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Question: In ancient medical cases, there are instances of "following the syndrome but not the pulse" and "following the pulse but not the syndrome." For the same disease, treatments vary, with some patients recovering and others not. What is the reason for this?

Answer: This refers to Mr. Jie'an's annotation on Zhang Zhongjing's (from Nanyang) treatment principles. Unfortunately, his explanation is incomplete. Whether one follows the syndrome or the pulse, there are specific formulas for each. For example, a floating pulse (Fú Mài, floating pulse) indicates an exterior condition, and treatment should involve sweating (Han Fa, diaphoresis). However, purgation (Xia Fa, purgation) may also be appropriate. Zhang Zhongjing stated: "If the pulse is floating and large, and the epigastrium feels hard, with heat entering the Zang organs, attack it with purgation; do not induce sweating." A deep pulse (Chén Mài, deep pulse) indicates an interior condition, and treatment should involve purgation. However, sweating may also be appropriate. For instance, in Shaoyin disease (Shàoyīn Bìng, Shaoyin Disease) at its onset, if there is fever and a deep pulse, use Ma Huang Fu Zi Xi Xin Tang (Ephedra, Aconite, and Asarum Decoction) to induce sweating. A rapid/intermittent pulse (Cù Mài, rapid pulse) indicates excess Yang, and treatment should involve clearing heat with Huang Qin (Scutellariae Radix) and Ge Gen (Puerariae Lobatae Radix). If the pulse is rapid accompanied by cold extremities, moxibustion at Baihui (GV20) is necessary to unblock Yang. This does not mean that a rapid pulse always indicates excess Yang. A slow pulse (Chí Mài, slow pulse) indicates Cold, and treatment should involve warming with Gan Jiang (Zingiberis Rhizoma) and Fu Zi (Aconiti Lateralis Radix Praeparata). However, in Yangming disease (Yángmíng Bìng, Yangming Disease), if the pulse is slow, there is no aversion to cold, and there is continuous sweating over the body, Da Cheng Qi Tang (Major Order the Qi Decoction) is used. This does not mean that a slow pulse always indicates Yin-Cold. These are all examples of "not following the pulse," because the syndrome is urgent. Furthermore, treating exterior syndromes with sweating is the standard method. Zhang Zhongjing said: "If the patient has fever and headache, but the pulse is unexpectedly deep, and there is body pain, warming is required; Si Ni Tang (Frigid Extremities Decoction) is appropriate." Treating interior syndromes with purgation is also standard. Fever at dusk (Ri Bu, late afternoon) belongs to Yangming, but if the pulse is floating and deficient, sweating is appropriate using Gui Zhi Tang (Cinnamon Twig Decoction). If the symptoms of Jie Xiong (Chest Binding) are complete, Xian Xiong Tang (Sinking Chest Decoction) should be given for purgation. However, if the pulse is floating and large, purgation is contraindicated; instead, Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction) should be used for warming. For body pain, Ma Huang Tang (Ephedra Decoction) or Gui Zhi Tang should be used for sweating. However, if the pulse at the Chi position (Chi Cun, distal radial pulse position) is slow, sweating is contraindicated; Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) should be used for harmonizing. These are all examples of "not following the syndrome," because the pulse indicates deficiency. The reason why the same disease is treated differently, with varying outcomes, lies in the failure to understand the root cause of the disease. I have examined the Nei Jing (Inner Canon), noting that many cases present identical symptoms, yet the affected meridians differ, and the observed pulses are distinct. How can one rigidly adhere to a single treatment principle? Moreover, physicians vary in skill, and diseases have root and branch aspects. If a person has strong Zheng Qi (Righteous Qi), whether treating the root or the branch, as long as the medicinal power can expel the pathogen, the Yuan Shen (Primordial Spirit) will naturally recover. However, if a person has inherent deficiency of Zheng Qi, they may present false syndromes and false pulses. Administering bitter-cold drugs that damage the root in such cases leads to unpredictable complications. Therefore, when treating diseases with fierce pathogens and sudden collapse of Zheng Qi, the prescription should be potent. Acute pathogens require urgent pursuit, and sudden deficiency requires vigorous tonification. Conversely, for diseases where weak pathogens linger and debility persists, the prescription should be mild, avoiding any herbs that might attract criticism. Thus, among wealthy and noble families, when critical and doubtful conditions arise, renowned physicians are invited to consult together. Amidst the mixture of tonifying and purging agents, one must not insist on personal views against the consensus. Even if compelled to act alone, one should prioritize mild formulations. If the condition is critical and adverse, one must not seek credit or display technical prowess, thereby inviting slander akin to "gold melted by gossip."