肝实肺虚。是真虚实。故直行补肺泻肝之道。肺实肝虚。即在脉。则当见其真。苟在证。则多见假者。何则。肺主 敛。
其脏嫩软。虽病有实。见证多似不足。肝主发生。其脏猛烈。虽病有虚。见证多似有余。故中工误认。以假实为真。以
真实为假。徒使病者受医之桎梏。非正命而死焉。悲夫。因前既尤中工粗无远略。故重深戒之。此难与七十八篇所云。
东实西虚。固有常变之分。义互相发。不宜为一例看。
（第八十一旧十二）难曰。经（灵枢第一第三）言五脏脉（气）已绝于内。（尺）用针者。反实其外。（阳经之合）
五脏脉（气）已绝于外。（寸）用针者反实其内。（阴经之合）内外之绝。何以别之。然。五脏脉（气）已绝于内（下部）
者。肾肝气已绝于内也。（下焦所治）而医（下工）反补其心肺。（无虚地）五脏脉（气）已绝于外（上部）者。其心肺
脉已绝于外也。（上焦所治）而医反补其肾肝。（无虚地）阳绝补阴。阴绝补阳。是谓实实虚虚。损不足益有余。（儆戒之
辞）如是死者。医杀之耳。
按灵枢第三篇云。五脏之气。已绝于内者。脉口气内绝不至。反取其外之病处。与阳经之合。有留针以致阳气。阳
气至则内重竭。重竭则死矣。五脏之气。已绝于外者。脉口气外绝不至。反取其四末之输。有留针以致其阴气。阴气至。
则阳气反入。入则逆。逆则死矣。张会卿曰。脉口浮虚。按之则无。是谓内绝不至。脏气之虚也。脉口沉微。轻取则无。
是谓外绝不至。阳之虚也。此篇问答。盖据此文变例。而发其余蕴。灵枢所谓内绝者。指阴经之虚。外绝者。指阳经之
虚。故内绝取阳经之合。外绝取四末之输。是乃议阴虚补阳。阳虚补阴之误也。素问云。治脏者治其俞。治腑者治其合。
是正道也。而今治脏反取阳合。治腑反取阴俞。其误可知矣。扁鹊所谓内外绝者。舍腑不论。偏举脏而言之。故知外绝
者。心肺之虚。而寸脉浮虚内绝者。肾肝之虚。而尺脉沉微。是为异也。下工动辄有此反治。故重深戒之曰。如此死者。
医杀之耳。前篇既举中工之害。则此言医者。当指下工。旧本误出于第十二篇。冯氏 谓此篇合入用针补泻之类。当在
六十难之后。以例相从也。今从其说。以类移于此云。
○余缵前修之业。自壮岁时讲究此书。业已数百遍。至今三十年所。无日不钻研。古人云。读书百遍。其义自通。
不佞如万卿。虽未曾中其肯綮。然且莫寓意。以俟左右逢其原之日久矣。顾其距春秋时邈焉。则其言亦渊乎深哉。故其
历世所注传。自吴吕广至明吴文 。凡十有九家。愈繁愈杂。辟犹百川派分。无繇寻源。于是舟之方之。渐得观溯洄之
澜。以问渤海之津。尝读韩非子说林。其中有言秦荆有 。荆人傍说晋叔向。叔向论城壶丘可否。以令二国和焉。余读
至是。喟然叹曰。呜呼。扁鹊设难之意。于叔向乎尽矣。无乃刻意叔向。以体扁鹊乎。乃余所注解。有取乎尔。亦有取
乎尔。
肝脏实证而肺部虚证，这是真虚假实的表现。因此应当遵循直接补肺、泻肝的治疗原则。若肺部实证而肝脏虚证，在脉象上则能显现出真实的病机；若在症状表现上，则多见假象。为什么呢？因为肺主收敛，其脏器娇嫩柔软，即使患病属实证，所呈现的症状也多类似不足（虚证）。肝主生发，其脏器性质猛烈，即使患病属虚证，所呈现的症状也多类似有余（实证）。所以中等水平的医生容易误判，将假实证当作真实证，将真实证当作真实证（此处原文逻辑似有笔误，结合上下文应指将假实当真，或将真实当假，导致误治），白白让患者承受错误的医疗束缚，并非自然死亡而是死于医家之手，可悲啊。鉴于前文已经批评中等水平医生粗疏且缺乏远见，故在此再次深切告诫。这一内容与第七十八篇所说的“东方实西方虚”一样，既有常法也有变法，义理相互阐发，不应视为同一类情况看待。
（第八十一难，旧本为第十二难）问：《灵枢》第一、第三篇中说，五脏之气在内已绝（尺部脉象反映下焦肝肾之气），使用针刺的医生，反而充实其外（阳经之合穴）；五脏之气在外已绝（寸部脉象反映上焦心肺之气），使用针刺的医生，反而充实其内（阴经之合穴）。内外之绝，如何辨别呢？答：五脏之气在内已绝（下部），是指肾和肝的气已在内部衰竭（下焦所主），但医生反而去补益心和肺（无虚之处）；五脏之气在外已绝（上部），是指心和肺的气已在外部衰竭（上焦所主），但医生反而去补益肾和肝（无虚之处）。阳气衰竭却补阴，阴气衰竭却补阳，这叫做“实实虚虚”，即损伤不足的正气，增加有余的邪气（这是警示之辞）。像这样导致死亡的，是医生杀死了病人。
按语：《灵枢》第三篇说：五脏之气在内已绝的，脉口之气向内断绝不至，反而取用外部的病处及阳经的合穴，留针以引致阳气，阳气至则内部更加枯竭，双重枯竭就会死亡。五脏之气在外已绝的，脉口之气向外断绝不至，反而取用四肢末端的输穴，留针以引致阴气，阴气至，则阳气反而内入，内入则逆乱，逆乱就会死亡。张会卿说：脉口浮虚，重按则无，这叫内绝不至，是脏气的虚损。脉口沉微，轻取则无，这叫外绝不至，是阳气的虚损。本篇的问答，大概是基于《灵枢》此文变化举例，而发挥其深层含义。《灵枢》所说的内绝，指的是阴经的虚损；外绝，指的是阳经的虚损。所以内绝取阳经的合穴，外绝取四肢末端的输穴，这是议论阴虚补阳、阳虚补阴的错误做法。《素问》说：治疗脏病取俞穴，治疗腑病取合穴，这才是正道。而现在治疗脏病反而取阳经合穴，治疗腑病反而取阴经俞穴，其错误可想而知。扁鹊所说的内外绝，舍弃了腑不论，只单独举脏来说，所以知道外绝是心肺的虚损，而寸脉浮虚内绝的是肾肝的虚损，以及尺脉沉微，这是与《灵枢》不同的地方。低水平的医生动辄出现这种反治法，所以深切告诫说：像这样死亡的，是医生杀死了病人。前篇既已列举中等水平医生的危害，那么这里说的医生，应当指低水平医生。旧本错误地将其放在第十二篇，冯氏认为此篇应归入用针补泻之类，应当在第六十难之后，以便同类相从。现在听从他的说法，按类别移置于此。
我继承前人的学业，从壮年时就开始钻研这本书，已经读了数百遍，至今三十年左右，没有一天不深入探究。古人说：读书百遍，其义自见。我虽然像万卿那样，未曾击中要害，但也早已寄托心意，等待左右逢源、追溯本源的那一天很久了。考虑到此书距离春秋时期已经遥远，那么其中的言语也是渊深奥妙啊。所以历代所作的注解传述，从吴国的吕广到明朝的吴文，共有十九家，越繁杂越混乱，就像百川分流，无法寻找到源头。于是我将它们整理规范，逐渐得以观察回溯的波澜，以此询问渤海般的津渡。曾经读《韩非子·说林》，其中有话说到秦、楚两国，楚人旁白晋国叔向，叔向论述修筑壶丘城墙是否可行，以此命令两国和解。我读到此处，感叹道：唉！扁鹊设立难问的用意，在叔向身上体现得淋漓尽致了。难道不是刻意模仿叔向，来体悟扁鹊的心意吗？于是我的注解，有的取自于此，有的也取自于此。
When the Liver is in a state of Excess and the Lung is in a state of Deficiency, this constitutes a case of "True Deficiency and False Excess" (Zhenshi Xu). Therefore, one should follow the direct path of tonifying the Lung and draining the Liver. If the Lung is in Excess and the Liver is in Deficiency, the true nature of the pathology can be seen in the pulse; however, if observed through symptoms, false manifestations are often prevalent. Why is this? Because the Lung governs consolidation/astringency, and its organ is delicate and soft. Even when diseased with an Excess pattern, the manifested symptoms often resemble Deficiency. The Liver governs growth and development, and its nature is fierce/active. Even when diseased with a Deficiency pattern, the manifested symptoms often resemble Excess. Consequently, physicians of average skill may misjudge, mistaking false Excess for true Excess, or true Deficiency for false Deficiency [Note: Text implies misdiagnosis leading to error], thereby causing patients to suffer from medical shackles unnecessarily, not dying a natural death but perishing due to medical error. How tragic! Since the preceding text already criticized average physicians for being crude and lacking foresight, I hereby issue a deep warning again. This content, like the statement in Difficulty 78 regarding "Excess in the East and Deficiency in the West," involves both constant principles and variable applications, with meanings mutually illuminating each other, and should not be viewed as a single uniform category.
(Difficulty 81, formerly Difficulty 12) Question: The *Ling Shu* (Spiritual Pivot), Chapters 1 and 3, states: When the Qi of the Five Zang organs has exhausted internally (reflected by the Chi position/pulse at the wrist), practitioners using acupuncture mistakenly tonify the exterior (the He-Sea points of Yang meridians). When the Qi of the Five Zang organs has exhausted externally (reflected by the Cun position/pulse at the wrist), practitioners using acupuncture mistakenly tonify the interior (the He-Sea points of Yin meridians). How can one distinguish between internal and external exhaustion? Answer: When the Qi of the Five Zang organs is exhausted internally (lower part), it means the Qi of the Kidney and Liver has exhausted internally (governed by the Lower Jiao). Yet the physician mistakenly tonifies the Heart and Lung (areas without deficiency). When the Qi of the Five Zang organs is exhausted externally (upper part), it means the Qi of the Heart and Lung has exhausted externally (governed by the Upper Jiao). Yet the physician mistakenly tonifies the Kidney and Liver (areas without deficiency). Tonifying Yin when Yang is exhausted, and tonifying Yang when Yin is exhausted, is called "making the Excess more Excess and the Deficiency more Deficient" (Shi Shi Xu Xu), i.e., damaging what is insufficient and augmenting what is already in excess (this is a cautionary phrase). Those who die in such a manner are killed by the physician.
Commentary: The *Ling Shu*, Chapter 3, states: When the Qi of the Five Zang organs is exhausted internally, the pulse at the mouth (Radial artery) does not reach inwardly. If one mistakenly treats the external disease sites and the He-Sea points of Yang meridians, retaining the needle to draw out Yang Qi, the arrival of Yang Qi will cause further depletion of the interior. Double depletion leads to death. When the Qi of the Five Zang organs is exhausted externally, the pulse at the mouth does not reach outwardly. If one mistakenly treats the Shu points at the four extremities, retaining the needle to draw out Yin Qi, the arrival of Yin Qi causes Yang Qi to retreat inward. Retreating inward leads to rebellion/reversal, and reversal leads to death. Zhang Huiqing said: A pulse that is floating and deficient, vanishing upon heavy pressure, is called "internal exhaustion not reaching," indicating Zang Qi deficiency. A pulse that is deep and minute, vanishing upon light pressure, is called "external exhaustion not reaching," indicating Yang Qi deficiency. The Q&A in this difficulty likely derives from variations of this text in the *Ling Shu* to expound upon deeper implications. In the *Ling Shu*, "internal exhaustion" refers to Yin Meridian deficiency, and "external exhaustion" refers to Yang Meridian deficiency. Thus, treating internal exhaustion by taking Yang He-Sea points, and external exhaustion by taking Four Extremity Shu points, represents the erroneous practice of tonifying Yang for Yin deficiency and tonifying Yin for Yang deficiency. The *Su Wen* (Plain Questions) states: To treat Zang diseases, take their Shu points; to treat Fu diseases, take their He-Sea points. This is the correct path. Now, treating Zang diseases by taking Yang He-Sea points, and treating Fu diseases by taking Yin Shu points, reveals the error clearly. Bian Que's mention of internal and external exhaustion sets aside the Fu organs and speaks solely of the Zang organs. Thus, we know that external exhaustion refers to the deficiency of the Heart and Lung, while the floating and deficient Cun pulse indicating internal exhaustion refers to the deficiency of the Kidney and Liver, along with the deep and minute Chi pulse. This differs from the *Ling Shu*. Low-skilled physicians frequently commit such contraindicated treatments, hence the deep warning: "Those who die thus are killed by the physician." Since the previous difficulty listed the harms of average-skilled physicians, the "physician" mentioned here refers to low-skilled physicians. The old edition erroneously placed this in Difficulty 12. Mr. Feng stated that this difficulty belongs to the category of acupuncture tonification and sedation and should follow Difficulty 60 to maintain categorical consistency. Following his view, I have moved it here by category.
I inherited the work of my predecessors and began studying this book earnestly in my youth. I have read it hundreds of times, and for nearly thirty years, there has been no day without deep investigation. The ancients said, "Read a hundred times, and the meaning will reveal itself." Although I, like Wan Qing, have not yet hit the crux of the matter, I have long entrusted my mind to wait for the day when I can find the source on all sides. Considering that this book is distant from the Spring and Autumn period, its words are indeed profound and deep. Therefore, the commentaries and transmissions throughout history, from Lu Guang of Wu to Wu Wen of Ming, total nineteen families. The more complex they become, the more chaotic they get, like rivers branching off, making it impossible to trace the source. Thus, I organized and standardized them, gradually allowing me to observe the waves of retrospection and inquire about the ferry crossing of the Bohai Sea. I once read the *Han Feizi · Shuo Lin*, which contains a story where Qin and Chu were involved, and Chu people spoke to Jin's Shu Xiang on the side. Shu Xiang discussed whether fortifying Huqiu was feasible, thereby ordering peace between the two states. Reading this, I sighed deeply and said: Alas! The intent behind Bian Que's formulation of difficulties is fully embodied in Shu Xiang. Is it not intentional imitation of Shu Xiang to comprehend Bian Que's mind? Thus, my annotations take from this source in some aspects, and also take from it in others.