The question is asked: “The superior physician treats illness before it arises — what does this mean?”

The Master replies: “To treat illness before it arises means: when one sees liver disease, one must recognize that the liver will transmit its pathology to the spleen. Therefore, the spleen should be strengthened first. However, when spleen qi is robust throughout the four seasons and can resist pathogenic invasion, there is no need to supplement it further. The mediocre physician, unaware of this pattern of transmission, upon seeing liver disease, fails to strengthen the spleen and treats only the liver.”

“For liver disease, use sour-flavored medicinals to supplement, bitter-roasted medicinals to assist, and sweet-flavored medicinals to regulate. Sour enters the liver, roasted bitterness enters the heart, and sweetness enters the spleen. When the spleen is overactive, it may impair the kidneys; when kidney qi is weakened, water fails to circulate; when water fails to circulate, heart fire becomes exuberant, which then damages the lungs; when the lungs are damaged, metal qi fails to function; when metal qi fails to function, liver qi becomes excessive. Therefore, by strengthening the spleen, the liver will heal of its own accord. This is the essential subtlety of treating the liver by supplementing the spleen. Use this method when there is liver deficiency, but not when there is excess. The Classic states: ‘Do not supplement the deficient when it is actually in excess, and do not drain the excessive when it is actually in deficiency; supplement what is insufficient and reduce what is excessive’ — this is its meaning. The same principle applies to all other organs.”

Reflections

This passage has long been regarded as Zhang Zhongjing’s foundational principle for treating visceral patterns — its theoretical roots trace back to the Huangdi Neijing, and it discusses the transmission and treatment of disease through the framework of Five Elements generation and restriction.

Personally, I suspect this paragraph may be a later interpolation with limited practical significance. The clinical application value emphasized in mainstream commentary has never been fully realized, which suggests that the concept of “treating illness before it arises” remains underappreciated in practice. On another note, the system of Five Elements generation and restriction is not always coherent in its details — the chains of interconnection are so flexible that almost anything can be explained retroactively. When liver disease presents, one could justify treating the spleen or the kidneys, leaving enormous room for clinical discretion. This places a heavy burden on the physician’s insight and judgment — and this, perhaps, is the greatest distinction between the Jingui Yaolue and the Shanghan Lun.

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。脾能伤肾，肾气微弱，则水不行；水不行，则心火气盛，则伤肺；肺被伤，则金气不行；金气不行，则肝气盛。故实脾，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。余藏准此。

学习

此段历来认为是仲景脏腑辨证的治疗原则，理论来源为黄帝内经，以五行制化为基础，论述了疾病的传变和治疗规律。

个人认为此段可能为衍文，意义不大，当前主流论述的临床应用价值没有得到充分体现，可见人们十分不重视治未病。另一方面，五行生克制化在许多方面并不是很系统，环环相扣，怎么解释都可以，见肝之病，可以治脾，也可以治肾，如此一来余地甚多，十分考验医者悟性，这也是金匮与伤寒最大不同之处。