难经五十八难曰∶伤寒有几，其脉有变否？然！伤寒有五∶有中风，有伤寒，有湿温，有热病，有温病。
其所苦各不同。
徐洄溪曰∶伤寒者，统名也。下五者，伤寒之分证也。
诒按∶中风伤寒，即仲景论中所列之证也，是感而即发者也。若寒邪郁伏而发，则因温风而发者，名曰风
温；因暑热而
发者，名曰热病，此即夏至后之暑病也；因湿邪而发者，名曰湿温。虽随时随病，各异其名，而由于受寒则一
，故皆谓之伤寒。
又按∶所苦不同，言五者之为病不同也。伤寒论云∶太阳病，发热而汗出，恶风脉缓者，名曰中风。太阳
病，或已发热，或未发热，必恶寒；体痛呕逆，脉阴阳俱紧者，名曰伤寒。太阳病，关节疼痛而烦；脉沉而细
者，此为湿痹。太阳中热者， 是也；其人汗出恶寒，身热而渴也。太阳病，发热而渴，不恶寒者，为温病。
此五条，即论列五种病之所苦，各有见证之不同也。前二条是感寒而即病者，后三条是寒伏于内，兼挟别气而
病者，仲景悉隶于伤寒论中，可见五证均因于寒，即均可谓之伤寒也。
中风之脉，阳浮而滑，阴濡而弱。伤寒之脉，阴阳俱盛而紧涩。湿温之脉，阳濡而弱，阴小而急。热病之
脉，阴阳俱浮，浮之而滑，沉之散涩。温病之脉，行在诸经，不知何经之动也，各随其经所在而取之。
诒按∶阴阳二字以脉言。凡脉寸为阳，尺为阴；右为阳，左为阴；浮为阳，沉为阴。就此节论，当以尺寸
分阴阳为是。风为阳邪，故阳脉浮滑。寒邪收引，故脉紧涩。湿为阴邪而伤阳，故阳濡而阴急。热病为阳邪而
伤阴，故浮滑而沉涩。热病是温邪之已化热而外出者，其未化热之前，名曰温病。邪伏少阴，随气而动，流行
于诸经，或乘经气之虚而发；或挟新感之邪气而发。其发也，或由三阳而出，或由肺胃；最重者热不外出，而
内陷于手足厥阴；或肾气虚，不能托邪，而燔结于少阴。是温邪之动。路径多歧，随处可发，初不能指定发于
何经，即不能刻定见何脉象也。
又按∶伏温之病，随经可发；经训昭垂，已无疑义。乃张石
顽谓温邪之发，必由少阳。陆九芝谓温热病必发于阳明。陈平伯则以肺胃为温邪必犯之地。吴又可又以募原为
温疫伏邪之所。诸家所论，虽亦各有所见；但只举温病之一端，而不可以概温病之全体。至吴鞠通温病条辨，
横分三焦。谓凡病温者，必始于上焦手太阴。是以时感温风之证，指为伏气发温之病。彼此混而不分；其背谬
为尤甚。学人当即此节经文，悉心参究，确知温病之发，随经可动，临证时始有真知灼见，而不至有他歧之感
也。
伤寒有汗出而愈，下之而死者；有汗出而死，下之而愈者；何也？然！阳虚阴盛，汗出而愈，下之即死；
阳盛阴虚，汗出而死，下之而愈。
滑氏本义引外台秘要谓∶表病里和为阳虚阴盛，邪在表，宜发汗；若反下之，引邪入里，诛伐无过，故死
。里病表和为阳盛阴虚，邪入里，宜急下；若反汗之，兼虚其表，故死。按伤寒例，亦有阳盛阴虚，汗之则死
，下之则愈，阳虚阴盛，汗之则愈，下之则死之文。诸家释之，不一其说。成无己注，则以阳邪乘虚入腑，为
阳盛阴虚；邪乘表虚，客于营卫，为阳虚阴盛。外台秘要及刘河间伤寒直格，俱以不病者为盛，病者为虚。活
人书以内外俱热，为阳盛阴虚；内外俱寒，为阳虚阴盛。惟王安道溯洄集，则以寒邪在外；为阴盛可汗；热邪
内炽，为阳盛可下。此说最为无弊。若不病为实，病者为虚之说，与表病里和，里病表和之说相近；但虚实二
字，其义终未妥也。
诒按∶寒邪初受，未经化热，卫阳被遏，则阳虚而阴盛，此即暴病之伤寒。但用辛温助阴，以发其汗，则
邪解矣。若未曾入腑化热，而遽下之，则里气伤而表邪陷，即死矣。若邪郁久而化热，阴液被烁，则阳盛而阴
虚，此即伏气之温病也。里热
既盛，当急下以救阴则生。若再用辛温，误发其汗，则阴愈烁而变证蜂起。是以受病之始，都属寒邪，故仍以
伤寒为提纲也。此节两层，以伤寒、温病分贴作解，亦甚熨帖。前所引诸家之论，似总不能若是之直捷。
《难经》第五十八难说：伤寒有几种？其脉象是否有变化？回答是：伤寒共有五种：有中风，有伤寒，有湿温，有热病，有温病。它们所表现出的痛苦症状各不相同。
徐洄溪说：伤寒是一个总称。下面的五种情况，是伤寒的不同证型。
我（柳宝诒）按语：中风和伤寒，就是张仲景在《伤寒论》中所列出的证候，这是感受邪气后立即发病的情况。如果是寒邪郁伏体内而后发作，那么因温风诱因而发的，名叫风温；因暑热诱因而发的，名叫热病，这就是夏至以后的暑病；因湿邪诱因而发的，名叫湿温。虽然随着季节不同、病因各异而名称不同，但都源于受寒，所以都称为伤寒。
我又按语：“所苦不同”，是指这五种病造成的痛苦各不相同。《伤寒论》中说：太阳病，发热且出汗，怕风，脉象缓的，名叫中风。太阳病，有的已经发热，有的尚未发热，必定怕冷；身体疼痛，呕吐逆气，寸关尺三部脉象都紧的，名叫伤寒。太阳病，关节疼痛且烦躁；脉象沉而细的，这是湿痹。太阳中热者，即暍病（中暑）；其人出汗怕冷，身体发热且口渴。太阳病，发热且口渴，不怕冷的，是温病。这五条，就是《伤寒论》列举的五种病的痛苦表现，各有不同的见证。前两条是感受寒邪立即发病的，后三条是寒邪伏于体内，兼夹其他邪气而发病的，张仲景全部将其归入《伤寒论》中，可见这五种证候均因于寒，因此都可以称为伤寒。
中风的脉象，阳部（浮取或寸部）浮滑，阴部（沉取或尺部）濡弱。伤寒的脉象，阴阳两部都盛大且紧涩。湿温的脉象，阳部濡弱，阴部小且急。热病的脉象，阴阳两部都浮，轻取滑利，重散涩。温病的脉象，流行在各条经络中，不知道是哪条经络发生变动，要随其经络所在之处来诊察。
我（柳宝诒）按语：这里的“阴阳”二字是从脉象角度说的。凡是脉象，寸为阳，尺为阴；右为阳，左为阴；浮为阳，沉为阴。就这一节经文而言，应当以寸口尺寸分部来分阴阳比较恰当。风为阳邪，所以阳脉浮滑。寒邪具有收引特性，所以脉紧涩。湿为阴邪且损伤阳气，所以阳脉濡弱而阴脉急。热病为阳邪且损伤阴液，所以轻取浮滑，重按散涩。热病是温邪已经化热并向外透发的阶段，其在未化热之前，名叫温病。邪气潜伏在少阴，随着气机运行，流布于各条经络，或者乘经络之气虚弱而发作；或者挟带新感的外邪而发作。它的发作，或者从三阳经外出，或者从肺胃发出；最严重的是热邪不能向外透发，而内陷入手足厥阴经；或者肾气虚弱，不能托举邪气外出，而燔结于少阴。因此温邪的活动路径多歧，随处可以发作，起初不能指定它发于哪条经络，也就不能刻板地确定见到何种脉象。
我又按语：伏气温病，随着经络而发作；经典训示明确昭著，已无疑问。然而张石顽认为温邪的发作，必然由少阳经发起。陆九芝认为温热病必然发于阳明经。陈平伯则认为肺胃是温邪必犯之地。吴又可又认为募原是温疫伏邪所在之处。各家论述，虽然也各有见解；但只举出了温病的一个方面，而不能概括温病的整体。至于吴鞠通在《温病条辨》中，横向划分三焦，认为凡是患温病的人，一定始于上焦手太阴肺经。从而将当时感受温风的证候，指认为是伏气引发的温病。两者混淆不分；这种背谬尤为严重。学者应当对此节经文悉心参究，确切知道温病的发作，是随着经络而动的，临证时才会有真知灼见，而不至于产生其他歧途的感觉。
伤寒中有出汗而痊愈，用攻下法反而致死的；有出汗而死，用攻下法反而痊愈的；为什么呢？回答是：阳虚阴盛，出汗则愈，攻下则死；阳盛阴虚，出汗则死，攻下则愈。
滑寿在《本义》中引用《外台秘要》说：表病里和为阳虚阴盛，邪气在表，宜用发汗法；如果反而用攻下法，引邪入里，诛伐无辜的正气，所以致死。里病表和为阳盛阴虚，邪气入里，宜急用攻下法；如果反而用发汗法，兼且使表气更虚，所以致死。按《伤寒例》，也有“阳盛阴虚，汗之则死，下之则愈；阳虚阴盛，汗之则愈，下之则死”的文字。各家解释，说法不一。成无己注解说，以阳邪乘虚入腑，为阳盛阴虚；邪气乘表虚，客居于营卫，为阳虚阴盛。《外台秘要》及刘河间《伤寒直格》，都以未患病者为盛，患病者为虚。《活人书》以内外俱热，为阳盛阴虚；内外俱寒，为阳虚阴盛。只有王安道在《溯洄集》中，认为寒邪在外，为阴盛可发汗；热邪内炽，为阳盛可攻下。这种说法最为没有弊端。如果不以“不病为实，病者为虚”的说法，与“表病里和，里病表和”的说法相近；但“虚实”二字的含义终究不够妥当。
我（柳宝诒）按语：寒邪初受，尚未化热，卫阳被遏制，则表现为阳虚而阴盛，这就是暴发的伤寒。只用辛温药物助阳，以发散其汗，邪气就能解除。如果邪气未曾入腑化热，就急于攻下，则里气受伤而表邪内陷，就会致死。如果邪气郁久化热，阴液被煎熬耗伤，则表现为阳盛而阴虚，这就是伏气温病。里热既然旺盛，应当急用攻下法以救阴液，这样才能生存。如果再用辛温药物，错误地发汗，则阴液更加耗伤而变证蜂拥而起。因此，在患病之初，都属于寒邪，所以仍以伤寒作为提纲。这一节包含两层意思，以伤寒、温病分别对应解释，也非常贴切。前面引用的各家论述，似乎都不能像这样直接明了。
The Fifty-Eighth Difficulty of the *Nan Jing* (Classic of Difficult Issues) states: How many types are there in Shanghan (Cold Damage diseases)? Do their pulses change? The answer is: There are five types of Shanghan: there is Zhongfeng (Wind Strike), there is Shanghan, there is Shiwen (Damp-Warmth), there is Rebing (Heat Disease), and there is Wenbing (Warm Disease). The suffering associated with each is different.
Xu Huixi stated: "Shanghan" is a general term. The following five categories are differentiated syndromes of Shanghan.
I (Liu Baozhi) comment: Zhongfeng (Wind Strike) and Shanghan refer to the syndromes listed in Zhang Zhongjing's treatise; these are conditions that manifest immediately upon pathogenic invasion. However, if Cold Evil remains latent and suppressed within the body before manifesting, then when triggered by warm winds, it is named Fengwen (Wind-Warmth); when triggered by summer heat, it is named Rebing (Heat Disease), which refers to Summerheat disease after the Summer Solstice; when triggered by dampness, it is named Shiwen (Damp-Warmth). Although they bear different names due to varying seasons and etiologies, since they all originate from cold exposure, they are all referred to as Shanghan.
I further comment: "The suffering differs" means that the pathological manifestations of these five conditions vary. The *Shanghan Lun* (Treatise on Cold Damage) states: In Taiyang disease (Taiyang Channel Syndrome), if there is fever, sweating, aversion to wind, and a slow pulse, it is named Zhongfeng (Wind Strike). In Taiyang disease, whether fever has already appeared or not, there must be aversion to cold; accompanied by body pain, vomiting, and a tight pulse at both yin and yang positions, it is named Shanghan. In Taiyang disease, if there is joint pain and irritability, with a deep and thin pulse, this is Shibi (Damp Bi syndrome). Taiyang Zhongre (Summerheat affecting Taiyang) refers to Ye (Heatstroke); the patient sweats, feels aversion to cold, has body heat, and thirst. In Taiyang disease, if there is fever and thirst without aversion to cold, it is Wenbing (Warm Disease). These five clauses describe the distinct sufferings and clinical presentations of the five diseases listed in the treatise. The first two clauses refer to conditions where cold pathogen induces immediate illness; the latter three refer to cold latent internally, complicated by other pathogens inducing illness. Zhang Zhongjing classified all five under the *Shanghan Lun*, demonstrating that all five syndromes stem from cold, and thus can all be termed Shanghan.
The pulse of Zhongfeng (Wind Strike) is floating and slippery at the yang position (superficial/cun), and soggy and weak at the yin position (deep/chǐ). The pulse of Shanghan is full and tight-rough at both yin and yang positions. The pulse of Shiwen (Damp-Warmth) is soggy and weak at the yang position, and small and rapid at the yin position. The pulse of Rebing (Heat Disease) is floating at both yin and yang positions; superficially it is slippery, deeply it is scattered and rough. The pulse of Wenbing (Warm Disease) moves through various meridians; one does not know which meridian is affected, so diagnosis should follow the location of the affected meridian.
I (Liu Baozhi) comment: Here, "yin and yang" refer to pulse characteristics. Generally, cun is yang, chǐ is yin; right is yang, left is yin; superficial is yang, deep is yin. Regarding this specific section, it is most appropriate to distinguish yin and yang by the cun and chǠ positions. Wind is a yang pathogen, hence the yang pulse is floating and slippery. Cold evil causes contraction, hence the pulse is tight and rough. Dampness is a yin pathogen that damages yang, hence the yang pulse is soggy and the yin pulse is rapid. Rebing (Heat Disease) is a yang pathogen that damages yin fluids, hence superficially floating and slippery, but deeply scattered and rough. Rebing (Heat Disease) represents Warm Evil that has transformed into heat and is moving outward; prior to heat transformation, it is called Wenbing (Warm Disease). The pathogen lies latent in Shaoyin (Lesser Yin), moves with qi, and circulates through various meridians. It may erupt when meridian qi is deficient, or it may erupt carrying newly acquired external pathogens. Its eruption may exit via the Three Yang channels or emerge from the Lung and Stomach. The most severe cases involve heat failing to exit externally and sinking inward into the Hand and Foot Jueyin (Pericardium/Liver) channels; or Kidney qi being deficient, unable to expel the pathogen, causing it to blaze and knot in Shaoyin. Thus, the movement of Warm Evil follows diverse paths and can erupt anywhere; initially, one cannot specify which meridian will be affected, nor can one rigidly predict the pulse manifestation.
I further comment: Latent Warmth disease erupts along the meridians; this teaching is clear and beyond doubt. However, Zhang Shiwang claimed that Warm Evil eruption must originate from Shaoyang (Lesser Yang). Lu Jiuzhi asserted that Warm-Heat disease must erupt in Yangming (Bright Yang). Chen Pingbo considered the Lung and Stomach as the inevitable sites of Warm Evil attack. Wu Keyou argued that the Mouyuan (Miao Yuan/Sea of Origin) is the residence of latent pathogens in Warm Epidemics. Although each school offers unique insights, they only highlight one aspect of Warm Disease and cannot represent its entirety. Furthermore, Wu Jutong, in his *Wenbing Tiaobian* (Systematic Differentiation of Warm Diseases), horizontally divided the pathology into the Triple Burner (San Jiao), asserting that all Warm Diseases begin in the Upper Burner, specifically the Hand Taiyin Lung channel. Consequently, he categorized contemporary seasonal warm wind patterns as diseases caused by latent qi erupting. This conflation is particularly erroneous. Scholars must carefully study this scriptural passage to firmly understand that Warm Disease eruption follows the meridians, thereby gaining true insight during clinical practice and avoiding misleading interpretations.
In Shanghan, some recover through sweating but die after purgation; others die after sweating but recover after purgation. Why? The answer is: In deficiency of Yang and excess of Yin, sweating leads to recovery, while purgation leads to death. In excess of Yang and deficiency of Yin, sweating leads to death, while purgation leads to recovery.
Slip Shou, in his commentary, cited the *Waitai Miyao* (Essential Prescriptions Worth a Thousand Gold for Emergencies): "Surface disease with harmonious interior constitutes Deficiency of Yang and Excess of Yin." When the pathogen is at the surface, diaphoresis (sweating method) is indicated; if purgation is mistakenly used, it draws the pathogen inward and attacks healthy qi unnecessarily, leading to death. "Interior disease with harmonious surface constitutes Excess of Yang and Deficiency of Yin." When the pathogen has entered the interior, urgent purgation is indicated; if diaphoresis is mistakenly used, it further depletes the surface qi, leading to death. The *Shanghan Li* also contains text stating: "Excess of Yang and Deficiency of Yin: sweating causes death, purgation causes recovery; Deficiency of Yang and Excess of Yin: sweating causes recovery, purgation causes death." Various commentators offer differing explanations. Cheng Wuji noted that Yang pathogen entering the fu organs due to deficiency constitutes Excess of Yang and Deficiency of Yin; pathogen invading Ying and Wei due to surface deficiency constitutes Deficiency of Yang and Excess of Yin. The *Waitai Miyao* and Liu Hejian’s *Shanghan Zhige* defined "non-diseased" as excess and "diseased" as deficiency. The *Huo Ren Shu* defined internal and external heat as Excess of Yang and Deficiency of Yin; internal and external cold as Deficiency of Yang and Excess of Yin. Only Wang Andao in his *Suhui Ji* stated that external Cold Evil indicates Excess of Yin suitable for sweating; internal blazing Heat Evil indicates Excess of Yang suitable for purgation. This explanation is the most sound. The theory that "non-diseased is excess, diseased is deficiency" aligns closely with "surface disease/interior harmony" and "interior disease/surface harmony," yet the terms "excess" and "deficiency" remain semantically imprecise in this context.
I (Liu Baozhi) comment: Upon initial invasion of Cold Evil, before heat transformation, Wei Yang is obstructed, resulting in Deficiency of Yang and Excess of Yin; this is acute Shanghan. Using acrid-warm herbs to assist yang and induce sweating resolves the pathogen. If purgation is applied prematurely before the pathogen enters the fu organs and transforms into heat, the interior qi is damaged and the exterior pathogen sinks inward, leading to death. If the pathogen remains suppressed for a long time and transforms into heat, consuming yin fluids, it results in Excess of Yang and Deficiency of Yin; this is latent Qi Wenbing (Warm Disease). Once interior heat is abundant, urgent purgation is required to preserve yin fluids for survival. If acrid-warm herbs are mistakenly used to induce sweating, yin fluids are further depleted and complications arise rapidly. Therefore, at the onset of illness, the pathogen is always cold, justifying the use of Shanghan as the overarching framework. This section comprises two layers, interpreted by contrasting Shanghan and Wenbing, which is highly appropriate. The previously cited scholarly opinions seem less direct than this explanation.