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In treating diseases, physicians should maintain sincerity without distinction between the rich and the poor; however, to ascertain the nature of the disease, one must differentiate between those of high status and those of low status. Why is this? The wealthy often exert their minds excessively, leading to deficiency in the middle jiao (Middle Burner), with soft sinews and fragile bones; the poor often engage in physical labor, resulting in solidity in the middle jiao, with strong sinews and tough bones. The wealthy enjoy fine foods, making their zang-fu organs delicate; the poor subsist on coarse food, keeping their zang-fu organs robust. The wealthy reside in deep, spacious houses, where their couli (skin pores) are loose, making them susceptible to invasion by the six exogenous pathogens (Liu Yin); the poor live in thatched huts and narrow alleys, with dense couli, making them resistant to external pathogens. The wealthy indulge in desires and harbor excessive thoughts, depleting the essence and marrow of the heart and kidney; the poor have few anger outbursts and desires, are easily satisfied, and only deplete the daily generated qi and blood. Therefore, diseases among the wealthy often stem from root deficiency, while those among the poor often manifest as branch excess, which is indeed different.

Those with constitutional weakness are suitable for tonification, but some cannot tolerate tonics due to improper application. Medication must be prescribed based on pulse diagnosis, not merely fixed formulas for specific diseases. Between the six pulses, variations in magnitude indicate differences in generating and overcoming cycles, and victory or defeat; within a prescription, adjustments in dosage reflect emphasis on certain aspects over others. Pulses can be true or false, and treatments can be contrary or conforming. For instance, if all six pulses are surging and forceful, this indicates deficiency of true yin, and Liuwei Dihuang Tang (Six-Flavor Rehmannia Decoction) should be used. If the right Cun pulse is even more surging, Maiwei Dihuang Tang (Lonicera and Schisandra Rehmannia Decoction) is indicated. If the pulse is surging and rapid, laypeople might attribute it to yin deficiency with yang hyperactivity and mistakenly use Zhibai Dihuang Tang (Anemarrhena, Phellodendron and Rehmannia Decoction). If there is genuine yang excess, one should support its illuminating function, aiding generation and nourishment, so that the pulse becomes spirited and regular. However, when true yang is deficient, false yang takes advantage, akin to the sun being obscured while lightning fire rages chaotically; in such cases, Liuwei Dihuang Tang added with Wuweizi (Schisandrae Fructus) and Rougui (Cinnamomi Cortex) is appropriate to boost the sun's light and dispel the dragon-fire of false heat. If the pulse is wiry-rapid or thready-rapid, it signifies damage to both true yin and true yang; one should heavily use Liuwei Dihuang Tang with small amounts of Rougui and Fuzi (Aconiti Lateralis Radix Praeparata) to use fire to regulate fire. Once the rapidity subsides, control mechanisms work, and yin can grow. A moderate, slightly slow pulse reflects stomach qi; if it is surging without being slight, or wiry-rapid without being moderate, it suggests a lack of stomach qi. This approach tonifies true yang to quell false yang and uses true fire to protect spleen earth, representing the supreme theory of tonifying true yin and yang in the kidney. Furthermore, excessive mental exertion or irregular diet/labor can damage post-heaven heart-spleen qi and blood. If treatment focuses solely on the root (kidney), yuan qi may sink further; if the source of transformation is cut off above, how can kidney qi suffice below? If the six pulses are floating, large, and powerless, it indicates insufficient middle qi and deficient young yin, failing to secure yuan qi. Tonifying qi and blood with astringent herbs, such as Yangrong Tang (Nourishing Vigor Decoction) with Wuweizi, and removing Chenpi (Citri Reticulatae Pericarpium), is suitable. If the six pulses are deep, thready, and powerless, it indicates severe deficiency of yuan yang and middle qi; strengthening the middle jiao (spleen/stomach) and warming qi and blood is essential, as the spleen and stomach are the source of qi and blood production. Ancient formulas always include Shengjiang (Zingiberis Rhizoma Recens) and Dazao (Jujubae Fructus) for this reason. When middle qi is weak and transport is impaired, acrid-warm herbs like Muxiang (Aucklandiae Radix) in Guipi Tang (Restore the Spleen Decoction) or Rougui in Shiquan Dabu Tang (Ten Significant Great Supplement Decoction) help move medicinal power without burdening the spleen and stomach. If the six pulses are slow and very faint, indicating severe yang deficiency, rescue yang primarily: Ren Shen Lizhong Tang (Ginseng and Poria Decoction) for mild cases, Fuzi Lizhong Tang (Aconite and Poria Decoction) for severe ones, avoiding yin-nourishing herbs, as yang generates yin. If the six pulses are thready-rapid and powerless upon prolonged pressure, it indicates concurrent deficiency of pre-heaven and post-heaven yin and yang; take Bawei Dihuang Wan (Eight-Ingredient Rehmannia Pill) in the morning and Renshen Yangrong Tang (Ginseng Nourishing Vigor Decoction, remove Chenpi) or Shiquan Dabu Tang (remove Chuanxiong, replace Shengdi with Shudi) at night. If both Cun pulses are surging and Chi pulses are powerless, it indicates upper heat/lower cold and upper excess/lower deficiency; use Bawei Dihuang Tang with Niuxi (Achyranthis Bidentatae Radix) and Wuweizi until pulses are level but weak, then administer Ginseng decoction separately. If Chi pulses are forceful and Cun pulses are weak, it indicates sinking yuan qi and lower excess/upper deficiency; use Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction) to raise qi. As earth rises, heaven descends, allowing interaction like rain and dew, preserving vital qi. Pre-heaven yang deficiency requires tonifying Mingmen (Gate of Life); post-heaven yang deficiency requires warming stomach qi. Pre-heaven yin deficiency requires tonifying kidney water; post-heaven yin deficiency requires tonifying heart and liver, as the heart governs blood and the liver stores blood. However, the Taiyin spleen is paramount, as it is the root of young qi, the foundation of transformation, and the controller of blood. In any formula, adjust based on pulse indications: add what is suitable, remove what is contraindicated. For example, in Shiquan Dabu Tang, if lung pulse is surging, remove Chuanxiong (Chuanxiong Rhizoma) and add Maidong (Ophiopogonis Radix) and Wuweizi, because Chuanxiong is acrid and ascending, while Maidong is sweet but heavy in qi, acting on spleen/lung and exterior. If all pulses are powerless, Shiquan Dabu Tang is best; if unable to take Ren Shen, increase Baizhu (Atractylodis Macrocephalae Rhizoma), use Danggui (Angelicae Sinensis Radix) only, and avoid Shaoyao (Paeoniae Radix Alba), as the focus is on tonifying qi; Danggui is yang within yin, while Shaoyao is yin within yin. Regarding Rehmannia-based formulas, they show miraculous effects for various diseases depending on pulse variations. However, they are temporarily contraindicated in cases of extreme yang deficiency with deep/faint pulses, as the yin herbs (Shudi, Shanzhuyu) act as sovereign/minister drugs, outweighing the assistant/drug-guiding heat of Rougui and Fuzi. Shudi can be increased to 2-3 liang, but Shanzhuyu (Corni Fructus) should not exceed 3-4 qian, as excessive sourness masks other herbs' efficacy and damages stomach qi. Zhang Jingyue provides these examples to demonstrate endless variations; students should infer from them to grasp the subtleties.