脉要精微论曰∶微妙在脉，不可不察。邪气脏腑病形篇曰∶按其脉，知其病，命曰神。
秦越
人六十一难曰∶切脉而知之谓之巧。许叔微曰∶脉之理幽而难明。吾意所解，口莫能宣也。
凡可以笔墨载，可以口舌言者，皆迹象也。至于神理，非心领神会，乌能尽其元微。方盛衰
论曰∶受师不卒，使术不明，不察从逆，是为妄行。推雌失雄，弃阴附阳，不知并合，诊故
不明。甚矣。脉之不可不辨也。其大要当合《素问》、《灵枢》，及各家论说，熟读而玩绎之
，自能领悟。惟常变之理，不可不知。凡人之脉，有素大素小，偏阴偏阳者，此其赋自先天
，各成一局也。邪变之脉，有倏缓倏疾，乍进乍退，此其病之骤至，脉随气见也。故诊脉者
，必须先识脏脉，而后可以察病脉。先识常脉，而后可以察变脉。然有脉病相符者，有脉病
相左者，有病亢极而脉忽反变者，如阳证见阳脉，阴症见阴脉，此脉病相符也。证似阳而脉
不鼓指，证似阴而脉鼓盛者，此脉病相左也。阳盛者，脉必洪大，至阳盛之极，而脉反伏匿
，阳极似阴也。阴盛者脉必微细，至阴盛而脉反躁疾，阴极似阳也。此病亢极，而脉忽反变
也。又有从合之辨，如脉浮为表，治宜汗之，此其常也。而亦有宜下者，仲景云∶若脉浮大
，心下梗，有热，属脏者攻之，不令发汗是也。脉沉为里，治宜下之，此其常也。而亦有宜
汗者，少阴病，始得之，反发热，脉沉者，麻黄附子细辛汤微汗之是也。脉促为阳，当用葛
根黄芩清之矣。若脉促厥冷为虚脱矣，非温不可，此又非促为阳盛之脉也。脉迟为寒，当用
附子干姜温之矣。若阳明脉迟，不恶寒，身体 汗出，则用大承气汤，此又非迟为阴寒之
脉也。是皆从证不从脉也。至于表症汗之，此其常也。仲景曰∶病发热头痛，脉反沉，身体
疼痛，当救其里，用四逆汤，此从脉之沉也。里症下之，此其常也。日晡发热者，属阳明，
脉浮虚者，宜发汗，用桂枝汤，此从脉之浮也。结胸症，当以大小陷胸下之矣。脉浮大者，
不可下，下之则死，是宜从脉而治其表也。身疼痛者，当以桂枝麻黄解之矣。然尺中迟者，
不可汗，以营血不足故也，是宜从脉而调其营矣，此皆从脉不从症也。世有切脉而不问症，
问症而忽脉者，得非仲景之罪人乎。陶节庵曰∶问病以知其外，察脉以知其内，全在治法
二字
，乃临症切脉之要诀也。余历来治目，无不详参脉证，以定治法。如陆某朱某，同一 肉壅
肿，黑珠内泛，一则脉沉迟，知其阴虚不足，复感寒邪，故余用六物汤加炮姜，以养阴温胃
。一则脉浮迟而细，知其气血两亏，寒而兼风，故余用四物逍遥，加苏木红花，以祛风理血
。张某艾某，同一珠大脱眶也，一则两尺浮洪无根，右寸濡弱无力，此肺金不能生水，肾火
浮越所致，故余用金匮肾气丸，以降其浮阳。一则两尺细数，右寸浮洪，此肾水枯涸，肺气
上冲所致，故余用人参固本煎加牛膝，以清其亢热，此证同脉异，而治亦异也。又如钱某瞳
神散大，李某两目 肉突出发痒，判然两症，然二人尺脉均细数，寸脉均洪大，皆由于心肾
不交，故余同以滋阴六味丸，去萸肉，加女贞子以治之。此证异脉同，故治亦同也。至如孔
某视白为黄，视红为紫，视正为横，乃阴极阳飞之症，脉宜浮洪，今反细涩，所谓过极者，
反兼胜已之化也。余以七味二地温补之，此凭症而不凭脉也。大抵阴阳虚实，最宜详审。张
介宾曰∶凡值疑似难明处，必须用四诊之法，详问其由，兼辨其声色。但于本末先后中，征
之以理，斯得其真。若不察此，而但谓一诊可凭，信手乱治，亦岂知脉症最多真假，见有不
确安能无误。且常诊者，知之犹易，初诊者，决之甚难，此四诊之所以不可忽也。
《素问·脉要精微论》说：脉理的奥妙在于细微之处，不可不仔细诊察。《灵枢·邪气脏腑病形篇》说：通过切按脉象来了解病情，这就叫做神妙。
秦越人（扁鹊）在《难经·六十一难》中说：通过切脉而知晓病情，这叫做技巧。许叔微说：脉理幽深难以阐明。我心中所领悟的，嘴上无法完全表达出来。
凡是可以用笔墨记载、可以用口舌言说的，都只是表象迹象。至于其中的神妙道理，如果不是心领神会，怎么能穷尽其极致的微妙呢？《素问·方盛衰论》说：从师学习未能结业，导致医术不明，不能辨别顺逆，这是妄自行事。判断错误，抛弃阴证而依附阳证，不知道综合参合，诊断自然就不明确。由此可见，脉象不可不辨别的道理是多么重要啊！其要点应当结合《素问》、《灵枢》以及各家的论述，熟读并细细玩味，自然能够领悟。只有常脉与变脉的道理，是不可不知道的。
一般人的脉象，有本来大、本来小，偏于阴、偏于阳的，这是先天禀赋不同，各自形成一种格局。邪气变化引起的脉象，有突然变缓、突然变急，时而进、时而退的，这是病邪骤然到来，脉象随着气机变化而显现的缘故。所以诊脉的人，必须先认识正常的脏脉，然后才能察知病变的脉象；先认识正常的脉象，然后才能察知变化的脉象。
然而，有脉象与病症相符的，也有脉象与病症相左的；有病势亢极而脉象忽然反变的。例如阳证见到阳脉，阴证见到阴脉，这叫脉病相符。症状看似阳证但脉搏不鼓指，症状看似阴证但脉搏鼓动旺盛，这叫脉病相左。阳气盛者，脉象必定洪大，到了阳气盛极之时，脉象反而伏匿，这是阳极似阴。阴气盛者，脉象必定微细，到了阴气盛极之时，脉象反而躁疾，这是阴极似阳。这就是病势亢极，而脉象忽然反变的情况。
又有“从合”的辨析。例如脉浮表示病在表，治疗适宜发汗，这是一般情况。但也有适宜攻下的，张仲景说：“如果脉浮大，心下痞硬，有热，属于里实证的，应当攻下，不让它发汗”，就是这种情况。脉沉表示病在里，治疗适宜攻下，这是一般情况。但也有适宜发汗的，如少阴病，刚得病时，反而发热，脉沉的，用麻黄附子细辛汤微微发汗，就是这种情况。脉促通常属阳，应当用葛根黄芩黄连汤清解。但如果脉促且四肢厥冷，这是虚脱了，非用温法不可，这又不是脉促代表阳盛的脉象了。脉迟通常主寒，应当用附子干姜温中散寒。但如果阳明病脉迟，不恶寒，身体出汗，则用大承气汤，这又不是脉迟代表阴寒的脉象了。这些都是“从证不从脉”。
至于表证发汗，这是一般情况。张仲景说：“病人发热头痛，脉反而沉，身体疼痛，应当救里，用四逆汤”，这是从脉象的沉来看待问题。里证攻下，这是一般情况。日晡时分发热，属于阳明病，但脉象浮虚的，适宜发汗，用桂枝汤，这是从脉象的浮来看待问题。结胸证，应当用大陷胸汤或小陷胸汤攻下。但如果脉象浮大，不可攻下，攻下就会死亡，这时适宜从脉象治疗其表证。身体疼痛，应当用桂枝麻黄汤解表。但如果尺部脉迟，不可发汗，因为营血不足的缘故，这时适宜从脉象调理营血。这些都是“从脉不从症”。
世上有人切脉却不问症状，或问症状却忽略脉象的，难道不是张仲景的罪人吗？陶节庵说：“询问病情以了解外在表现，诊察脉象以了解内在机理，关键在于‘治法’二字，这是临证切脉的要诀。”我历来治疗眼病，无不详细参考脉象和症状，以确定治疗方法。
例如陆某、朱某，都是眼睑肉壅肿，黑珠内部泛红，其中一人脉象沉迟，我知道他是阴虚不足，又感受寒邪，所以我用六物汤加炮姜，以滋养阴液、温补胃气。另一人脉象浮迟而细，我知道他是气血两亏，寒邪兼夹风邪，所以我用四物逍遥散加苏木、红花，以祛风理血。张某、艾某，都是眼球突出眼眶，其中一人两尺脉浮洪无根，右寸脉濡弱无力，这是肺金不能生肾水，肾火浮越所致，所以我用金匮肾气丸，以降敛浮阳。另一人两尺脉细数，右寸脉浮洪，这是肾水枯涸，肺气上冲所致，所以我用人参固本煎加牛膝，以清降亢热。这是证同脉异，所以治疗也不同。
又如钱某瞳神散大，李某眼睑肉突出且发痒，显然是两种不同的症状，然而两人的尺脉都细数，寸脉都洪大，都是由于心肾不交所致，所以我都用滋阴六味丸，去掉山茱萸，加女贞子来治疗。这是证异脉同，所以治疗也相同。
至于孔某视白为黄，视红为紫，视直为斜，这是阴极阳飞的症状，脉象本该浮洪，现在反而细涩，这就是所谓“过极者，反兼胜己之化”（即真寒假热或真热假寒等复杂病机）。我用七味二地丸温补，这是凭症状而不凭脉象。
大抵阴阳虚实，最宜详细审察。张介宾说：“凡遇到疑似难明的情况，必须运用望闻问切四诊方法，详细询问病因，同时辨别患者的声音和面色。但在事物的本末先后中，以理征验，才能得到真相。如果不考察这些，却只说凭一次诊脉就可以信赖，信手乱治，哪里知道脉症最多真假难辨，见解如果不确切，怎么能不出错呢？况且经常诊脉的人，了解病情还容易，初次诊脉的人，决断非常困难，这就是四诊不可轻视的原因。”
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."