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The *Suwen: Treatise on the Essential and Subtle Aspects of Pulse* states: The subtlety lies in the pulse, which must not be neglected. The *Lingnan: Chapter on Pathogenic Factors, Zang-Fu Organs, and Disease Manifestations* states: Palpating the pulse to know the disease is called divine skill.

Qin Yue Ren (Bian Que) in the *Nanjing: Difficulty 61* states: Knowing through palpation is called skillful. Xu Shuwei stated: The principles of the pulse are profound and difficult to clarify. What I understand with my mind, my mouth cannot fully express.

Whatever can be recorded in writing or spoken by words are merely superficial signs. As for the spiritual principles, unless one grasps them intuitively, how can one exhaust their ultimate subtlety? The *Suwen: Treatise on Approaching and Receding Qi* states: If one does not complete studies under a master, leading to unclear medical techniques, and fails to examine compliance and opposition, this constitutes reckless practice. Misjudging yin and yang, abandoning yin to follow yang, and failing to integrate findings results in unclear diagnosis. Thus, it is crucial that pulses must be differentiated. The general principle is to combine the *Suwen*, *Lingnan*, and discussions from various schools, reading them thoroughly and pondering them carefully; one will naturally comprehend. One must particularly understand the principles of normal and variable pulses.

Generally, people's pulses may be inherently large or small, biased toward yin or yang; this is due to innate endowment, each forming its own pattern. Pulses changed by pathogenic factors may suddenly become slow or rapid, advancing or retreating intermittently; this indicates the sudden arrival of disease, where the pulse manifests according to qi dynamics. Therefore, those who diagnose pulses must first recognize the pulses of healthy organs before examining pathological pulses; they must first recognize normal pulses before examining variable pulses.

However, there are cases where the pulse matches the syndrome, and cases where the pulse contradicts the syndrome; there are also cases where extreme disease causes the pulse to reverse. For example, a yang syndrome presenting with a yang pulse, or a yin syndrome presenting with a yin pulse, is called pulse-syndrome concordance. A syndrome resembling yang but with a pulse that does not beat forcefully against the fingers, or a syndrome resembling yin but with a forceful pulse, is called pulse-syndrome discordance. When yang is excessive, the pulse must be surging and large; but when yang reaches its extreme, the pulse may instead become hidden and deep, representing "extreme yang resembling yin." When yin is excessive, the pulse must be faint and fine; but when yin reaches its extreme, the pulse may instead become restless and rapid, representing "extreme yin resembling yang." This is when the disease is at its peak and the pulse suddenly reverses.

There is also the differentiation of "following" (conforming to). For instance, a floating pulse indicates exterior pathology, and treatment should involve sweating; this is the norm. However, purgation may sometimes be appropriate. Zhang Zhongjing said: "If the pulse is floating and large, there is epigastric stiffness, and heat is present, indicating an interior organ excess, one should purge it and not induce sweating." This is such a case. A deep pulse indicates interior pathology, and treatment should involve purgation; this is the norm. However, sweating may sometimes be appropriate. For Shaoyin disease, if upon onset there is fever and a deep pulse, Ma Huang Fu Zi Xi Xin Tang should be used to induce slight sweating. This is such a case. A hurried (cu) pulse is typically yang, and Ge Gen Huang Qin Huang Lian Tang should be used to clear heat. But if the pulse is hurried accompanied by cold limbs, this indicates collapse, requiring warming methods; thus, this is no longer a pulse of yang excess. A slow (chi) pulse typically indicates cold, and Fu Zi Gan Jiang should be used to warm. However, in Yangming disease, if the pulse is slow, there is no aversion to cold, and the body sweats, Da Cheng Qi Tang should be used; thus, this is no longer a pulse of yin-cold. These are all instances of "following the syndrome rather than the pulse."

Regarding exterior syndromes, sweating is the norm. Zhang Zhongjing said: "If the patient has fever and headache, the pulse is unexpectedly deep, and the body aches, one should rescue the interior using Si Ni Tang." This follows the deepness of the pulse. Regarding interior syndromes, purgation is the norm. If there is afternoon tidal fever, indicating Yangming involvement, but the pulse is floating and deficient, sweating is appropriate using Gui Zhi Tang. This follows the floating nature of the pulse. In Jie Xiong (chest binding) syndrome, Da Xian Xiong Tang or Xiao Xian Xiong Tang should be used to purge. However, if the pulse is floating and large, purgation is contraindicated as it leads to death; here, one should treat the exterior following the pulse. If the body aches, Gui Zhi Ma Huang Tang should be used to resolve the exterior. However, if the cunameter (chi position) pulse is slow, sweating is contraindicated because Ying blood is insufficient; here, one should regulate Ying blood following the pulse. These are all instances of "following the pulse rather than the syndrome."

In the world, some palpate the pulse without asking about symptoms, or ask about symptoms while neglecting the pulse; are these not sinners against Zhang Zhongjing? Tao Jie'an stated: "Asking about the disease reveals the exterior; observing the pulse reveals the interior. The key lies in 'treatment methods,' which is the essential secret of clinical pulse diagnosis." In my years of treating eye diseases, I have always carefully consulted both pulse and syndrome to determine treatment.

For example, Lu and Zhu both presented with eyelid swelling and redness within the black part of the eye. One had a deep and slow pulse; knowing he had yin deficiency compounded by cold pathogens, I used Liu Wu Tang with roasted ginger to nourish yin and warm the stomach. The other had a floating, slow, and thin pulse; knowing he had dual deficiency of qi and blood with cold complicated by wind, I used Si Wu Xiao Yao San with Su Mu and Hong Hua to dispel wind and regulate blood. Zhang and Ai both presented with eyeball protrusion. One had floating, surging, rootless pulses at both chi positions and weak, soggy, powerless pulses at the right cun position; this indicated Lung Metal failing to generate Kidney Water, causing Kidney Fire to float upward. I used Jin Kui Shen Qi Wan to descend the floating yang. The other had fine, rapid pulses at both chi positions and floating, surging pulses at the right cun position; this indicated dryness of Kidney Water and upward rushing of Lung Qi. I used Ren Shen Gu Ben Jian with Niu Xi to clear hyperactive heat. Here, the syndromes were the same but the pulses differed, so the treatments differed.

Again, Qian had dilated pupils, and Li had protruding eyelids with itching. These are clearly two different syndromes, yet both had fine, rapid chi pulses and surging, large cun pulses, both resulting from Heart-Kidney non-interaction. I treated both with Zi Yin Liu Wei Wan, removing Shan Zhu Yu and adding Nu Zhen Zi. Here, the syndromes differed but the pulses were the same, so the treatments were the same.

Consider Kong, who saw white as yellow, red as purple, and straight lines as slanted. This is a syndrome of extreme yin with flying yang. The pulse should be floating and surging, but here it is fine and choppy. This is what is meant by "when extremes are reached, they assume the transformation of the overcoming element." I treated him with Qi Wei Er Di Wan to warm and tonify; this relied on symptoms rather than the pulse.

Generally, yin and yang, deficiency and excess, require careful examination. Zhang Jiabin stated: "Whenever situations are suspected and difficult to clarify, one must use the four diagnostic methods, inquire in detail about the cause, and simultaneously observe voice and complexion. By verifying with reason amidst the primary and secondary aspects, one obtains the truth. If one ignores this and claims that a single pulse diagnosis is sufficient, treating arbitrarily, how can one know that pulses and syndromes often present true and false appearances? If one's insight is not accurate, how can errors be avoided? Moreover, for experienced diagnosticians, understanding is relatively easy; for novices, decision-making is very difficult. This is why the four diagnostic methods must not be neglected."