七十七难曰∶经言上工治未病，中工治已病者，何谓也？
然∶所谓治未病者，见肝之病，则
知肝当传之与脾，故先实其脾气，无令得受肝之邪，故曰治未病焉。中工治已病者，见肝之病，
不晓相传，但一心治肝，故曰治已病也。
《灵枢·逆顺篇》曰∶上工刺其未生者也，其次刺其未盛者也，其次刺其已衰者也，下工刺
其方袭者也，与形之盛者也，其病之与脉相逆者也。故曰∶方其盛也，勿敢毁伤，刺其已衰，事
必大昌。故曰∶上工治未病，不治已病，此之谓也。此言治病，上工刺其病之未生，其次刺其
初来未盛，再其次则刺其已衰，如兵法之避其来锐，击其惰归也。故伯高曰∶无迎逢逢之气，
无击堂堂之阵，无刺 之热，无刺漉漉之汗，无刺浑浑之脉，无刺病与脉相逆者是也。下工
不知此义，刺其邪之方袭于经脉之中，或刺其邪之方盛于皮腠之间，或刺其邪正相攻之时，不
能图功，皆足以偾事也。此论刺法须及其病未生，并方退之时，乃可用针。然凡病皆当预图于
早，勿待病成方治，以贻后悔也。治之早则用力少而成功多，所谓曲突徙薪之勋，宜加于焦头
烂额之上也。治病固当如此，而处天下事概当如此，岂止针法为然哉？夫五脏之气旺，则资其
所生，由肝生心，心生脾，脾生肺，肺生肾，肾生肝，顺传则吉也。病则侮其所克，肝克脾，
脾克肾，肾克心，心克肺，肺克肝，逆传则凶也。上工治未病者，治所传未病之脏也。是以见
肝之病，知肝传脾，当先实脾，使肝病不得传而可愈也。故曰治未病。中工昧此，见肝病而徒
治其肝，则肝病未已，脾病复起，故曰治已病也。《素问·玉机真藏论》曰∶五脏受气于其所生，
传之于其所胜，气舍于其所生，死于其所不胜，病之且死，必先传行至其所不胜，病乃死，此
言气之逆行也，故死。亦此义也。
按∶此章乃古医经奥旨微言，越人畅其厥义，然又有未尽者，仲景《金匮》引申之，足为后
学津筏。问曰∶上工治未病，何也？师曰∶夫治未病者，见肝之病，知肝传脾，当先实脾，四
季脾旺不受邪，即勿补之。中工不晓相传，见肝之病，不解实脾，惟治肝也。夫肝之病，补用
酸，助用焦苦，益用甘味之药调之。酸入肝，焦苦入心，甘入脾，脾能制肾，肾气微弱，则水
不行，水不行，则心火气盛，心火气盛，则制肺，肺被制，则金气不行，金气不行，则肝气盛，
则肝自愈，此治肝补脾之要妙也。肝虚则用此法，实则不在用之。经曰∶虚虚实实，补不足，
损有余，是其义也。余脏准此。此条须分三段看，上段言肝病必传于脾，木克土也。上工必先
实脾，脾实不受木克，则肝病以不得传而可愈也。然脏气之衰旺，与时令相流通，四季辰戌丑未
四月，每季土旺十八日，合算奇零，以五行各旺七十二日之数。脾土当旺，则不受邪，即勿补
之，而肝木亦不得肆其侮也。设过补脾，又犯实实之戒矣。中工不识五行衰旺传克之义，见肝
之病，惟治已病之肝，不知实未病之脾也。中段言肝之为病多虚，盖虚则受邪也。肝木既虚，
肺金必侮其不胜，上工治此，必在肺金未侮肝木之先有以制之。用酸以补肝之本体，用焦苦以
助其子心火，使不泄肝木之气，而克制肺金，用甘以益脾土而制水，水弱则火旺，火旺则金制，
金制则木不受克，而肝病自愈矣。此亢则害，承乃制，隔二隔三之治，故曰此治肝补脾之要妙
也。末段言肝虚则用此法，肝实不用此法也。中工不明虚实之理，虚者泻之，是为虚虚，实者
补之，是为实实。故又引经文补不足，泻有余、以证其义。而再曰，余脏准此，盖举一肝脏，
一隅三反，余可类推也。此与七十五难之泻南方，补北方之义略同。而尤氏注《金匮》，不明
隔治之理，谓酸入肝以下十五句，为后人添注，误矣。
第七十七难说：医经上讲，高明的医生治疗尚未发生的疾病，一般的医生治疗已经发生的疾病，这是什么意思呢？
回答说：所谓治疗尚未发生的疾病，是指看到肝脏有病，就知道肝病会传变给脾脏，所以预先使脾气充实，不让脾脏受到肝邪的侵害，这就叫做治疗尚未发生的疾病。一般医生治疗已经发生的疾病，看到肝脏有病，不懂得脏腑之间相互传变的规律，只一心一意治疗肝脏，所以叫做治疗已经发生的疾病。
《灵枢·逆顺篇》说：高明的医生在病邪尚未产生时进行针刺，其次是在病邪尚未强盛时进行针刺，再次是在病邪已经衰退时进行针刺；低劣的医生则在病邪正侵袭人体时进行针刺，或在形体正气正强盛时进行针刺，或在病症与脉象相逆的时候进行针刺。所以说：当病邪正强盛时，不敢贸然攻伐损伤正气，要在病邪衰退后施治，事情一定能大吉大利。所以说：高明的医生治疗尚未发生的疾病，不治疗已经发生的疾病，说的就是这个道理。这里讲的是治病，高明的医生在病邪未生时刺之，其次在病邪初来未盛时刺之，再次在病邪已衰时刺之，就像兵法中避开敌人锐气，攻击其懈怠归来的时机一样。所以伯高说：不要迎击气势旺盛的敌军，不要攻击阵容严整的军队，不要在热势炽盛时针刺，不要在大汗淋漓时针刺，不要在脉象混乱时针刺，不要在病症与脉象相逆时针刺，说的就是这些情况。低劣的医生不懂这个道理，在邪气正侵袭经脉时针刺，或在邪气正强盛于皮肤腠理间时针刺，或在邪正相争激烈时针刺，不能取得疗效，都足以导致失败。这段论述说明针刺疗法必须把握在病邪未生或方退之时，才能使用针法。然而所有疾病都应当预先谋划于早期，不要等到病已成定局才去治疗，以免留下后悔。治疗得早则用力少而成功多，所谓“曲突徙薪”（把烟囱改建成弯的，把灶旁的柴草搬走）的功劳，应该高于“焦头烂额”（救火时烧焦了头、烧坏了脸）之上。治病固然应当如此，处理天下万事也都应当如此，岂止是针刺疗法是这样呢？
五脏之气旺盛时，资助其所生的脏器，由肝生心，心生脾，脾生肺，肺生肾，肾生肝，顺次传变则是吉利的。生病时则会反侮其所克的脏器，肝克脾，脾克肾，肾克心，心克肺，肺克肝，逆次传变则是凶险的。高明的医生治疗尚未发生的疾病，是治疗将要被传变但尚未发病的脏器。因此看到肝脏有病，知道肝病会传脾，应当先使脾气充实，使肝病不得传变从而痊愈。所以叫治疗尚未发生的疾病。一般医生不明白这个道理，看到肝病却只治疗肝脏，那么肝病还没好，脾病又起来了，所以叫治疗已经发生的疾病。《素问·玉机真藏论》说：五脏的病气来源于其所生的脏器，传变到其所克的脏器，气停留于所生的脏器，死于其所不胜的脏器。病快要死亡时，必定先传行至其所不胜的脏器，病才会死，这是讲气的逆行，所以致死。也是这个道理。
按语：这一章是古代医经深奥精微的宗旨，越人（秦越人/扁鹊）阐发了其中的义理，但还有未尽之处，张仲景在《金匮要略》中加以引申，足以成为后学者的渡河工具。问：什么是治疗尚未发生的疾病？老师说：所谓治疗尚未发生的疾病，是指看到肝脏有病，知道肝病会传脾，应当先使脾气充实。如果在四季中脾气旺盛不受邪气侵犯，就不要补益。一般医生不懂得脏腑相传的道理，看到肝脏有病，不知道要使脾气充实，只是治疗肝脏。对于肝脏的疾病，用酸味药来补益，用焦苦味药来辅助，用甘味药来调和。酸味入肝，焦苦味入心，甘味入脾。脾能制约肾，肾气微弱，则水液不行；水液不行，则心火气盛；心火气盛，则制约肺金；肺金被制约，则金气不行；金气不行，则肝气旺盛，这样肝病就能自愈，这就是治疗肝病兼补脾脏的精妙之处。肝脏虚弱时才用这种方法，肝脏实证则不适用。医经说：不要使虚证更虚，实证更实，要补不足，损有余，就是这个道理。其他脏器也以此类推。这条经文需要分三段来看。上段讲肝病必然传于脾，这是木克土的关系。高明的医生必先充实脾气，脾气充实就不受木气克制，那么肝病因无法传变而可愈。然而脏气的衰旺与时令相通应，辰、戌、丑、未四个月（即每季最后一个月），每季土旺十八日，合计奇零，以五行各旺七十二日之数计算。如果脾土当旺，则不受邪气侵犯，就不要补益，而肝木也不敢肆意欺侮。如果过度补脾，又犯了“实实”（使实证更实）的禁忌。一般医生不识五行衰旺传克的道理，看到肝病，只治疗已病的肝脏，不知道充实未病的脾脏。中段讲肝之为病多为虚证，因为虚则容易受邪。肝木既已虚弱，肺金必然欺侮它不能胜的脏器（即反侮）。高明的医生治疗这种情况，必须在肺金尚未欺侮肝木之前加以制约。用酸味药补肝之本体，用焦苦味药助其子脏心火，使心火不泄肝木之气，从而克制肺金；用甘味药益脾土以制约肾水，水弱则火旺，火旺则金受制，金受制则木不受克，肝病自然痊愈。这就是“亢则害，承乃制”以及隔二、隔三治疗的原理，所以说是治疗肝病补脾的精妙之处。末段讲肝虚才用此法，肝实不用此法。一般医生不明虚实之理，对虚证用泻法，这叫“虚虚”（使虚者更虚）；对实证用补法，这叫“实实”（使实者更实）。所以又引用经文“补不足，泻有余”来证明其义理。再说“余脏准此”，是举出肝脏一例，举一反三，其余脏器可以类推。这与第七十五难中“泻南方，补北方”的意义大致相同。而尤氏注解《金匮要略》，不明白隔脏治疗的道理，认为从“酸入肝”以下十五句是后人添加的注释，这是错误的。
Chapter 77 states: The medical classics say that excellent physicians treat diseases before they occur, while average physicians treat diseases after they have occurred. What does this mean?
The answer is: Treating diseases before they occur means that upon observing a disease of the Liver, one knows that the Liver disease will transmit to the Spleen. Therefore, one first strengthens the Qi of the Spleen (Pi Qi) so that it is not affected by the pathogenic factors of the Liver. This is called treating diseases before they occur. Average physicians treat diseases after they have occurred; upon observing a disease of the Liver, they do not understand the principle of transmission between Zang organs and focus solely on treating the Liver. Hence, this is called treating diseases after they have occurred.
The *Ling Shu: Ni Shun Pian* (Spiritual Pivot: Chapter on Reversal and順顺) states: Excellent physicians apply acupuncture when the pathogen has not yet arisen; next best is applying it when the pathogen is not yet vigorous; next is applying it when the pathogen has already declined. Inferior physicians apply acupuncture when the pathogen is just invading, or when the body's righteous Qi is at its peak, or when the symptoms contradict the pulse. It is said: When the pathogen is vigorous, do not dare to damage the righteous Qi; apply treatment after it has declined, and success is guaranteed. Thus, it is said: Excellent physicians treat diseases before they occur and do not treat diseases after they have occurred; this is what is meant. This refers to treatment: excellent physicians needle when the disease has not yet formed, next when it has just arrived and is not yet strong, and again when it has declined, similar to military strategy avoiding the enemy's sharp advance and striking when they are tired and retreating. Bo Gao said: Do not confront the formidable energy of the enemy, do not attack their well-ordered formations, do not needle when the heat is intense, do not needle when sweating profusely, do not needle when the pulse is chaotic, and do not needle when the disease contradicts the pulse. These are the situations referred to. Inferior physicians do not understand these principles; they needle when the pathogen is just invading the meridians, or when the pathogen is vigorous in the skin and interstices, or when the pathogen and righteous Qi are clashing fiercely. They cannot achieve therapeutic effects, all of which lead to failure. This discussion indicates that acupuncture must be used when the disease has not yet formed or is receding. However, all diseases should be planned for early, not waited until the disease is established to be treated, lest regret ensue. Early treatment requires less effort and yields more success. The merit of "bending the chimney and moving the firewood" (preventing disaster) should be ranked above that of "scorched heads and burnt faces" (treating disaster after it happens). Treating disease should indeed be like this, and managing affairs in the world should also be like this; is it only acupuncture that is like this?
When the Qi of the Five Zang organs is prosperous, it nourishes the organ it generates: Liver generates Heart, Heart generates Spleen, Spleen generates Lung, Lung generates Kidney, and Kidney generates Liver. Transmission in this order is auspicious. In disease, the affected organ insults the organ it normally controls: Liver controls Spleen, Spleen controls Kidney, Kidney controls Heart, Heart controls Lung, and Lung controls Liver. Reverse transmission is ominous. Excellent physicians treat diseases before they occur by treating the Zang organ that is about to be transmitted to but has not yet become diseased. Thus, seeing a Liver disease, knowing it will transmit to the Spleen, one should first strengthen the Spleen, preventing transmission and allowing the Liver disease to heal. Hence, it is called treating diseases before they occur. Average physicians fail to grasp this; seeing a Liver disease, they merely treat the Liver. Consequently, the Liver disease is not resolved, and a Spleen disease arises anew. Hence, it is called treating diseases after they have occurred. The *Su Wen: Yu Ji Zhen Zang Lun* (Basic Questions: Chapter on the True Depositions of the Five Zang) states: The Five Zang receive Qi from the organ that generates them, transmit it to the organ they control, retain Qi in the organ that generates them, and die when afflicted by the organ that overcomes them. Before death, the disease must transmit to the organ that overcomes it, and then death occurs. This speaks of the reverse flow of Qi, hence death. This is also the same principle.
Commentary: This chapter contains the profound and subtle tenets of ancient medical classics. Yue Ren (Bian Que) expounded on its meaning, though not exhaustively. Zhang Zhongjing expanded upon it in the *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet), providing a valuable guide for later students. Question: What is treating diseases before they occur? Answer: Treating diseases before they occur means seeing a Liver disease, knowing it will transmit to the Spleen, and thus first strengthening the Spleen. If the Spleen is prosperous in the four seasons and immune to pathogens, supplementation is unnecessary. Average physicians do not understand transmission; seeing a Liver disease, they fail to strengthen the Spleen and only treat the Liver. For Liver disease, sour flavors supplement the Liver, bitter flavors assist the Heart, and sweet flavors regulate the Spleen. Sour enters the Liver, bitter enters the Heart, and sweet enters the Spleen. The Spleen controls the Kidney; if Kidney Qi is weak, Water fails to circulate. If Water fails to circulate, Heart Fire becomes vigorous. If Heart Fire is vigorous, it controls Lung Metal. If Lung Metal is controlled, Metal Qi fails to circulate. If Metal Qi fails to circulate, Liver Wood becomes vigorous, and the Liver disease heals itself. This is the subtlety of treating the Liver by supplementing the Spleen. This method applies to Liver deficiency, not Liver excess. The classics state: Do not make deficiency more deficient or excess more excessive; supplement insufficiency and reduce excess. This is the principle. The same applies to other Zang organs.
This passage should be read in three parts. The first part states that Liver disease inevitably transmits to the Spleen due to Wood controlling Earth. Excellent physicians first strengthen the Spleen; if the Spleen is strong and immune to Wood control, the Liver disease cannot transmit and heals. However, Zang Qi prosperity correlates with seasonal timing. In the months of Chen, Xu, Chou, and Wei (the last month of each season), Earth is prosperous for eighteen days per season, totaling seventy-two days for each element. If Spleen Earth is at its peak, it resists pathogens, so no supplementation is needed, and Liver Wood cannot insult it. Over-supplementing the Spleen would violate the prohibition against "making excess more excessive." Average physicians ignore the principles of Five Element decline/prosperity and transmission/control; seeing Liver disease, they treat only the diseased Liver, neglecting to strengthen the healthy Spleen.
The second part states that Liver diseases are often deficient, as deficiency invites pathogens. If Liver Wood is weak, Lung Metal may insult it (reverse control). Excellent physicians intervene before Metal insults Wood. They use sour flavors to tonify the Liver's substance, bitter flavors to assist its offspring, the Heart Fire, preventing the leakage of Liver Wood Qi and thereby controlling Lung Metal. They use sweet flavors to benefit Spleen Earth and control Kidney Water. Weak Water leads to vigorous Fire; vigorous Fire controls Metal; controlled Metal allows Wood to remain uncontrolled, healing the Liver disease. This reflects the principle that "excess causes harm, and restraint brings balance," utilizing indirect treatment methods (intervening through two or three organs). Hence, it is called the subtlety of treating the Liver by supplementing the Spleen.
The third part states this method applies to Liver deficiency, not Liver excess. Average physicians misunderstand deficiency and excess; using purgation on deficiency makes it "more deficient," and using tonification on excess makes it "more excessive." Thus, the classic text cites "supplement insufficiency, drain excess" to validate this principle. "The rest follow this pattern" implies drawing inferences from the Liver example. This aligns roughly with the principle in Chapter 75 of "draining the South and supplementing the North." You Shi's commentary on the *Jin Gui* failed to understand the logic of indirect treatment, erroneously claiming that the fifteen sentences starting from "Sour enters the Liver" were added by later authors.