3.卫气营血脉象演变规律：卫气营血辨证是中医治疗各种传染病，和烧伤病人发热的主要辨证方法。病邪侵袭到卫气营血，虽各有其本经见证，而脉象变化每见于证候出现之前，掌握其演变规律，防治可以主动。一般外感热性病在发展演变过程中，必然引起机体卫气营血变化，从而发生各部分的复杂证候。机体和这些证候的内部联系和规律性，都能从脉象上体现出来，细心体察，可早期作好防御措施。
根据临床体验，一般外感热性病和各种急性传染病，初起多现卫分症状。迨热邪内犯，病势加重，则由卫分转入气分。邪在卫分，则发热恶寒，脉浮大或浮数，舌质偏红，苔微黄。及深入气分，则身发壮热，而不恶寒，脉象洪大滑数，脉力较强，沉取每在5个脉力单位左右，浮取多在6-7个脉力单位，脉力愈大表示毒热愈猛，应放胆大剂用清热解毒药物，以防止病邪内陷。如邪在气分身热不退、心烦不宁、脉象转沉，是病邪由气分犯营的先兆，应予清解毒热宣邪外出，分化其内攻之势。如神识模糊、嗜睡、心烦不安、左脉数急、舌质红绛，是已入营，应以清解毒热，清营宣透为主，辅以醒神熄风。由营分再深陷血分，则脉多沉数虚数，弦细数之脉。其它各种疾病的脉，于其发生发展和转化亦均有其规律，应细心体察。
4．从伤寒的临床观察，研究探讨卫气营血和脉、舌的演变规律：伤寒是由伤寒杆菌引起的急性传染病。其最显著的病理改变，是肠道内淋巴组织增生和坏死。临床特点有持续性体温升高，相对缓脉，脾肿大，玫瑰疹及白细胞减少。本病不同于祖国医学《伤寒论》中的伤寒，可包括于祖国医学温病范畴。今据几年来临床治疗31例伤寒的资料，研究伤寒等急性传染病在卫气营血和脉、舌变化规律，供临床讨论。
31例(伤寒杆菌培养阳性者23例，培养阴性者8例。伤寒血清凝集试验：21例中有27例“O”及“H”抗原的凝集效价在1:160以上，仅4例为1:80，此4例伤寒杆菌培养均阳性)初起均有恶寒体痛发热、头痛、目眩、心烦，不思食、脉现浮濡、浮大、浮数，以邪在卫分故舌多淡，如内有郁热，舌质亦能淡红或红。迨邪入气分，则发壮热不恶寒，心烦口渴引饮。邪入气分之里者，主要症状为身热不退或潮热、腹满痛、大便燥结、神昏谵语、舌质红、苔黄燥、或黄褐而燥，甚或舌起芒刺，系因热邪伤津，郁浊不降所致，脉沉实、或沉弦有力。邪深陷营，则身热心烦、神识不清，抽搐、或发斑，昼轻夜重，或大便下血、舌质红绛少津，或红绛光亮、无苔或黄燥、脉弦数有力、或弦细数、沉弦数。入血分，则身热不退、烦躁不宁、神昏谵妄、或便血发斑、舌红绛光滑、无苔，或黄糙、灰糙、脉虚数、细数，为阴津枯竭、热邪未解所致。
舌质舌苔和脉象的演变规律，对临床辨证很重要。张石顽说：“凡舌苔白滑，为邪在表，苔现白腻，为湿邪郁滞，舌苔渐黄，为热邪渐盛，黄而滑为热尚未盛，黄而干燥为热盛入府，苔现黄腻为湿热壅滞。”若邪热不解、损伤津液，则逐渐出现黄燥、黄褐、灰黑裂纹、芒刺等变化。一般邪在卫则苔白，邪入里则苔黄，津伤则燥，津存则滑，湿盛则腻。迨至邪深入营，或舌苔剥脱或黄褐灰黑之苔尚有残留，而舌质由淡而红而绛。邪在卫则淡，入气则红，深陷营血，则现红绛。从实践中体会到，掌握舌质舌苔的演变规律，对辨证立法颇有帮助，如再结合脉象将更准确。其脉象的演变，邪在卫则脉浮，挟热则浮数、浮大；挟寒则浮紧；挟湿则浮濡。迨邪入气分，脉多浮大滑数。温热病脉象的特点为病在卫分、气分,右手之脉多大于左手，或右脉较左脉有力。病深陷营血，则右脉较沉，而左脉偏盛，或现细数、沉弦数等。如气分之邪未罢而又犯及营分，则脉左右双盛。
病在气分之所以脉多洪大滑数，右脉多大于左脉者，以右脉主气分，邪在气分故右脉偏盛，气分之邪偏重于表，其脉多兼浮，如浮象骤见沉敛，而热势不衰反增烦躁，是病邪由表转里，有内陷趋势，热邪内犯往往诱起烦躁谵语昏迷。肠出血多发生于热邪深陷血分，或气血两燔之际。出血前脉多数疾，出血后顿现无力；如出血过多，亦可出现微细欲绝，或浮大而芤之脉。临床体会，凡热入血分，而身热不退脉数疾时，除用凉血解毒退热之剂外，应随时注意防止出血，庶可减少或阻止出血的发生。
疾病的恢复和发展，脉象之变化常出现于症状之前，这种变化可能代表恶化，亦可能代表好转。在脉象表现恶化，而症状尚未转变时，掌握病机，及时用药，可以阻止疾病转变和发展，临诊时应随时细心注视脉象变化，掌握转变规律，早期诊断，有效的治疗。九、诊脉应注意脉证之顺逆，必要时可舍脉从证或舍证从脉脉象和证候，是病邪侵袭机体之反应，有某种证候，即应当现某种脉象，脉证一致称之为顺，脉证相反，称之为逆。如伤寒初起发热恶寒，头项强痛，其脉应浮紧，设脉反沉，是病邪深陷，正不胜邪，故称逆证。又如热毒犯肺，发热恶寒，咳嗽胸满，咯血如铁锈色，喘促气短，脉应洪大滑数为顺；如高热不退，饮食不振，心烦不宁，神识昏惑，脉变沉微、细数，是热毒郁闭正气衰竭之坏病，亦称为逆证。如心气衰微之虚证，心悸气短，面色苍白，食少身倦，肢冷自汗，脉象或沉细，或弦细，或弦细数，为脉证一致；如忽身热心烦，面赤，虚汗淋漓，脉现浮大有力，重按全无，是脉证不符，为逆证。简言之，脉证相应为顺，相反为逆。如病属阳证,脉应洪数滑实，是谓脉证相符，为顺。若脉反见沉细微弱，是脉证相反，为逆。张景岳说：“凡内出不足之证，忌见阳脉，如浮、洪、紧、数之类是世。外入有余之病，忌见阴脉，如沉、细、微、弱之类是也。如此之脉最不易治。”以气血虚损，正气不足，脉必细弱，而反见浮、洪、数、紧，即为逆象。浮为阴气不敛，虚阳外越，洪为阴竭格阳，数为阴不制阳，总由阴气衰竭，不能维持自身最低之阴阳平衡，而现离决之危象。
凡暴病脉浮、洪、数、实为顺，久病脉微、缓、虚、弱为顺，新病而见沉、微、细、弱，久病而见浮、洪、数、实，皆为逆，脉证贵乎相合，设如证有余，而脉不足，或脉有余，而证不足，轻者必病势延绵，重者每致不救。
论舍脉从症，或舍证从脉：人体正常时，不论内伤外感，破坏了机体阴阳平衡，发生疾病。病人每发现种种不适证候和不正常脉象，这种证候和脉象，在一般情况下是多相适应的。但在各别情况下，如身体素弱，再受病邪，致机体功能受损，不能正常反应病理变化，而使脉证不能相应。如阴证见阳脉，虚证见实脉，临床见此情况，必须运用四诊综合分析，弄清其真实情况，方能立法用药。如病人身发潮热，大便燥结，腹胀脘满，不思饮食，舌红苔黄垢，脉沉迟，此系阳明燥结，虽现沉迟之阴脉，应舍脉从证，而以承气汤下之。如患者发热恶寒，身疼痛，脉沉细，虽有太阳病之表证，不能发汗宣表，而应以扶阳温透，宜舍证从脉。还有一些复杂的脉证，如不细心体察，综合辨证，往往为假象所迷惑，以致贻误病情。何梦瑶说：“凡脉证不相合必有一真一假，须细辨之，如外虽烦热，而脉见微弱者必虚火也，腹虽胀满而脉见微弱者必胃虚也。虚火虚胀岂堪攻乎?此宜从脉之真虚，不从证之假剧也。其有本无烦热而脉见洪数者，非火邪也；本无胀滞而脉见弦强者，非内实也，无热无胀其堪泻乎?此宜从证之真虚不从脉之假居也。”“如寒邪内伤，或食停气滞，而心腹急痛，以致脉道沉伏或促或结，此以邪闭经络而然，既有痛胀等实证可据，则脉之虚乃假虚，当从证不从脉。又若伤寒四肢厥逆寒战，而脉见数滑，此由内热格阴。何以知之?以病由传经渐致，并非直中阴经，从无热证转寒之理，既有数滑之脉可据，则外症之虚为假虚，亦从脉不从证也。”舍脉从证，与舍证从脉，是临床辨证中重要之一环，须四诊合参，全面分析，方能取舍切当得到疾病的真相。
十、二十八脉的示意图、脉象、示意图解、主病脉象由脉位、脉力、脉率、脉形等的混合演变构成28脉。脉象示意图即以图象表达脉象的位置、力量、形状和频率等。以便初学脉学者易于识别掌握。脉象示意图，将正常人的脉搏力量假设作6个脉力单位，在示意图上以五个黑格表示浮、中、沉，每部脉象分别用三图表示之。代表诊脉时浮中沉三候。正常人脉的宽度，假设作两个单位计算，在示意图中于脉搏升波的基底部用两个黑格表示，如脉细则填画一个或一个半横格，大脉、洪脉较正常为宽则填画两个半或三个格，以示比正常脉象宽的倍数。正常脉的波峰，假设为7个波，为正常人脉搏跳动的次数。
1.浮脉
(一)脉象：轻按即得，浮泛于皮肤之表。举之则泛泛流利，按之则稍减而不空。(二)浮脉体状诗：浮脉惟从肉上行，如循榆荚似毛轻；三秋得令知无恙，久病逢之却可惊。(三)图解：以浮取上边之黑线为皮层，其波峰透出黑线，表示脉搏浮泛于皮肤之上，其脉力浮取脉力较猛，正常脉力一般为五个脉力单位，在最上大黑线中为五个小黑格。浮脉的脉力，浮取超过正常，故浮取黑线中为6格；中取较弱，故在中取部位为5格；重取有的为4个脉力单位，在沉取部位画4格。脉形一般不宽，故在起波基底横线上，绘两个格。说明浮脉脉力，浮取较猛，中取稍软，而重取显弱。而浮脉在持脉时毫不加压，即明显的泛泛于皮肤之上。若轻按不显，中取方见，重取明显，即非浮脉。(四)主病：浮脉主表，为六淫之邪侵入肌表，当外邪侵袭肌表，人体之气血为捍卫机体，而趋向于表，故脉应之而浮。浮脉虽属外邪袭表之征，但有虚实之分，浮而有力为表实，浮而无力为表虚。不论表实表虚，只要脉现浮象，必有发热恶寒头痛身痛之表证。表实者可发汗以宣邪，麻黄汤主之。表虚者，可解肌散风，桂枝汤主之。如脉浮兼迟，为胸阳不足，风寒外袭，宜温散寒邪，宜麻黄附子细辛汤。如浮而兼濡，多为伤暑。浮而兼数，多为风热。久病见浮，为阴气过伤，无以维阳，致虚阳上泛，而脉现浮象。另有久病体虚，脉多沉细，如突变浮脉，多因正气虚损，外邪内犯所致，故久病见浮，病多反复。(五)浮脉主病诗浮脉为阳表病居，迟风数热紧寒拘，浮而有力多风热，无力而浮是血虚。寸浮头痛眩生风，或有风痰聚在胸，关上土衰兼木旺，尺中溲便亦流通。(六)浮脉辨证分析表浮脉主表(1)外邪侵袭一实证①浮而有力——表实②浮而无力——表虚③浮而兼迟——表寒④浮而兼洪——表热⑤浮而兼缓——中风风湿⑥浮而兼濡——伤暑⑦浮而兼实——阳胜⑧浮而兼滑——风痰(2)里证内伤--虚证①浮而兼散——极虚②浮而兼细——气虚③浮而兼涩——血虚2.洪脉
3. 卫气营血脉象演变规律：卫气营血辨证（Wèi Qì Yíng Xuè Biàn Zhèng，以卫、气、营、血四个层次为纲的辨证方法）是中医治疗各种传染病和烧伤病人发热的主要辨证方法。病邪侵袭到卫气营血，虽然各有其本经见证，但脉象变化往往出现在证候出现之前，掌握其演变规律，防治就可以处于主动地位。一般外感热性病在发展演变过程中，必然引起机体卫气营血的变化，从而发生各部分的复杂证候。机体和这些证候的内部联系和规律性，都能从脉象上体现出来，细心体察，可以早期做好防御措施。
根据临床体验，一般外感热性病和各种急性传染病，初起多现卫分症状。等到热邪内犯，病势加重，则由卫分转入气分。邪在卫分，则发热恶寒，脉浮大或浮数，舌质偏红，苔微黄。及深入气分，则身发壮热，而不恶寒，脉象洪大滑数，脉力较强，沉取每在5个脉力单位左右，浮取多在6-7个脉力单位，脉力愈大表示毒热愈猛，应放胆大剂用清热解毒药物，以防止病邪内陷。如邪在气分身热不退、心烦不宁、脉象转沉，是病邪由气分犯营的先兆，应予清解毒热宣邪外出，分化其内攻之势。如神识模糊、嗜睡、心烦不安、左脉数急、舌质红绛，是已入营，应以清解毒热，清营宣透为主，辅以醒神熄风。由营分再深陷血分，则脉多沉数虚数，弦细数之脉。其它各种疾病的脉，于其发生发展和转化亦均有其规律，应细心体察。
4．从伤寒的临床观察，研究探讨卫气营血和脉、舌的演变规律：伤寒是由伤寒杆菌引起的急性传染病。其最显著的病理改变，是肠道内淋巴组织增生和坏死。临床特点有持续性体温升高，相对缓脉，脾肿大，玫瑰疹及白细胞减少。本病不同于祖国医学《伤寒论》中的伤寒，可包括于祖国医学温病范畴。今据几年来临床治疗31例伤寒的资料，研究伤寒等急性传染病在卫气营血和脉、舌变化规律，供临床讨论。
31例(伤寒杆菌培养阳性者23例，培养阴性者8例。伤寒血清凝集试验：21例中有27例“O”及“H”抗原的凝集效价在1:160以上，仅4例为1:80，此4例伤寒杆菌培养均阳性)初起均有恶寒体痛发热、头痛、目眩、心烦，不思食、脉现浮濡、浮大、浮数，以邪在卫分故舌多淡，如内有郁热，舌质亦能淡红或红。迨邪入气分，则发壮热不恶寒，心烦口渴引饮。邪入气分之里者，主要症状为身热不退或潮热、腹满痛、大便燥结、神昏谵语、舌质红、苔黄燥、或黄褐而燥，甚或舌起芒刺，系因热邪伤津，郁浊不降所致，脉沉实、或沉弦有力。邪深陷营，则身热心烦、神识不清，抽搐、或发斑，昼轻夜重，或大便下血、舌质红绛少津，或红绛光亮、无苔或黄燥、脉弦数有力、或弦细数、沉弦数。入血分，则身热不退、烦躁不宁、神昏谵妄、或便血发斑、舌红绛光滑、无苔，或黄糙、灰糙、脉虚数、细数，为阴津枯竭、热邪未解所致。
舌质舌苔和脉象的演变规律，对临床辨证很重要。张石顽说：“凡舌苔白滑，为邪在表，苔现白腻，为湿邪郁滞，舌苔渐黄，为热邪渐盛，黄而滑为热尚未盛，黄而干燥为热盛入府，苔现黄腻为湿热壅滞。”若邪热不解、损伤津液，则逐渐出现黄燥、黄褐、灰黑裂纹、芒刺等变化。一般邪在卫则苔白，邪入里则苔黄，津伤则燥，津存则滑，湿盛则腻。迨至邪深入营，或舌苔剥脱或黄褐灰黑之苔尚有残留，而舌质由淡而红而绛。邪在卫则淡，入气则红，深陷营血，则现红绛。从实践中体会到，掌握舌质舌苔的演变规律，对辨证立法颇有帮助，如再结合脉象将更准确。其脉象的演变，邪在卫则脉浮，挟热则浮数、浮大；挟寒则浮紧；挟湿则浮濡。迨邪入气分，脉多浮大滑数。温热病脉象的特点为病在卫分、气分,右手之脉多大于左手，或右脉较左脉有力。病深陷营血，则右脉较沉，而左脉偏盛，或现细数、沉弦数等。如气分之邪未罢而又犯及营分，则脉左右双盛。
病在气分之所以脉多洪大滑数，右脉多大于左脉者，以右脉主气分，邪在气分故右脉偏盛，气分之邪偏重于表，其脉多兼浮，如浮象骤见沉敛，而热势不衰反增烦躁，是病邪由表转里，有内陷趋势，热邪内犯往往诱起烦躁谵语昏迷。肠出血多发生于热邪深陷血分，或气血两燔之际。出血前脉多数疾，出血后顿现无力；如出血过多，亦可出现微细欲绝，或浮大而芤之脉。临床体会，凡热入血分，而身热不退脉数疾时，除用凉血解毒退热之剂外，应随时注意防止出血，庶可减少或阻止出血的发生。
疾病的恢复和发展，脉象之变化常出现于症状之前，这种变化可能代表恶化，亦可能代表好转。在脉象表现恶化，而症状尚未转变时，掌握病机，及时用药，可以阻止疾病转变和发展，临诊时应随时细心注视脉象变化，掌握转变规律，早期诊断，有效的治疗。九、诊脉应注意脉证之顺逆，必要时可舍脉从证或舍证从脉脉象和证候，是病邪侵袭机体之反应，有某种证候，即应当现某种脉象，脉证一致称之为顺，脉证相反，称之为逆。如伤寒初起发热恶寒，头项强痛，其脉应浮紧，设脉反沉，是病邪深陷，正不胜邪，故称逆证。又如热毒犯肺，发热恶寒，咳嗽胸满，咯血如铁锈色，喘促气短，脉应洪大滑数为顺；如高热不退，饮食不振，心烦不宁，神识昏惑，脉变沉微、细数，是热毒郁闭正气衰竭之坏病，亦称为逆证。如心气衰微之虚证，心悸气短，面色苍白，食少身倦，肢冷自汗，脉象或沉细，或弦细，或弦细数，为脉证一致；如忽身热心烦，面赤，虚汗淋漓，脉现浮大有力，重按全无，是脉证不符，为逆证。简言之，脉证相应为顺，相反为逆。如病属阳证,脉应洪数滑实，是谓脉证相符，为顺。若脉反见沉细微弱，是脉证相反，为逆。张景岳说：“凡内出不足之证，忌见阳脉，如浮、洪、紧、数之类是世。外入有余之病，忌见阴脉，如沉、细、微、弱之类是也。如此之脉最不易治。”以气血虚损，正气不足，脉必细弱，而反见浮、洪、数、紧，即为逆象。浮为阴气不敛，虚阳外越，洪为阴竭格阳，数为阴不制阳，总由阴气衰竭，不能维持自身最低之阴阳平衡，而现离决之危象。
凡暴病脉浮、洪、数、实为顺，久病脉微、缓、虚、弱为顺，新病而见沉、微、细、弱，久病而见浮、洪、数、实，皆为逆，脉证贵乎相合，设如证有余，而脉不足，或脉有余，而证不足，轻者必病势延绵，重者每致不救。
论舍脉从症，或舍证从脉：人体正常时，不论内伤外感，破坏了机体阴阳平衡，发生疾病。病人每发现种种不适证候和不正常脉象，这种证候和脉象，在一般情况下是多相适应的。但在各别情况下，如身体素弱，再受病邪，致机体功能受损，不能正常反应病理变化，而使脉证不能相应。如阴证见阳脉，虚证见实脉，临床见此情况，必须运用四诊综合分析，弄清其真实情况，方能立法用药。如病人身发潮热，大便燥结，腹胀脘满，不思饮食，舌红苔黄垢，脉沉迟，此系阳明燥结，虽现沉迟之阴脉，应舍脉从证，而以承气汤下之。如患者发热恶寒，身疼痛，脉沉细，虽有太阳病之表证，不能发汗宣表，而应以扶阳温透，宜舍证从脉。还有一些复杂的脉证，如不细心体察，综合辨证，往往为假象所迷惑，以致贻误病情。何梦瑶说：“凡脉证不相合必有一真一假，须细辨之，如外虽烦热，而脉见微弱者必虚火也，腹虽胀满而脉见微弱者必胃虚也。虚火虚胀岂堪攻乎?此宜从脉之真虚，不从证之假剧也。其有本无烦热而脉见洪数者，非火邪也；本无胀滞而脉见弦强者，非内实也，无热无胀其堪泻乎?此宜从证之真虚不从脉之假居也。”“如寒邪内伤，或食停气滞，而心腹急痛，以致脉道沉伏或促或结，此以邪闭经络而然，既有痛胀等实证可据，则脉之虚乃假虚，当从证不从脉。又若伤寒四肢厥逆寒战，而脉见数滑，此由内热格阴。何以知之?以病由传经渐致，并非直中阴经，从无热证转寒之理，既有数滑之脉可据，则外症之虚为假虚，亦从脉不从证也。”舍脉从证，与舍证从脉，是临床辨证中重要之一环，须四诊合参，全面分析，方能取舍切当得到疾病的真相。
十、二十八脉的示意图、脉象、示意图解、主病脉象由脉位、脉力、脉率、脉形等的混合演变构成28脉。脉象示意图即以图象表达脉象的位置、力量、形状和频率等。以便初学脉学者易于识别掌握。脉象示意图，将正常人的脉搏力量假设作6个脉力单位，在示意图上以五个黑格表示浮、中、沉，每部脉象分别用三图表示之。代表诊脉时浮中沉三候。正常人脉的宽度，假设作两个单位计算，在示意图中于脉搏升波的基底部用两个黑格表示，如脉细则填画一个或一个半横格，大脉、洪脉较正常为宽则填画两个半或三个格，以示比正常脉象宽的倍数。正常脉的波峰，假设为7个波，为正常人脉搏跳动的次数。
1.浮脉
(一)脉象：轻按即得，浮泛于皮肤之表。举之则泛泛流利，按之则稍减而不空。(二)浮脉体状诗：浮脉惟从肉上行，如循榆荚似毛轻；三秋得令知无恙，久病逢之却可惊。(三)图解：以浮取上边之黑线为皮层，其波峰透出黑线，表示脉搏浮泛于皮肤之上，其脉力浮取脉力较猛，正常脉力一般为五个脉力单位，在最上大黑线中为五个小黑格。浮脉的脉力，浮取超过正常，故浮取黑线中为6格；中取较弱，故在中取部位为5格；重取有的为4个脉力单位，在沉取部位画4格。脉形一般不宽，故在起波基底横线上，绘两个格。说明浮脉脉力，浮取较猛，中取稍软，而重取显弱。而浮脉在持脉时毫不加压，即明显的泛泛于皮肤之上。若轻按不显，中取方见，重取明显，即非浮脉。(四)主病：浮脉主表，为六淫之邪侵入肌表，当外邪侵袭肌表，人体之气血为捍卫机体，而趋向于表，故脉应之而浮。浮脉虽属外邪袭表之征，但有虚实之分，浮而有力为表实，浮而无力为表虚。不论表实表虚，只要脉现浮象，必有发热恶寒头痛身痛之表证。表实者可发汗以宣邪，麻黄汤主之。表虚者，可解肌散风，桂枝汤主之。如脉浮兼迟，为胸阳不足，风寒外袭，宜温散寒邪，宜麻黄附子细辛汤。如浮而兼濡，多为伤暑。浮而兼数，多为风热。久病见浮，为阴气过伤，无以维阳，致虚阳上泛，而脉现浮象。另有久病体虚，脉多沉细，如突变浮脉，多因正气虚损，外邪内犯所致，故久病见浮，病多反复。(五)浮脉主病诗浮脉为阳表病居，迟风数热紧寒拘，浮而有力多风热，无力而浮是血虚。寸浮头痛眩生风，或有风痰聚在胸，关上土衰兼木旺，尺中溲便亦流通。(六)浮脉辨证分析表浮脉主表(1)外邪侵袭一实证①浮而有力——表实②浮而无力——表虚③浮而兼迟——表寒④浮而兼洪——表热⑤浮而兼缓——中风风湿⑥浮而兼濡——伤暑⑦浮而兼实——阳胜⑧浮而兼滑——风痰(2)里证内伤--虚证①浮而兼散——极虚②浮而兼细——气虚③浮而兼涩——血虚2.洪脉
3. Evolutionary Laws of Pulse Manifestations in Wei (Defensive), Qi (Nutritive), Ying (Nutrient), and Xue (Blood) Levels: The Bian Zheng (Syndrome Differentiation) based on Wei, Qi, Ying, and Blood levels is the primary method for syndrome differentiation in treating various infectious diseases and fever in burn patients in Traditional Chinese Medicine (TCM). When pathogenic factors invade the Wei, Qi, Ying, and Blood levels, although each level has its own specific manifestations, pulse changes often appear before the symptoms manifest. Mastering these evolutionary laws allows for proactive prevention and treatment. Generally, the development and evolution of external febrile diseases inevitably cause changes in the body's Wei, Qi, Ying, and Blood levels, thereby generating complex syndromes in various parts. The internal connections and regularities between the organism and these syndromes are all reflected in the pulse. Careful observation can enable early preventive measures.
Based on clinical experience, general external febrile diseases and various acute infectious diseases initially mostly present with Wei-level symptoms. When heat pathogens invade internally and the disease severity increases, the condition transitions from the Wei level to the Qi level. When pathogens are at the Wei level, there is fever and aversion to cold, the pulse is floating-large or floating-rapid, the tongue body is slightly red, and the coating is slightly yellow. Upon deepening into the Qi level, there is high fever without aversion to cold; the pulse is surging-large, slippery, and rapid, with strong pulse force. Deep pressing yields approximately 5 units of pulse force, while light pressing yields 6-7 units. The greater the pulse force, the more fierce the toxic heat; thus, bold use of large doses of drugs that clear heat and detoxify should be employed to prevent the pathogen from sinking inward. If the pathogen remains in the Qi level with persistent fever, mental restlessness, and a turning-sinking pulse, this is a precursor to the pathogen moving from the Qi level to the Ying level. Treatment should focus on clearing toxic heat, releasing pathogens outward, and dissipating their internal attacking momentum. If consciousness is blurred, drowsiness occurs, mental restlessness persists, the left pulse is rapid and urgent, and the tongue body is crimson-red, the pathogen has entered the Ying level. Treatment should primarily clear toxic heat and clear the Ying level to release pathogens outward, assisted by methods to awaken the spirit and extinguish wind. If the pathogen sinks deeply from the Ying level into the Blood level, the pulse is mostly sinking-rapid, deficiency-rapid, wiry-thin-rapid, or thin-rapid. The pulses of other various diseases also have their own laws during their occurrence, development, and transformation, which should be carefully observed.
4. Clinical Observation of Typhoid Fever to Study and Explore the Evolutionary Laws of Wei, Qi, Ying, Blood, Pulses, and Tongues: Typhoid fever is an acute infectious disease caused by *Salmonella typhi*. Its most significant pathological change is the hyperplasia and necrosis of lymphoid tissue in the intestines. Clinical characteristics include sustained elevated body temperature, relative bradycardia, splenomegaly, rose spots, and leukopenia. This disease is different from "Shang Han" (Cold Damage) in the TCM classic *Shang Han Lun* (Treatise on Cold Damage); it can be included within the category of Wen Bing (Warm Diseases) in TCM. Based on clinical data from treating 31 cases of typhoid fever over recent years, this study explores the laws of changes in Wei, Qi, Ying, Blood, pulses, and tongues in typhoid fever and other acute infectious diseases for clinical discussion.
Of the 31 cases (23 culture-positive for *Salmonella typhi*, 8 culture-negative; Widal test: among 21 tested, 27 instances showed agglutination titers for "O" and "H" antigens above 1:160, only 4 cases were 1:80, and all 4 of these had positive *Salmonella typhi* cultures), initial symptoms included aversion to cold, body pain, fever, headache, vertigo, mental restlessness, and loss of appetite. The pulse was floating-soggy, floating-large, or floating-rapid. Because the pathogen was at the Wei level, the tongue was mostly pale; if there was internal stagnant heat, the tongue body could be pale-red or red. When the pathogen entered the Qi level, high fever without aversion to cold occurred, accompanied by mental restlessness, thirst, and desire to drink. For pathogens entering the interior of the Qi level, main symptoms included persistent fever or tidal fever, abdominal fullness and pain, dry and hard stools, confusion and delirious speech, red tongue body, yellow-dry coating, or yellow-brown-dry coating, and even prickles on the tongue. These are caused by heat damaging body fluids and turbidity failing to descend; the pulse is sinking-solid or sinking-wiry-strong. When pathogens sink deeply into the Ying level, there is fever, mental restlessness, unclear consciousness, convulsions, or macules (rash), which are lighter during the day and heavier at night, or bloody stools; the tongue body is crimson-red with little fluid, or bright crimson-red with no coating or yellow-dry coating; the pulse is wiry-rapid-strong, wiry-thin-rapid, or sinking-wiry-rapid. Entering the Blood level, there is persistent fever, severe irritability, confusion and delirium, bloody stools or macules; the tongue is crimson-red and smooth with no coating, or yellow-coarse, grey-coarse; the pulse is deficiency-rapid or thin-rapid. This is caused by exhaustion of Yin fluids and unresolved heat pathogens.
The evolutionary laws of tongue body/coating and pulse manifestations are crucial for clinical syndrome differentiation. Zhang Shiwan said: "Whenever the tongue coating is white and slippery, the pathogen is at the exterior; if the coating becomes white and greasy, damp pathogens are stagnant; if the coating gradually turns yellow, heat pathogens are increasing; yellow and slippery means heat is not yet intense; yellow and dry means intense heat has entered the Fu organs; yellow and greasy coating indicates stagnation of damp-heat." If pathogenic heat is not resolved and damages body fluids, changes such as yellow-dry, yellow-brown, grey-black cracks, and prickles gradually appear. Generally, when the pathogen is at the Wei level, the coating is white; when it enters the interior, the coating is yellow; when fluids are damaged, it is dry; when fluids are preserved, it is slippery; when dampness is abundant, it is greasy. When pathogens deeply enter the Ying level, the coating may peel off, or remnants of yellow-brown/grey-black coating remain, while the tongue body changes from pale to red to crimson-red. Pathogens at the Wei level show a pale tongue; entering the Qi level shows red; sinking deeply into Ying/Blood shows crimson-red. From practice, mastering the evolutionary laws of tongue body and coating greatly assists in formulating treatment principles; combining this with pulse analysis makes it even more accurate. Regarding pulse evolution: when pathogens are at the Wei level, the pulse is floating; with heat, it is floating-rapid or floating-large; with cold, it is floating-tight; with dampness, it is floating-soggy. When pathogens enter the Qi level, the pulse is mostly floating-large, slippery, and rapid. A characteristic of warm-heat disease pulses is that when the disease is at the Wei or Qi level, the right-hand pulse is often larger than the left, or the right pulse is stronger than the left. When the disease sinks deeply into Ying/Blood, the right pulse becomes relatively sinking, while the left pulse predominates, presenting as thin-rapid or sinking-wiry-rapid. If Qi-level pathogens persist and invade the Ying level, both left and right pulses become prominent.
The reason why Qi-level diseases often present with surging-large, slippery, rapid pulses and the right pulse is larger than the left is that the right pulse governs the Qi level; since the pathogen is in the Qi level, the right pulse predominates. Qi-level pathogens tend toward the exterior, so the pulse often includes a floating quality. If the floating quality suddenly sinks and收敛 (converges), while heat does not subside but irritability increases, this indicates the pathogen is moving from exterior to interior with a trend of sinking inward. Internal invasion by heat pathogens often induces irritability, delirium, and coma. Intestinal bleeding mostly occurs when heat pathogens sink deeply into the Blood level or when Qi and Blood are simultaneously scorched. Before bleeding, the pulse is mostly rapid and hurried; after bleeding, it instantly becomes weak. If bleeding is excessive, a faint-thin pulse nearing extinction, or a floating-large and hollow (Kou) pulse may appear. Clinical experience suggests that whenever heat enters the Blood level with persistent fever and a rapid/hurried pulse, besides using blood-cooling, detoxifying, and antipyretic formulas, one must constantly monitor to prevent bleeding, thereby reducing or stopping hemorrhage.
In the recovery and development of diseases, pulse changes often appear before symptoms. These changes may represent deterioration or improvement. When the pulse indicates deterioration but symptoms have not yet changed, grasping the pathogenesis and administering medication promptly can stop the disease from transforming and developing. During clinical examination, one should attentively observe pulse changes, master transformation laws, diagnose early, and treat effectively.
IX. Attention to the Harmony (Shun) and Opposition (Ni) of Pulse and Syndrome in Diagnosis; When Necessary, Abandon Pulse for Syndrome or Abandon Syndrome for Pulse. Pulse and syndrome are reactions of pathogenic factors invading the organism. Certain syndromes should correspond to certain pulses. Consistency between pulse and syndrome is called Harmony (Shun); opposition is called Opposition (Ni). For example, in the initial stage of Shang Han (Cold Damage) with fever, aversion to cold, and stiffness/pain in the head and neck, the pulse should be floating-tight. If the pulse is instead sinking, the pathogen has sunk deeply, and righteous Qi cannot overcome the pathogen; this is called an Opposition Syndrome (Ni Zheng). Again, if toxic heat invades the Lung, causing fever, aversion to cold, cough, chest fullness, rust-colored hemoptysis, panting, and shortness of breath, a surging-large, slippery, rapid pulse is Harmony (Shun); if high fever persists, poor appetite, mental restlessness, confused consciousness, and the pulse becomes sinking-faint or thin-rapid, this is a deteriorated disease due to closure of toxic heat and exhaustion of righteous Qi, also called an Opposition Syndrome. In deficiency syndromes of declining Heart Qi, with palpitations, shortness of breath, pale complexion, poor appetite, fatigue, cold limbs, and spontaneous sweating, the pulse may be sinking-thin, wiry-thin, or wiry-thin-rapid; this is consistency between pulse and syndrome. If suddenly there is fever, mental restlessness, flushed face, profuse cold sweat, and the pulse becomes floating-large and strong, but vanishes completely upon heavy pressure, this is inconsistency between pulse and syndrome, constituting an Opposition Syndrome. In short, corresponding pulse and syndrome are Harmony; opposite are Opposition. If the disease belongs to Yang Syndromes, the pulse should be surging, rapid, slippery, and solid; this is consistent, hence Harmony. If the pulse is instead sinking, fine, faint, and weak, it is opposite, hence Opposition. Zhang Jingyue said: "For deficiencies arising internally, Yang pulses such as floating, surging, tight, and rapid are contraindicated. For excesses entering externally, Yin pulses such as sinking, fine, faint, and weak are contraindicated. Such pulses are the most difficult to treat." Due to deficiency of Qi and Blood and insufficiency of righteous Qi, the pulse must be thin and weak; if it instead shows floating, surging, rapid, or tight qualities, it is an Opposition image. Floating indicates Yin Qi failing to contain and Deficient Yang escaping outward; Surging indicates Yin exhaustion repelling Yang; Rapid indicates Yin failing to control Yang. All result from Yin Qi exhaustion, inability to maintain minimum Yin-Yang balance, and presentation of a critical state of separation.
For sudden diseases, floating, surging, rapid, and solid pulses are Harmony; for chronic diseases, faint, slow, deficient, and weak pulses are Harmony. New diseases showing sinking, faint, thin, or weak pulses, and chronic diseases showing floating, surging, rapid, or solid pulses, are all Opposition. Pulse and syndrome should ideally match. If syndrome indicates excess but pulse indicates deficiency, or pulse indicates excess but syndrome indicates deficiency, mild cases will have lingering disease progression, and severe cases may become incurable.
Discussion on Abandoning Pulse for Syndrome or Abandoning Syndrome for Pulse: In a normal human body, whether due to internal injury or external contraction, disruption of Yin-Yang balance leads to disease. Patients often exhibit various uncomfortable syndromes and abnormal pulses. Generally, these syndromes and pulses are well-adapted. However, in specific cases, such as a constitutionally weak person contracting pathogens, resulting in impaired bodily function unable to normally reflect pathological changes, pulse and syndrome may not correspond. For instance, Yin Syndromes showing Yang pulses, or Deficiency Syndromes showing Excess pulses. Clinically, in such situations, comprehensive analysis using the Four Diagnostic Methods is required to ascertain the true situation before formulating treatment. For example, if a patient has tidal fever, dry and hard stools, abdominal distension and fullness, loss of appetite, red tongue with yellow-greasy coating, and a sinking-slow pulse, this is Yangming Dryness Accumulation. Although a sinking-slow (Yin) pulse appears, one should abandon the pulse for the syndrome and use Chengqi Tang to purge. If a patient has fever, aversion to cold, body pain, and a sinking-thin pulse, despite having Taiyang Exterior Syndrome, sweating to release the exterior is contraindicated; instead, supporting Yang and warming/unblocking should be used, abandoning syndrome for pulse. Some complex pulse-syndrome combinations, if not carefully observed and comprehensively differentiated, can be misled by false images, delaying treatment. He Mengyao said: "Whenever pulse and syndrome do not match, one must be true and the other false; careful discrimination is needed. For example, if externally there is irritability and heat but the pulse is faint and weak, it must be Deficient Fire; if abdomen is full but pulse is faint and weak, it must be Spleen/Stomach Deficiency. Can Deficient Fire and Deficient Fullness be attacked? One should follow the true deficiency of the pulse, not the apparent severity of the syndrome. Conversely, if there is no irritability/heat but the pulse is surging-rapid, it is not Fire Pathogen; if there is no fullness/stagnation but the pulse is wiry-strong, it is not Interior Excess. Can lack of heat/fullness be purged? One should follow the true deficiency of the syndrome, not the apparent excess of the pulse." "If Cold pathogens injure internally, or food stagnation causes Qi stagnation, leading to acute heart/abdominal pain, causing the pulse channel to sink-hidden, hurried, or knotted, this is due to pathogen blocking meridians. Since there are excess signs like pain and fullness, the pulse's deficiency is false deficiency; one should follow the syndrome, not the pulse. Furthermore, if Shang Han presents with cold extremities and chills, but the pulse is rapid and slippery, this is internal heat repelling Yin. How do we know? Because the disease progressed via transmission of channels, not direct attack on Yin channels, and there is no logic of heat syndromes turning to cold. With a rapid-slippery pulse as evidence, the external deficiency symptoms are false deficiency; one should follow the pulse, not the syndrome." Abandoning pulse for syndrome and abandoning syndrome for pulse are important links in clinical differentiation. Only through integrating the Four Diagnostics and comprehensive analysis can appropriate choices be made to reveal the truth of the disease.
X. Diagrams, Pulse Manifestations, Diagrammatic Interpretations, and Main Disease Associations of the Twenty-Eight Pulses. The 28 pulses are constituted by mixed evolutions of pulse position, force, rate, and shape. Pulse manifestation diagrams graphically express the position, strength, shape, and frequency of pulses to facilitate identification and mastery for beginners. In the diagram, normal pulse force is assumed to be 6 units. Five black grids represent Superficial (Fu), Middle (Zhong), and Deep (Chen) pressures. Each pulse type is represented by three diagrams, corresponding to the three positions (Superficial, Middle, Deep) during diagnosis. Normal pulse width is assumed to be 2 units. In the diagram, two black grids at the base of the systolic wave represent this width. If the pulse is thin, one or one-and-a-half horizontal grids are filled. Large (Da) and Surging (Hong) pulses, being wider than normal, fill two-and-a-half or three grids to indicate multiples of normal width. The normal pulse peak is assumed to be 7 waves, representing the number of beats per cycle.
1. Floating Pulse (Fu Mai)
(I) Pulse Manifestation: Obtained with light pressure, floating on the surface of the skin. Lifting reveals a smooth flow; pressing reduces it slightly but it does not feel empty.
(II) Poem on the Form of the Floating Pulse: The Floating Pulse rises only from the flesh, like touching elm seeds, light as hair; Obtaining it in the third autumn season indicates health; Encountering it in long-standing illness is indeed startling.
(III) Diagram Explanation: The upper black line of the superficial pressure represents the skin layer. The wave peak protruding through the black line indicates the pulse floating on the skin. The pulse force at superficial pressure is vigorous. Normal pulse force is generally 5 units, represented by five small black grids in the largest top black line. The Floating Pulse's force at superficial pressure exceeds normal, so 6 grids are drawn in the superficial black line; middle pressure is weaker, so 5 grids are drawn at the middle position; deep pressure may be 4 units, so 4 grids are drawn at the deep position. The pulse shape is generally not wide, so two grids are drawn on the baseline of the wave origin. This illustrates that the Floating Pulse is vigorous at superficial pressure, softer at middle pressure, and weak at deep pressure. When holding the pulse, without any pressure, it clearly floats on the skin. If not visible with light pressure, seen only with middle pressure, and obvious with deep pressure, it is not a Floating Pulse.
(IV) Main Diseases: The Floating Pulse governs the Exterior. It indicates invasion of the Six Evils (pathogenic factors) into the muscle surface. When external pathogens invade, the body's Qi and Blood move toward the exterior to defend the organism, causing the pulse to float. Although the Floating Pulse is a sign of external invasion, it has deficiency and excess distinctions. Floating and strong indicates Exterior Excess; floating and weak indicates Exterior Deficiency. Regardless of excess or deficiency, if the pulse shows a floating image, there must be exterior symptoms such as fever, aversion to cold, headache, and body pain. For Exterior Excess, sweating can be used to release pathogens, governed by Mahuang Tang (Ephedra Decoction). For Exterior Deficiency, resolving the muscle and dispersing wind can be used, governed by Guizhi Tang (Cinnamon Twig Decoction). If the pulse is floating combined with slow, it indicates insufficient Chest Yang and external invasion of Wind-Cold; warming and dispersing cold pathogens is suitable, using Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite Root, and Asarum Decoction). If floating combined with soggy, it is mostly Summerheat Injury. If floating combined with rapid, it is mostly Wind-Heat. In long-standing illness, seeing a floating pulse indicates excessive damage to Yin Qi, inability to sustain Yang, leading to floating of Deficient Yang and a floating pulse. Additionally, in long-standing illness with weakness, the pulse is mostly sinking-thin; if it suddenly becomes floating, it is mostly due to deficiency of Righteous Qi and internal invasion of external pathogens; thus, floating in long-standing illness often indicates recurrent disease.
(V) Poem on Main Diseases of the Floating Pulse: The Floating Pulse is Yang, residing in exterior diseases; Slow indicates Wind, Rapid indicates Heat, Tight indicates Cold constriction. Floating and strong indicates much Wind-Heat; Weak and floating indicates Blood Deficiency. Floating at the Cun (Inch) position brings headache, vertigo, and Wind generation; or Wind-Phlegm gathering in the chest. At the Guan (Bar) position, Earth decline combined with Wood hyperactivity; at the Chi (Cubit) position, urination and defecation also flow freely.
(VI) Floating Pulse Differentiation Analysis Table: Floating Pulse Governs Exterior.
(1) External Pathogen Invasion - Excess Syndrome:
① Floating and strong — Exterior Excess
② Floating and weak — Exterior Deficiency
③ Floating combined with slow — Exterior Cold
④ Floating combined with surging — Exterior Heat
⑤ Floating combined with slow/relaxed — Wind-Stroke/Wind-Damp
⑥ Floating combined with soggy — Summerheat Injury
⑦ Floating combined with solid — Yang Excess
⑧ Floating combined with slippery — Wind-Phlegm
(2) Interior Syndrome/Internal Injury - Deficiency Syndrome:
① Floating combined with scattered — Extreme Deficiency
② Floating combined with thin — Qi Deficiency
③ Floating combined with choppy — Blood Deficiency
2. Surging Pulse (Hong Mai)