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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.