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The text states that the differentiation of deficiency and excess in diseases is often based solely on whether the pulse is forceful or feeble. (Forcefulness indicates the presence of "root" vitality. The *Nan Jing* [Classic of Difficult Issues] says: If there is a pulse at the upper part but none at the lower part, the patient should vomit; if they do not vomit, death ensues. If there is no pulse at the upper part but there is one at the lower part, although the condition is severe, it is not fatal. This is because the Chi pulse [pulse felt at the wrist corresponding to the Kidneys] in humans is like the roots of a tree; as long as there are roots, death does not occur. Feebleness indicates the absence of root vitality. The *Nan Jing* says: If the Cun Kou pulse [radial artery pulse] appears level yet leads to death, it means the vital energy [Sheng Qi] is completely severed internally. "Level" here refers to an image of middle Qi deficiency and inability to generate, hence it is judged as death.)

However, consider cases where the pulse and symptoms contradict each other. If the pulse appears hard, strong, and forceful, while the symptoms include abdominal pain relieved by pressure, vomiting with counterflow qi, and shivering/chills, can this pulse be treated as an excess syndrome, thereby using bitter-cold herbs to purge excess? Conversely, if the pulse appears empty, soft, and feeble, while the symptoms include abdominal fullness, panting, and phlegm rales, can this pulse be treated as a deficiency syndrome, thereby using warming and tonifying formulas containing Aconite [Fuzi], Cinnamon Twig [Guizhi], or Lizhong Decoction [Belly Center Regulating Decoction]? Furthermore, the pulsation of the pulse originates from Qi, which flows and does not remain static. How can we ensure that cold qi has not generated internally, causing the Qi to stir only due to the stimulation of cold? The softness of the pulse stems from Dampness, which stagnates and does not move. How can we ensure that heat pathogen carrying dampness has not arrived, causing the pulse to become soft due to obstruction by Phlegm-Dampness? (Pulse forcefulness is often caused by internal stirring of cold or heat pathogens. However, people today only know that internal accumulation of heat constitutes excess, failing to realize that internal accumulation of cold can also constitute excess. Pulse feebleness is often caused by internal relaxation of the vessels due to cold-damp or heat-damp. However, people today only know that cold-damp leads to Phlegm and deficiency, failing to realize that heat-damp can also lead to Phlegm and excess. All such situations must be analyzed in conjunction with Observation, Auscultation-Olfaction, and Inquiry.)

Observation, Auscultation-Olfaction, Inquiry, and Palpation constitute the essential matters for physicians. If diagnosis relies solely on palpation, leading to misidentifying cold as heat, heat as cold, exterior as interior, or interior as exterior, resulting in chaotic reversal, it will inevitably endanger the patient's life. Moreover, classics state that a floating pulse may correspond to wind, deficiency, qi stagnation, vomiting, jue [cold extremities/reversal], pi [glomus/fullness], distension, inability to eat, or internal heat accumulation, among dozens of symptoms. If a floating pulse is detected without combining observation, auscultation-olfaction, and inquiry to investigate the truth, how can the disease be diagnosed? Therefore, those skilled in pulse diagnosis examine the patient's innate constitution thickness [vitality reserve], (some have thick constitution and pure Yang, some have thin constitution and pure Yin, some have average constitution and balance.), body fatness or leanness, (Hui Bian [Compendium of Differentiation] states: In obese individuals, Qi resides at the surface, and the six pulses often carry a floating and flooding quality; in slender individuals, Qi is contained within, and the six pulses often carry a deep and rapid quality. For tall persons, finger placement should be spaced widely; for short persons, closely. People from the North often show strong and solid pulses; people from the South often show weak and soft pulses. Young and vigorous people often have larger pulses; elderly people often have deficient pulses. After drunkenness, pulses are often rapid; after drinking alcohol, pulses are often flooding. Virgins and nuns often have soggy and weak pulses; infants' pulses are often seven beats per breath. It is also said: These are the norms of form and Qi, but within form and Qi, one must adapt to geographical changes to fully grasp the subtleties beyond words.) complexion dryness or luster, (either dry and exhausted, or moist and harmonious.) voice pitch and volume, (low and faint voice indicates Yin constitution and Yin disease; loud and robust voice indicates Yang constitution and Yang disease.) temperament rigidity or flexibility, (rigidity governs Yang, flexibility governs Yin. Hui Bian states: For irritable people, five beats per breath is the normal pulse; for slow-tempered people, four beats per breath may indicate heat.) dietary preferences, (preference for strongly aromatic foods suggests Yang deficiency; preference for strongly flavored foods suggests Yin weakness.) and habitual pulse characteristics, (pulse body leaning towards stillness showing Six Yin pulses; leaning towards movement showing Six Yang pulses; neither moving nor still showing extremely balanced pulses. Ren Zhai states: Even if the disease is cold, Yang pulses often appear floating and flooding; even if the disease is heat, Yin pulses often appear minute and fine.) along with the newness or chronicity of the current illness, (new illnesses due to external contraction often present with rapid, flooding, and large pulses; old illnesses due to internal injury often present with minute, short, and choppy pulses.) whether the pathology is internal or external, (external contraction belongs to the exterior and is easier to treat; internal injury belongs to the interior and is harder to treat.) whether the nature is Yin or Yang, (Yang governs exterior, upper, Qi, and Fire; Yin governs interior, lower, Blood, and Water.) and whether previous physicians caused harm through medication errors, (e.g., treating false cold with hot herbs, or false heat with cold herbs; treating branch symptoms with root-targeting drugs, or root symptoms with branch-targeting drugs, etc.), all of which require meticulous scrutiny. (This is the crucial method. However, patients today rarely request detailed examination by physicians. Zong stated: The Su Wen [Basic Questions] says that in treating any disease, one must observe the patient's form, Qi, color, and luster. Observing courage or timidity, bones, flesh, and skin allows one to understand their condition as a diagnostic method. If a patient's pulse and disease are inconsistent, and since one cannot see their form, relying solely on the pulse to prescribe medication—is this acceptable? Now, in wealthy households, women hide behind curtains and cover their arms with silk. Lacking the divine eye for observing color and the holy ear for hearing sounds, and unable to master the skill of palpation fully, detailed inquiry becomes necessary. Patients' families find this tedious, suspecting medical negligence, and often refuse the prescribed medicine. Thus, one fails to utilize the Four Diagnostic Methods, which is indeed difficult. Alas!) Only then, combining the diagnosed pulse image, can one judge the disease condition and determine auspiciousness or inauspiciousness. (Judgment requires a comprehensive assessment and grasping the main issue. Do not merely treat the head for head pain or the foot for foot pain.) If the disease is excess, the pulse should appear floating, flooding, tight, or rapid; if the pulse lacks Shen [spirit/vitality] or instead appears deep, minute, fine, or weak, it is not auspicious. If the disease is deficiency, the pulse should appear deep, minute, fine, or weak; if the pulse lacks Wei Qi [stomach Qi/nourishing quality] or instead appears flooding, large, rapid, or urgent, it is not auspicious. Extending this logic, acute diseases should present with Yang pulses, and chronic diseases with Yin pulses; all should correspond to the disease to be considered smooth/ favorable. (The Ling Shu [Spiritual Pivot] chapter Dong Shu states: Yang disease with small Yang pulses is adverse; Yin disease with large Yin pulses is adverse.)