Introduction: This article introduces four pulse conditions: "large, wiry, rapid, and slow." Except for the first one, "large," the other three are very common in clinical practice. The pulse-symptom discordance discussed in this article is not actually discordance but rather the application of stereotypical labels to certain pulses. To interpret a pulse, it must be analyzed in the context of the specific disease, which is the essence of the four diagnostic methods.

Discard the Pulse and Follow the Symptoms

Gao Huiyuan, Liu Yuejin, Guo Qilai

Pulse diagnosis is an important method in traditional Chinese medicine for diagnosing diseases. Under normal circumstances, the pulse and symptoms are consistent. However, clinically, there are also cases where the pulse and symptoms do not match, as illustrated below.

1. A Large Pulse Does Not Always Indicate Excessive Pathogenic Factors

The "Inner Canon: Treatise on the Essentials of the Pulse" states: "A large pulse indicates the progression of disease." Later generations also generally regard a large pulse as a sign of excessive pathogenic factors and disease progression. However, I have observed that in some patients with pulmonary heart disease during non-acute episodes, the main symptoms include chest tightness, shortness of breath, cough, wheezing, fatigue, and worsening dyspnea upon exertion. Their pulse is large and slightly taut, particularly prominent in the cun and guan regions, which still indicates excessive pathogenic factors. If one relies solely on the pulse and focuses exclusively on clearing lung heat with bitter-cold herbs to expel pathogenic factors and relieve wheezing, there is a risk of damaging the body's vital energy and depleting qi.

"In a man who appears healthy, a large pulse indicates exhaustion, and an extremely weak pulse also indicates exhaustion."

—"Synopsis of the Golden Chamber: Pulse Patterns and Treatment of Blood Impediment and Exhaustion Disorders"

This indicates that in cases of exhaustion disorders, the pulse may be weak or large. Chronic illness inevitably leads to deficiency, and prolonged deficiency results in exhaustion. Patients with pulmonary heart disease suffer from long-term coughing and wheezing, where lung disease affects the kidneys, characterized by a root deficiency and branch excess as the pathological feature.

During acute exacerbations, the primary manifestation is often pathogenic qi congesting the lungs; during non-acute periods, the main issue is deficiency of both the lungs and kidneys. Clinicians must not mistake a large and forceful pulse as a sign of excessive pathogenic factors, and should heed the ancient warning that "extreme deficiency may present with signs of excess."

2. Not All Wiry Pulses Indicate Excess

In the practice of diagnosing and treating geriatric diseases, I have observed that many elderly individuals develop a physiological wiry pulse as they age due to degenerative changes in their blood vessels. This wiry pulse in healthy elderly individuals is essentially a manifestation of the normal aging process and should be regarded as a "normal pulse," not hastily judged as a pathological pulse.

Additionally, some elderly patients who previously suffered from hypertension may still exhibit "arteriosclerosis" even after their blood pressure has normalized through treatment. Consequently, during diagnosis, they often present with patterns of deficiency, yet their pulse paradoxically appears "straight and long, like pressing on a taut string."

In such cases where liver wind has subsided but kidney essence is depleted, aggressive treatments are particularly contraindicated. Extreme caution must be exercised during pattern differentiation and treatment.

3. Rapid Pulse Does Not Always Indicate Heat

In clinical practice, some patients with heart disease experience "heart failure" due to cardiac insufficiency, with a pulse rate of 6–7 beats per breath, or even 8–9 beats per breath. In such cases, it is crucial not to interpret the rapid pulse as indicative of heat, nor to assume that a forceful pulse signifies excess heat or a weak pulse signifies deficient heat.

Based on the patient's symptoms of palpitations, shortness of breath, chest tightness, and a pale tongue—all signs of heart yang deficiency—I often prescribe formulas to replenish qi, nourish the heart, and harmonize the nutritive and defensive aspects, which frequently yield positive results.

Once, a student expressed confusion, asking why cinnamon twig (Guizhi) was used despite the rapid pulse.

I explain it as follows: This rapid pulse is not due to pathogenic heat, but rather to the deficiency of heart yang and the weakness of heart qi, which compensates by becoming rapid. Therefore, warming heart yang and promoting heart qi align precisely with the disease mechanism.

Additionally, in clinical practice, a "rapid pulse" may also occur due to the use of Western medications. For example, after administering atropine or epinephrine, patients often experience an accelerated pulse, presenting as a rapid pulse. This type of rapid pulse is temporary and should not be used as a basis for syndrome differentiation.

4. A Slow Pulse Does Not Always Indicate Cold

In clinical practice, the use of certain Western medications can slow the pulse, resulting in a relatively "slow pulse." For instance, cardiac patients taking propranolol or digitalis may exhibit a slow pulse.

This type of drug-induced pulse pattern often masks the underlying pathological signs of the disease, representing a "false appearance" in pulse diagnosis. During examination, it is particularly important to inquire in detail about the patient's past medication history to avoid confusion.

Given physiological changes in the human body, various diseases, and the use of Western medications, all of which can influence pulse patterns, practitioners must understand the norm to grasp the variations. Only then can they reasonably disregard or appropriately follow the pulse findings in cases of "pulse-symptom mismatch," avoiding the pitfall of "seeking a sword from a boat's mark."