它们之间都有一定的关系。如疟疾病患应该是先发寒、再发热、后出汗，这三个疟疾的主要症状，有它们时间先后的关系，这种关系是诊断疟疾的标志。又如发热和头痛的关系，一般急性热病都是热度愈高的时候头痛愈厉害，热度降低头痛也减轻了。凭着这个关系就可以知道这个头痛是因为发热而起的，绝不是其他原因。因此，我们的问症状就应注意它们互相之间的关系，而不应把每一个症状孤立起来，否则，就会造成诊断上的错误。其他，如症状对生理功能的影响，症状本身的分析，各个系统详细状症的采取，可能致病的诱因等；都应该加以注意和考虑。至于询问“过去病史”，应根据现下病史的情形而变化，现下病史中那一个系统是最主要的症状，过去病史也应详细询问那个系统。所谓“新病引起旧病”如第九章伤寒夹证中的夹痰、夹血、夹疝、夹痨等，这些病史的早日获得，对诊断和将来的治疗是很有意义的。
Ask what medicines the patient has taken. Which medicine showed slight efficacy and which did not, to clarify whether there were medication errors, so as to verify the previous causes of disease, deliberate on one's own insights, and secretly take measures for rescue. There is no need to nitpick or speak recklessly, which would harm medical ethics and elegance. If the condition is already critical and beyond rescue, one must not be greedy for merit or show off skills, nor prescribe arbitrarily against common opinion, thereby inviting slander ("many mouths can melt metal"). This is a habitual practice among doctors in Shaoxing: failing to investigate the coldness, heat, deficiency, or excess of the disease, as well as its root and branch, yin and yang; instead, patients specialize in discussing medications to question doctors, while doctors specialize in discussing prescriptions to harm colleagues, fostering a bad custom of discussing drugs rather than diseases. This is why Yu Jiayan (courtesy name Xichang) formulated the "Formula for Discussing Diseases," proposing the famous theory of "discussing the disease first, then the medication."
[Note by Rongzhai] The role of "checking old prescriptions" has other important significance. Past treatments can affect current symptoms and signs. If a typhoid fever patient has taken antipyretics, their normal fever pattern (continued fever) will change. If a patient with pain has taken analgesics, their pain sensation will temporarily alleviate. We must understand which symptoms are aggravated or alleviated due to treatment or medication. Therefore, we must thoroughly understand the relationship between symptoms and past treatments.
Newly acquired diseases are easy to treat; chronic diseases are difficult to cure. It is widely known that acute diseases do not involve deficiency, and chronic diseases do not involve excess. However, sudden onset diseases such as wind-stroke, cold-stroke, summerheat-stroke, dampness-stroke, evil-stroke, poisoning, as well as phlegm syncope, deficiency syncope, food syncope, and sexual syncope, are by no means easy to treat, nor are they devoid of deficiency syndromes. Chronic diseases such as stubborn phlegm, retained fluids, qi stagnation, blood stasis, and the "three chronicities and six depressions" often present as excess syndromes mimicking deficiency. If symptoms are carefully examined and clearly differentiated, and medication is administered decisively, the disease trend will naturally gradually subside, showing daily improvement, and it may not necessarily be difficult to cure. Asking about the duration of the disease aims to observe whether it is an external contraction, internal injury, external contraction complicated by internal injury, internal injury complicated by external contraction, excess or deficiency, excess complicated by deficiency, or deficiency complicated by excess, thereby determining the accurate target of treatment. In summary, it lies in the physician being knowledgeable through extensive experience, understanding the disease, mastering pulse diagnosis through frequent examination, proficient in using effective medicines, possessing true learning, taking responsibility, while the patient trusts completely and maintains good self-care. When both conditions are met, achieving perfection, how could there be sighs about the lack of good physicians and untreatable diseases? As for the method of pulse diagnosis, the six meridian pulse images and essentials of pulse diagnosis have been recorded previously, so they are not repeated here.
[Note by Xiu] Yu's diagnostic methods are concise yet essential, serving as a model for future learners. Yu Xichang's formula for discussing diseases is detailed yet appropriate, also serving as a model for future learners. Let us describe its format: Year, month, place, person, age. What is the body type (fat/thin, long/short)? What is the complexion (black/white, dry/moist)? What is the voice (clear/turbid, long/short)? What is the physical and mental state (suffering/joy)? On which day did the disease start? What was the initial medication? What was taken subsequently? Which medicine showed slight efficacy, and which did not? Which time of day (day/night) shows heavier symptoms? Is cold or heat more prevalent? What are the dietary preferences and quantities? Are bowel movements and urination smooth or obstructed? Regarding the three positions and nine inspections of the pulse, which inspection is uniquely abnormal? Among the twenty-four pulse types, which pulse appears alone? Which pulses appear concurrently? Are the symptoms internal injury, external contraction, both internal and external, or neither? Based on the classics, what disease is diagnosed? Where are the root and branch, and what is the sequence? How should sweating, vomiting, purging, harmonizing, cooling, warming, tonifying, and draining be applied? Which of the Seven Formulas is suitable? Which of the Ten Categories? Which of the Five Qi? Which of the Five Flavors? With which decoction name should modifications and combinations be made? When is the efficacy expected? All details must be clear and precise, ensuring accuracy without error, gaining public trust, truly serving as a model for the medical profession, without need for rhetorical embellishment. Its self-interpretation states: "Year" refers to the Heavenly Stems and Earthly Branches, indicating that treating disease requires first understanding the Six Qi and Six Climatic Factors. "Month" indicates understanding the Four Seasons. "Place" involves distinguishing high/low and dry/damp, noting different适宜 (suitability) of the five directions. "Age, body type, voice, qi" are used in conjunction with pulse diagnosis to ensure safety. "Physical and mental state" verifies the seven emotions and labor/rest. "Start date" examines the duration and transmission changes. "Asking about past medications and efficacy" aids in deliberating one's own views. "Day/night cold/heat" distinguishes qi vs. blood levels. "Diet and excretion" inspects gastrointestinal harmony. "Which inspection is uniquely abnormal" deduces the location of disease in the twelve meridians. "Which pulse appears" examines yin/yang and exterior/interior for errors. "Diagnosing based on classics" ensures correct naming leads to smooth speech and lawful success. "Root and branch sequence" identifies severity and order. "Application of sweating, vomiting, purging, etc." seeks a definitive method for non-healing cases. "Seven Formulas" (Great, Small, Slow, Urgent, Odd, Even, Compound) prevent arbitrary drug preparation. "Ten Categories" (Dispersing, Unblocking, Tonifying, Draining, Light, Heavy, Slippery, Astringent, Dry, Damp) prevent indiscriminate drug use. "Five Qi and Five Flavors" represent the highest method of medication, combining Cold, Heat, Warm, Cool, Neutral with Sour, Pungent, Sweet, Bitter, Salty. "Decoction names for modification" follows ancient traditions. "Expected efficacy time" allows precise differentiation and determines recovery period based on disease duration. Thus, medical records depend on the individual; skill varies. Accumulating decades of experience treating thousands without error is possible.
[Note by Lian] Zhang Shiwan, an elder physician from the early Qing Dynasty, made many innovations in diagnostic methods. I hereby summarize his theories to supplement Yu's shortcomings. (1) Differentiating Form: Carefully observe the slipperiness or roughness of the skin to infer the abundance or decline of body fluids; the density or sparseness of texture to infer the strength or weakness of Ying and Wei; the firmness or softness of flesh to infer the deficiency or excess of Stomach Qi; the thickness or thinness of tendons to infer the fullness or emptiness of Liver Blood; the size of bones to infer the courage or timidity of Kidney Qi; the hardness or flexibility of nails to infer the purity or turbidity of Gallbladder fluid; the fatness or thinness of fingers to infer the prosperity or withering of Meridian Qi; the thickness or thinness of palms to infer the abundance or scarcity of Zang Qi; the coldness or heat of the Chi position (forearm) to infer the yin or yang of interior and exterior. For women in secluded quarters who often hide behind screens, preventing visual inspection of the face, inspecting the color, pallor, fatness, or leanness of the wrist veins suffices to gain insight. Furthermore, observing skin texture, muscle firmness, tendon thickness, bone size, nail flexibility, finger shape, palm thickness, and forearm temperature, combined with movement stability, breath intensity, pulse, and symptoms, makes the deficiency or excess of qi and blood, the rigidity or gentleness of temperament, the劳逸 (work/rest) of the body, the refinement or coarseness of diet, and the favorable or unfavorable nature of the illness clear in mind. (2) Differentiating Color: Complexion should be bright and moist, not dull or lifeless. Colors from sudden external pathogens may be cloudy or turbid; colors from chronic qi deficiency should be emaciated and clear. If pathogenic factors are sharp but the complexion is pale and spiritless, or if the patient is chronically weak yet looks charming and glossy, these are not normal colors. Among the five colors, dark blue/black indicates depressed Yang qi regardless of disease duration. Yellow appearing on the face without dryness indicates recovery. Dark circles under eyes like soot indicate cold phlegm; dark eyes with red cheeks indicate hot phlegm; dark eyes with difficulty walking and groaning indicate phlegm-fluid entering bones; dark eyes with earthy complexion, flaccid limbs, and stiff joints indicate wind-phlegm. Yellow luster indicates Stomach Qi presence and survival; dry yellow indicates fluid exhaustion and poor prognosis. Yellow sclera indicates jaundice or epistaxis; severe irritability with yellow eyes indicates worsening disease. Black qi arising from mouth, nose, ears, or eyes in healthy people indicates danger. Red on cheekbones and black at Shenting point indicate fire entering Heart and Kidney, a sign of sudden death. Yellow belongs to Spleen/Stomach: fat yellow indicates phlegm-dampness; dry yellow indicates stomach fire; pale yellow indicates original Spleen Qi deficiency; dark yellow indicates prolonged fluid consumption. Yellow is the central color; its deficiency/excess and cold/heat mechanisms are judged by diet and excretion. White belongs to Lung: moist white indicates Lung/Stomach fullness; fat white and soft to touch indicates qi deficiency with phlegm; thin white with bright red nails indicates qi deficiency with fire; dull white with pale nails indicates Lung/Stomach deficiency-cold; slightly blue-white or prominent blue arm veins indicates qi deficiency failing to control blood; if nails are also blue, it indicates yin-cold. White represents qi deficiency; even with bleeding or fever, it is deficient fire, never excess heat. Blue-black belongs to Liver/Kidney: coarse texture indicates musculoskeletal strain; dry/withered indicates depletion of Ying blood; fat/moist black indicates marrow fullness; thin/emaciated black indicates internal damage by yin fire. Blue-black indicates strong Lower Jiao qi; even if attacked by external cold, it transforms into pathogenic heat, never deficiency-cold. Red belongs to Heart and governs Sanjiao: deep red and firm indicates innate fire tendency; red with firm popliteal fossa indicates Ying blood fullness; slightly red and fresh indicates qi deficiency with fire; red and dry/shiny indicates blood deficiency with hyperactive fire. Red is the color of flaming fire; worry only about fluid exhaustion and blood depletion, not deficiency-cold. Fire-type individuals are rarely fat with dampness; even with phlegm-cough, it is dry qi. These are the essentials of observation. (3) Differentiating Voice: Although voice originates from the Lung, it actually stems from the Dantian. Its clarity or turbidity depends on constitution, but remaining consistent with one's usual voice is auspicious. Clear voice despite illness indicates body sick but qi healthy. Turbid voice at onset indicates pathogen invading clear pathways. Weak voice continuing shortly after onset indicates original Middle Jiao deficiency. Groaning indicates pain. Slow speech indicates wind. Excessive talking indicates fire activity. Muffled voice as if speaking from a room indicates dampness in Middle Jiao. Faint voice, speaking only once a day, indicates loss of upright qi. Disheveled clothes, inappropriate speech, ignoring social boundaries indicates disorder of Shen (Spirit). Lazy/cowardly speech, heavy then light, indicates internal injury to Yuan Qi. Loud/aggressive speech, light then heavy, indicates external pathogenic invasion. Furrowed brows and groaning indicate headache. Belching while holding the heart area indicates Zhongwan pain. Groaning unable to turn over, sitting with one leg down indicates lower back pain. Shaking head while touching cheek indicates tooth/jaw pain. Moaning unable to walk indicates waist/foot pain. Sighing during examination indicates qi stagnation. Shaking head while speaking indicates interior pain. Emaciated body with hoarse voice indicates consumption (Lao Zhai) or lung ulcers. Sudden aphonia indicates latent wind-phlegm/fire or caused by shouting/crying. Slurred speech indicates wind-phlegm. Talking alone/disconnectedly indicates mental injury from overthinking. Typhoid complication with hoarse voice and oral ulcers indicates Huo Huo (Erosive ulcerative disease). Healthy person without chills/fever but short of breath indicates phlegm-fire. These are the essentials of listening. Mr. Shi Feinan (Qing Dynasty, Xiantong era) was concise in inquiry. I summarize his views to supplement Yu's omissions. Disease hides internally; symptoms manifest externally. Skilled inquirers do not just ask about symptoms but seek causes through them. First, ask about past habits: history of phlegm, anger/worry, dietary preferences (light/heavy, dry/moist), tea/alcohol habits, stool consistency. For women, ask about pregnancy/birth, menstrual cycle (early/late), distension/pain. Then ask about current disease: cause, initial symptoms, progression, severity of chills/fever, sweating status (amount, origin, cessation), taste (bland/bitter), thirst, drinking preference (hot/cold - note: preference for hot drinks does not always mean cold syndrome, sometimes due to obstruction relieved by heat). Appetite, digestion speed, chest/flank/abdominal pain, bowel/bladder status (dry/loose stool, clear/turbid urine, yellow/light color - excretion is crucial as it reflects external manifestation). Detailed questioning based on symptoms to determine causes aligns with Xuanyuan/Qibo's principle of seeking the root. These are the essentials of inquiry. Kou Zongshi said: Inquiry before diagnosis is most accurate. For women, menstruation must be asked first. Zhang Zihe said: Ask about pregnancy for female patients; avoid blood-moving drugs if pregnancy is uncertain. Peng Yongguang said: For postpartum women, ask about lochia amount and abdominal masses. He Xichi said: For women with missed periods of 4-5 months, check if nipples/root are dark and breasts elevated; if pregnant, menstruation continues monthly, so ask about flow and fetal movement. These are essential gynecological inquiries. Jingyue's Ten Questions Song covers chills/fever, sweat, head/body, excretion, diet, chest, deafness/thirst, past illness, causes, and medication response. For women, menstruation and lochia are key. This is a brief overview of inquiry methods. Elder doctor Zhao Qingchu stated that while detailed inquiry is necessary, it must be combined with color and pulse analysis; do not be misled by patient statements.
[Note by Rongzhai] The methods for diagnosing typhoid fever discussed by Yu and reproduced from Yu Xichang and eight other families in this chapter align well with modern requirements for "medical history investigation." The section on "observing new vs. old" refers to collecting "current medical history" and "past medical history." This not only provides diagnostic evidence but can serve as the basis for diagnosis under certain special conditions; this constitutes the "Inquiry" aspect of our "Four Diagnostic Methods." I believe that besides the items mentioned in this chapter, the scope of medical history collection should also pay attention to: (1) Time and circumstances of onset—accuracy is better. Use various timing methods, e.g., specific date/time, morning/noon/evening/midnight, before/after meals, etc. Onset can be sudden (e.g., lobar pneumonia, malaria), gradual (e.g., typhoid), or insidious (e.g., chronic diseases). (2) Relationship between symptoms and time—symptoms have temporal patterns. Ignoring temporality loses diagnostic value. E.g., malaria fever occurs every other day or every third day, lasting minutes to hours. Typhoid presents with continuous high fever, while tuberculosis shows low-grade afternoon fever. Thus, timing is crucial. (3) Relationship between symptoms—symptoms are interconnected. E.g., malaria typically starts with chills, then fever, then sweating; this sequence is a diagnostic marker. Fever and headache relation: in acute febrile diseases, higher fever correlates with worse headache; as fever drops, headache alleviates. This relationship indicates the headache is caused by fever, not other reasons. Therefore, when asking about symptoms, note their interrelationships rather than isolating them, to avoid diagnostic errors. Other factors like impact on physiological functions, symptom analysis, system-specific details, and potential triggers should also be considered. Regarding "past medical history," it should vary based on current history; if a specific system dominates current symptoms, inquire deeply into that system historically. "New disease triggering old disease," such as complications in Chapter 9 (typhoid with phlegm, blood, hernia, consumption), obtaining these histories early is significant for diagnosis and future treatment.