凡初诊伤寒者，以其寒从外入，伤于表也。寒邪自外而入，必由浅渐深，故先自皮毛，次入经
络，又次入筋骨，而后及于脏腑，则病日甚矣。故凡病伤寒者，初必发热，憎寒无汗，以邪闭皮毛，
病在卫也。渐至筋脉拘急，头背骨节疼痛，以邪入经络，病在营也。夫人之卫行脉外，营行脉中，
今以寒邪居之，则血气混淆，经络壅滞，故外证若此，此即所谓伤寒证也。自此而渐至呕吐、不食
、胀满等证，则由外入内，由经入腑，皆可
因证而察其表里矣。若或肌表无热，亦不憎寒，身无疼痛，脉不紧数者，此其邪不在表，病必属里
。凡察伤寒，此其法也。
伤寒之邪，实无定体，或入阳经气分，则太阳为首，或入阴经精分，则少阴为先。其脉以浮紧
而有力无力，可知表之虚实；沉紧而有力无力，可知里之虚实；中而有力无力，可知阴阳之凶吉。
诊之之法，当问证以知其外，察脉以知其内，先病为本，后病为标。能参合脉证，而知缓急先后者
，乃为上工。
一、诊法曰∶浮脉为在表。故凡脉见浮紧而数者，即表邪也。再加以头项痛，腰脊强等证，此
即太阳经病，当求本经轻重而解散之。
一、脉见洪长有力，而外兼阳明证者，即阳明在经之邪也，宜求本经之寒热以散之。
一、脉见弦数，而兼少阳之证者，即少阳经半表半里之病，宜和解而散之。
一、沉脉为在里，病属三阴，详具后六经证辨中。但沉数有力，是即热邪传里也，若表证深入，
而内见大满大实，阳邪热结等证，治当从下也。
一、沉紧无力，而外无大热，内无烦渴等病，此阴证也。若或畏寒厥冷，及呕吐、腹痛、泻痢者
，此即阴寒直中，治宜温中也。
一、脉大者为病进，大因邪气胜，病日甚也。脉渐缓者为邪退，缓则胃气至，病将愈也。此以
大为病进，固其然也，然亦有宜大不宜大者，又当详辨。如脉体本大，再加洪数，此则病进之脉，
不可当也。如脉体本小，因服药后而渐见滑大有力者，此自阴转阳，必将汗解，乃为吉兆。盖脉至
不鼓者，由气虚而然，无阳岂能作汗也。后论汗条中有按，当并阅之。
仲景《伤寒论》曰∶脉有阴阳者，何谓也？曰∶凡脉浮大数动滑，皆阳也；沉涩弱弦微，皆阴
也。诸脉浮数，而发热恶寒，身痛不欲饮食者，伤寒也。若洒淅恶寒，饮食如常，而痛偏一处者，
必血气壅遏不通，成痈脓也。寸口脉浮为在表，沉为在里，数为在腑，迟为在脏。寸关尺三部，浮
沉、大小、迟数同等，虽有寒热不解者，此脉阴阳为和平，虽剧必愈。其脉浮而汗出如流珠者，阳
气衰也。脉瞥瞥如羹上珠者，阳气微也。脉萦萦如蜘蛛丝者，阳气衰也。脉绵绵如泻漆之绝者，亡
其血也。其脉沉者，荣气微也。若脉浮大者，气实血虚也。脉微缓者，为欲愈也。阳脉浮，阴脉弱
者，为血虚，血虚则筋急也。脉微弱而恶寒者，此阴阳俱虚，不可更发汗、更吐、更下也。阴证无
脉，温之而脉微续者生，暴出者死。阴病见阳脉者生，阳病见阴脉者死。
《论》曰∶寸脉微，名曰阳不足，阴气上入于阳中，则洒淅恶寒也。尺脉微，名曰阴不足，阳
气下陷入阴中，则发热也。寸口脉微而涩，微者卫气不行，涩者荣气不足。卫气衰，面色黄，荣气
不足，面色青。荣为根，卫为叶，荣卫俱微，则根叶枯槁，而寒栗、咳逆、唾腥、吐涎沫也。
《论》曰∶紧脉从何而来？曰∶假令亡汗若吐，以肺里寒，故令脉紧也。假令咳者，坐饮冷水
，故令脉紧也。假令下痢，以胃中虚冷，故令脉紧也。按此言紧者，即弦搏不软之谓，盖单言其紧
，而无滑数之意，
乃阳明胃气受伤之脉，故主为阴寒之证。若紧而兼数，则必以外邪所致。
愚按∶浮为在表，沉为在里，此古今相传之法也。然沉脉亦有表证，此阴实阳虚，寒胜者然也
。浮脉亦有里证，此阳实阴虚，水亏者然也。故凡欲察表邪者，不宜单据浮沉，只当以紧数与否为
辨，方为的确。盖寒邪在表，脉皆紧数，紧数甚者邪亦甚，紧数微者邪亦微，紧数浮洪有力者，邪
在阳分，即阳证也，紧数浮沉无力者，邪在阴分，即阴证也。以紧数之脉而兼见表证者，其为外感
无疑，即当治从解散。然内伤之脉，亦有紧数者，但内伤之紧，其来有渐，外感之紧，发于陡然，
以此辨之，最为切当。其有似紧非紧，但较之平昔，稍见滑疾而不甚者，亦有外感之证，此其邪之
轻者，或以初感而未甚者，亦多见此脉，是又不可不兼证而察之也。若其和缓而全无紧疾之意，则
脉虽浮大，自非外邪之证。
按陶节庵曰∶夫脉浮当汗，脉沉当下，固其宜也。然其脉虽浮，亦有可下者，谓邪热入腑，大
便难也，设使大便不难，岂敢下乎？其脉虽沉，亦有可汗者，谓少阴病，身有热也，设使身不发热
，岂敢汗乎？若此之说，可见沉有表，而浮亦有里也。
凡初诊伤寒的患者，是因为寒邪从外部侵入，损伤了体表。寒邪由外而入，必然由浅入深，所以先侵犯皮毛，接着进入经络，再深入筋骨，最后才波及脏腑，这样病情就会日益加重。因此，凡是患伤寒的人，初期必定发热、怕冷且无汗，这是因为邪气闭塞皮毛，病位在卫分（行于脉外，主防御）。逐渐发展到筋脉拘挛紧急、头项背部及骨节疼痛，这是因为邪气进入经络，病位在营分（行于脉中，主营养）。人的卫气行于脉外，营气行于脉中，现在被寒邪占据，导致血气混乱，经络壅滞不通，所以出现上述外在症状，这就是所谓的伤寒证。从此以后，若逐渐出现呕吐、不能进食、腹胀满等症状，则说明病邪由表入里，由经络传入腑脏，可以根据这些症状来辨别病位的表里。如果肌表没有发热，也不觉得怕冷，身体没有疼痛，脉搏不紧促快速，这说明邪气不在体表，疾病一定属于里证。凡是诊察伤寒，这是基本的方法。
伤寒的邪气，实际上没有固定的形态，如果侵入阳经的气分，则以太阳经为首要；如果侵入阴经的精分，则以少阴经为先导。诊脉时，通过脉象浮紧而有力或无力，可以知道表证的虚实；沉紧而有力或无力，可以知道里证的虚实；脉象在中部而有力或无力，可以判断阴阳病情的吉凶。诊察的方法，应当询问症状以了解外部情况，诊察脉象以了解内部情况，先发生的病为本，后发生的病为标。能够综合脉象和症状，并懂得处理缓急先后顺序的医生，才是高明的医生。
一、诊法说：浮脉表示病在表。所以凡是脉象见浮紧而数的，就是表邪。如果再伴有头痛项强、腰脊僵硬等症状，这就是太阳经病，应当根据本经病情的轻重进行发散解表治疗。
二、脉象见洪大长而有力，且外部兼有阳明经症状的，就是阳明经在表的邪气，应当根据本经的寒热性质进行发散治疗。
三、脉象见弦数，且兼有少阳经症状的，就是少阳经半表半里的病，应当采用和解的方法进行治疗。
四、沉脉表示病在里，疾病属于三阴经，详细情况在后面六经证候辨析中详述。但是沉数而有力的，是热邪传入里部，如果表证深入体内，并且内部出现大满大实、阳邪热结等症状，治疗应当采用攻下法。
五、沉紧而无力，且外部没有大热，内部没有烦躁口渴等病症，这是阴证。如果出现畏寒肢冷，以及呕吐、腹痛、腹泻痢疾等症状，这就是阴寒之邪直中内脏，治疗应当温补中焦。
六、脉象大的表示病情进展，因为邪气盛，病情日益加重。脉象逐渐缓和的表示邪气消退，缓和则胃气恢复，疾病将要痊愈。这以大脉为病情进展，确实是这样的，然而也有宜大不宜大的情况，又应当详细辨别。如脉体本来大，再加上洪大数急，这是病情进展的脉象，难以抵挡。如脉体本来小，服药后逐渐变得滑大有力，这是自阴转阳，必将通过发汗而解，这是吉兆。因为脉象至而不鼓动，是由于气虚所致，没有阳气怎么能出汗呢？后面论述发汗的条目中有记载，应当一并阅读。
张仲景《伤寒论》说：脉象有阴阳之分，是什么意思呢？回答说：凡是脉象浮、大、数、动、滑，都属于阳脉；沉、涩、弱、弦、微，都属于阴脉。各种脉象浮数，且伴有发热恶寒、身体疼痛、不想饮食的，是伤寒。如果是战栗怕冷，饮食正常，但疼痛局限于一处，必然是血气壅遏不通，形成痈脓。寸口脉浮表示病在表，沉表示病在里，数表示病在腑，迟表示病在脏。寸、关、尺三部，浮沉、大小、迟数都同等协调，虽然患有寒热不解的疾病，但脉象阴阳平和，即使病情严重也一定会痊愈。其脉象浮而汗出如流珠般的，是阳气衰微。脉象瞥瞥如羹汤上浮珠般的，是阳气微弱。脉象萦萦如蜘蛛丝般的，是阳气衰微。脉象绵绵如泻漆将断绝般的，是亡血。其脉象沉的，是营气微弱。如果脉象浮大，是气实血虚。脉象微缓的，是即将痊愈。阳脉浮，阴脉弱的，是血虚，血虚则筋脉拘急。脉微弱且恶寒的，这是阴阳俱虚，不可以再发汗、催吐或攻下。阴证无脉，温补后脉象微微续接的能生，突然出现的会死。阴病见到阳脉的能生，阳病见到阴脉的会死。
《伤寒论》说：寸脉微，名叫阳不足，阴气上入于阳中，就会战栗怕冷。尺脉微，名叫阴不足，阳气下陷入阴中，就会发热。寸口脉微而涩，微代表卫气运行不畅，涩代表营气不足。卫气衰，面色发黄，营气不足，面色发青。营气是根，卫气是叶，营卫都微弱，则根叶枯槁，出现寒战、咳嗽气逆、唾吐腥臭、吐涎沫等症状。
《伤寒论》说：紧脉是从哪里来的？回答说：假如大汗出或者呕吐，因为肺里有寒，所以令脉象紧。假如咳嗽，因为喝冷水，所以令脉象紧。假如下痢，因为胃中虚冷，所以令脉象紧。按此所说紧脉，就是弦搏而不柔软的意思，单言其紧，而没有滑数的意思，这是阳明胃气受伤的脉象，所以主为阴寒之证。如果紧而兼数，则一定是由外邪所致。
我按语：浮脉表示病在表，沉脉表示病在里，这是古今相传的方法。然而沉脉也有表证，这是阴实阳虚，寒邪胜的表现。浮脉也有里证，这是阳实阴虚，水亏的表现。所以凡是想要诊察表邪的，不应该只依据浮沉，只应当以是否紧数为辨别标准，这才是确切的。因为寒邪在表，脉象皆紧数，紧数严重的邪气也重，紧数轻微的邪气也轻，紧数浮洪有力的，邪气在阳分，即阳证；紧数浮沉无力的，邪气在阴分，即阴证。以紧数的脉象而兼见表证的，肯定是外感，就应当治以发散解表。然而内伤的脉象，也有紧数的，但内伤的紧，是逐渐形成的，外感的紧，是突然发作的，以此辨别，最为恰当。那些似紧非紧，只是比平时稍见滑疾但不严重的，也有外感的证候，这是邪气较轻的，或者是刚感受邪气尚未严重的，也常见这种脉象，这又不可不结合症状来诊察。如果脉象和缓而完全没有紧疾的意思，那么脉象虽然浮大，自然不是外邪的证候。
按陶节庵说：脉浮应当发汗，脉沉应当攻下，固然是适宜的。然而脉虽浮，也有可以攻下的，是说邪热入腑，大便困难，假使大便不难，怎么敢用下法呢？脉虽沉，也有可以发汗的，是说少阴病，身体有发热，假使身体不发热，怎么敢用汗法呢？像这样的说法，可见沉脉也有表证，而浮脉也有里证。
For patients initially diagnosed with Shanghan (Cold Damage), the pathogen enters from the exterior, damaging the Tai Biao (Exterior). Cold pathogens enter from outside and must progress from shallow to deep; thus, they first affect the Mao Pi (Skin and Hair), then enter the Jing Luo (Meridians and Collaterals), subsequently penetrate the Jin Gu (Tendons and Bones), and finally reach the Zang Fu (Internal Organs), causing the disease to worsen daily. Therefore, anyone suffering from Shanghan will initially experience Fa Re (Fever), Zeng Han (Aversion to cold), and Wu Han (Absence of sweating), because the pathogen blocks the skin and hair, and the disease is in the Wei Fen (Wei Level/Defensive Qi). Gradually, it progresses to Jin Mai Jiu Ji (Muscle and tendon stiffness/spasm) and pain in the head, back, and joints, because the pathogen has entered the meridians, and the disease is in the Ying Fen (Ying Level/Nutritive Qi). The human Wei Qi circulates outside the vessels, while Ying Qi circulates inside the vessels. Now that cold pathogens occupy these spaces, blood and qi become confused, and the meridians become congested and stagnant, resulting in the aforementioned external symptoms. This is what is referred to as the Shanghan syndrome. From this point, if symptoms such as Ou Tu (Vomiting), Bu Shi (Inability to eat), and Zhang Man (Abdominal distension and fullness) gradually appear, it indicates that the pathogen has moved from the exterior to the interior, and from the meridians to the Fu organs. One can thereby inspect the location of the disease as either exterior or interior based on these symptoms. If there is no heat on the body surface, no aversion to cold, no body pain, and the pulse is not tight and rapid, this indicates that the pathogen is not at the exterior, and the disease must belong to the interior. This is the method for examining Shanghan.
The pathogen of Shanghan actually has no fixed form. If it enters the Qi Fen (Qi Level) of the Yang meridians, the Tai Yang (Greater Yang) meridian is primary; if it enters the Jing Fen (Essence Level) of the Yin meridians, the Shao Yin (Lesser Yin) meridian is primary. Regarding the pulse: a floating and tight pulse, whether forceful or weak, reveals the deficiency or excess of the exterior; a sinking and tight pulse, whether forceful or weak, reveals the deficiency or excess of the interior; a pulse in the middle position, whether forceful or weak, reveals the auspicious or ominous nature of the Yin and Yang conditions. The method of diagnosis involves asking about symptoms to know the exterior and examining the pulse to know the interior. The initial illness is the Ben (Root/Etiology), and the subsequent illness is the Biao (Branch/Symptom). A physician who can integrate pulse and symptom analysis to understand the urgency and sequence of treatment is considered a Shang Gong (Superior Physician).
1. Diagnostic method states: A Floating Pulse (Fu Mai) indicates the disease is at the exterior. Therefore, if the pulse is floating, tight, and rapid, it signifies exterior pathogenic factors. If accompanied by Tou Xiang Tong (Head and neck pain), Yao Ji Qiang (Stiffness of the lower back and spine), etc., this is a disease of the Tai Yang Meridian. Treatment should focus on dispersing and resolving according to the severity within this meridian.
2. If the pulse is Hong Chang You Li (Surging, long, and forceful), and externally accompanied by Yang Ming symptoms, it is pathogenic factors in the Tai Yang Meridian at the exterior level. Treatment should disperse them according to the cold or heat nature of this meridian.
3. If the pulse is Xuan Shu (Wiry and rapid), and accompanied by Shao Yang symptoms, it is a disease of the Shao Yang Meridian at the half-exterior, half-interior level. Treatment should employ He Jie (Harmonizing) methods to disperse it.
4. A Sinking Pulse (Chen Mai) indicates the disease is at the interior, belonging to the Three Yin meridians. Details are provided in the later section on Six Meridian Syndrome Differentiation. However, a sinking and rapid pulse with force indicates that Heat Pathogens have transmitted to the interior. If exterior symptoms have penetrated deeply into the interior, presenting with signs of severe fullness, solid accumulation, and Yang pathogenic heat binding, treatment should follow the Xia Fa (Purgative/Lowering Method).
5. A sinking and tight pulse without force, combined with no significant external heat and no internal irritability or thirst, indicates a Yin Syndrome. If accompanied by Wei Han (Fear of cold) and Jue Leng (Cold extremities), as well as vomiting, abdominal pain, and diarrhea/dysentery, this is Yin-Cold directly striking the interior. Treatment should employ Wen Zhong (Warming the Middle) methods.
6. A large pulse indicates disease progression, as the pathogenic factor is strong and the disease worsens daily. A pulse that gradually becomes slow indicates the retreat of the pathogen; slowness implies the arrival of Stomach Qi, and the disease will heal. While a large pulse generally signifies disease progression, there are cases where a large pulse is appropriate and others where it is not, requiring detailed differentiation. For instance, if the pulse body is already large, and becomes surging and rapid, this is a pulse of disease progression that is difficult to withstand. Conversely, if the pulse body was originally small but gradually becomes slippery, large, and forceful after medication, this indicates a shift from Yin to Yang, promising resolution through sweating, which is an auspicious sign. A pulse that arrives but does not throb is due to Qi deficiency; without Yang Qi, how can sweat be produced? Notes on this can be found in the subsequent section on Sweating Methods; readers should consult both.
Zhang Zhongjing's *Shanghan Lun* states: What does it mean when pulses have Yin and Yang distinctions? It is answered: Pulses that are floating, large, rapid, moving, and slippery all belong to Yang; those that are sinking, choppy, weak, wiry, and minute all belong to Yin. Various pulses that are floating and rapid, accompanied by fever, aversion to cold, body pain, and loss of appetite, indicate Shanghan. If there is shivering aversion to cold, normal diet, but pain localized to one area, it must be due to stagnation of blood and qi leading to the formation of abscesses/pus. A floating pulse at the Cun Kou (Radial Artery) indicates the exterior; sinking indicates the interior; rapid indicates the Fu organs; slow indicates the Zang organs. If the Floating, Sinking, Large, Small, Slow, and Rapid qualities are equal across the Cun, Guan, and Chi positions, even if cold-heat disorders persist, the pulse indicates Yin-Yang harmony, and recovery is certain despite severity. If the pulse is floating and sweating occurs like flowing pearls, it indicates the decline of Yang Qi. A pulse flickering like beads on soup indicates slight Yang Qi. A pulse winding like a spider's thread indicates declining Yang Qi. A pulse continuous like the end of pouring lacquer indicates loss of Blood. A sinking pulse indicates weak Ying Qi. A floating and large pulse indicates Excess Qi and Deficient Blood. A slightly slow pulse indicates impending recovery. A floating Yang pulse and weak Yin pulse indicate Blood Deficiency, which leads to tendon stiffness. A weak and minute pulse with aversion to cold indicates simultaneous deficiency of Yin and Yang; sweating, emesis, or purgation should not be used. In Yin syndromes without a pulse, if warming therapy results in a slowly returning pulse, life is preserved; if the pulse suddenly appears, death ensues. Yin diseases showing Yang pulses survive; Yang diseases showing Yin pulses die.
The *Lun* states: A minute pulse at the Cun position is named Yang Insufficiency, where Yin Qi ascends into the Yang region, causing shivering aversion to cold. A minute pulse at the Chi position is named Yin Insufficiency, where Yang Qi sinks into the Yin region, causing fever. A minute and choppy pulse at the Cun Kou indicates that minute quality reflects non-circulation of Wei Qi, and choppy quality reflects insufficiency of Ying Qi. Decline of Wei Qi manifests as yellow complexion; insufficiency of Ying Qi manifests as green complexion. Ying is the root, Wei is the leaf; if both Ying and Wei are minute, the roots and leaves wither, leading to chills, coughing and reverse qi flow, bloody sputum, and salivation.
The *Lun* asks: Where does the Tight Pulse come from? It answers: Suppose excessive sweating or vomiting occurs due to cold in the Lungs, causing a tight pulse. Suppose coughing occurs due to drinking cold water, causing a tight pulse. Suppose dysentery occurs due to deficiency-cold in the Stomach, causing a tight pulse. According to this, "tight" refers to a wiry, pulsating, non-soft quality. Speaking solely of tightness without slipperiness or rapidity indicates injury to the Stomach Qi of the Yang Ming, thus governing Yin-Cold syndromes. If tightness is accompanied by rapidity, it must be caused by external pathogens.
My commentary: Floating indicates the exterior, sinking indicates the interior; this is the method passed down through generations. However, a sinking pulse can also indicate an exterior condition, resulting from Yin excess and Yang deficiency with dominant cold. A floating pulse can also indicate an interior condition, resulting from Yang excess and Yin deficiency with water depletion. Therefore, when inspecting for exterior pathogens, one should not rely solely on floating or sinking, but rather distinguish based on whether the pulse is tight and rapid. This is more accurate. When cold pathogens are at the exterior, the pulse is always tight and rapid. Severe tightness and rapidity indicate severe pathogens; mild tightness and rapidity indicate mild pathogens. Tight, rapid, floating, surging, and forceful pulses indicate pathogens in the Yang aspect, i.e., Yang syndromes. Tight, rapid, floating/sinking, and weak pulses indicate pathogens in the Yin aspect, i.e., Yin syndromes. If a tight and rapid pulse is accompanied by exterior symptoms, it is undoubtedly an external contraction, and treatment should focus on dispersing and resolving. However, internal injury pulses can also be tight and rapid. The tightness of internal injury develops gradually, whereas the tightness of external contraction appears suddenly; distinguishing by this criterion is most appropriate. Cases that seem tight but are not, merely slightly slippery and rapid compared to the baseline, may also indicate external contraction, representing mild pathogens or early-stage infections. These pulses are common, so symptoms must be examined concurrently. If the pulse is harmonious and completely lacks tightness or rapidity, even if floating and large, it is naturally not an external pathogenic condition.
According to Tao Jie'an: A floating pulse warrants sweating, and a sinking pulse warrants purgation; this is indeed appropriate. However, even if the pulse is floating, purgation may be indicated if heat pathogens have entered the Fu organs causing difficult defecation. If defecation is not difficult, how dare one use purgation? Even if the pulse is sinking, sweating may be indicated if it is a Shao Yin disease with body heat. If there is no fever, how dare one use sweating? Such statements demonstrate that sinking pulses can indicate exterior conditions, and floating pulses can indicate interior conditions.