脉浮紧恶寒，谓之伤寒；脉数寒少热多，谓之温病；脉缓恶风，谓之伤风；脉盛壮热，谓之热病；脉虚身热，谓之
伤暑。医者不可不辨。
凡温病脉，不浮不沉，中按洪长滑数，右手反盛于左手，总由怫热郁滞，脉结于中故也。若左手脉盛，或浮而紧，
自是感冒风寒之病，非温病也。
凡温病脉，怫热在中，多见于肌肉之分，而不甚浮。若热郁少阴，则脉沉伏欲绝，非阴脉也，阳邪闭脉也。
凡伤寒自外之内，从气分入，始病发热恶寒，一二日不作烦渴，脉多浮紧，不传三阴，脉不见沉；温病由内达外，
从血分出，始病不恶寒，而发热，一热即口燥咽干而渴，（杨如候曰∶此论伏气。若外感温病，亦有微恶寒者。）脉多洪
滑，甚则沉伏，此发表清里之所以异也。
凡浮诊中诊，浮大有力，浮长有力，伤寒得此脉，自当发汗，此麻黄、桂枝证也；温病始发，虽有此脉，切不可发
汗，乃白虎、泻心证也。死生关头，全于此分。
凡温病内外有热，其脉沉伏，不洪不数，但指下沉伏而小急，断不可误为虚寒。若以辛温之药治之，反益其热也。
所以伤寒多从脉，温病多从证，盖伤寒风寒外入，循经传也，温病怫热内炽，溢于经也。
凡伤寒始本太阳，发热头痛，而脉反沉者，虽曰太阳，实见少阴之脉，故用四逆汤温之。若温病始发，未尝不发热
头痛，而见脉沉涩而小急，此伏热之毒滞于少阴，不能发出阳分。所以身大热而四肢不热者，此名厥，正杂气怫郁，火邪闭脉而伏也。急以咸寒大苦之味，大清大泻之。断不可误为伤寒太阳始病、反见少阴脉沉而用四逆汤温之。温之则坏
事矣。又不可误为伤寒阳厥、慎不可下而用四逆散和之。和之则病甚也。盖热郁亢闭，阳气不能交接于四肢，故脉沉而
涩，甚至六脉俱绝，此脉厥也；手足厥冷，甚至通身冰凉，此体厥也。即仲景所谓阳厥，厥浅热亦浅、厥深热亦深是也。
下之断不可迟。非见真守定、通权达变者，不足以语此。（吴锡璜曰∶王士雄说∶谓沉细之脉，亦有因热邪闭塞使然，
形症实者，下之可生，未可概以阴脉见而断其必死。凡热邪壅遏，脉多细实迟涩，按证清解，自形滑数，不比内伤病服
凉药而脉加数为虚也。又马元仪谓∶三阳症亦有脉微弱不起者，以邪热抑遏，不得外达，待清其热，则脉自起，勿谓阳
衰脉微也。二公论脉，与栗山前说均合，乃经验日久，确切不易之理解，为医者当切记之。）
凡温病脉，中诊洪长滑数者轻，重则脉沉，甚则闭绝。此辨温病与伤寒脉浮脉沉异治之要诀也。
凡温病脉，洪长滑数兼缓者易治，兼弦者难治。
凡温病脉，沉涩小急，四肢厥逆，通身如冰者危。
凡温病脉，两手闭绝，或一手闭绝者危。
凡温病脉，沉涩而微，状如屋漏者死。
凡温病脉，浮大而散，状若釜沸者死。
按伤寒、温病，必须诊脉施治。有脉与证相应者，则易于识别；若脉与证不相应，却宜审察缓急，或该从脉，或该
从证，务要脉证两得。即如表证脉不浮者，可汗而解；里证脉不沉者，可下而解。以邪气微，不能牵引抑郁正气，故脉
不应。下利脉实，有病愈者，但得证减，复有实脉，乃天年脉也。又脉法之辨，以洪滑者，为阳为实，以微弱者，为阴
为虚，不待问也。然仲景曰∶若脉浮大者，气实血虚也；《内经》曰∶脉大四倍以上，为关格。皆为真虚；陶氏曰∶不
论浮沉大小，但指下无力，重按全无，便是阴脉。此洪滑之未必尽为阳也实也。景岳曰∶其脉如有如无，附骨乃见，沉
微细脱，乃阴阳潜伏闭塞之候；陶氏曰∶凡内外有热，其脉沉伏，不洪不滑，指下沉涩而小急，是为伏热。此微弱之未
必尽为阴也虚也。
脉象浮紧且伴有恶寒症状的，称为伤寒；脉象数而寒冷感少、发热感多的，称为温病；脉象缓弱且伴有恶风症状的，称为伤风；脉象盛大且伴有壮热症状的，称为热病；脉象虚弱且伴有身体发热的，称为伤暑。医生对此不可不加以辨别。
凡是温病的脉象，既不浮也不沉，中取时呈现洪大、长、滑、数的特征，右手脉反而比左手脉盛，这总归是因为怫热（郁结之热）郁滞，脉气结聚于中部所致。如果左手脉盛，或者脉浮而紧，这自然是感冒风寒的疾病，而不是温病。
凡是温病的脉象，怫热郁结在体内，多表现在肌肉层次，而不显得特别浮浅。如果热邪郁结在少阴经，则脉象沉伏欲绝，这并不是真正的阴脉，而是阳邪闭塞脉道所致。
凡是伤寒病，邪气从外部侵入内部，从气分进入，起初发病表现为发热恶寒，一两天内不会出现烦躁口渴，脉象多呈浮紧，不会传入三阴经，脉象也不会出现沉象；温病是由内达外，从血分发出，起初发病不恶寒而发热，一发热就出现口燥咽干而渴。（杨如候说：这是论述伏气温病。如果是外感温病，也有轻微恶寒的情况。）脉象多呈洪滑，严重时甚至沉伏，这就是解表与清里治法不同的原因。
凡是浮诊和中诊，脉象浮大有力、浮长有力，伤寒得到这种脉象，自然应当使用发汗法，这是麻黄汤、桂枝汤的适应证；温病刚开始发作，即使有这种脉象，也千万不可发汗，这是白虎汤、泻心汤的适应证。生死的关头，全在于此处的区分。
凡是温病内外都有热邪，其脉象沉伏，不洪大也不数急，但指下感觉沉伏而小急，绝对不可误认为是虚寒证。如果用辛温的药物来治疗，反而会助长热邪。所以伤寒多依据脉象辨证，温病多依据症状辨证，因为伤寒是风寒从外部侵入，沿着经络传变；温病是怫热在内炽盛，溢出到经络。
凡是伤寒起初本属于太阳病，出现发热头痛，但脉象反而沉的，虽然说是太阳病，实际上显现的是少阴脉，所以用四逆汤来温补。如果温病刚开始发作，未尝不出现发热头痛，但出现脉象沉涩而小急，这是伏热毒邪滞留在少阴经，不能发散到阳分。所以身体大热但四肢不热的，这叫厥证，正是杂气怫郁，火邪闭塞脉道而伏匿所致。必须紧急使用咸寒大苦的药物，进行大清大泻。绝对不可误认为是伤寒太阳初起、反见少阴脉沉而使用四逆汤温补。如果温补就会造成坏证了。又不可误认为是伤寒阳厥，切忌不可用攻下法而用四逆散调和。如果调和则病情加重。这是因为热邪郁结亢盛闭塞，阳气不能交接于四肢，所以脉象沉涩，甚至六脉俱绝，这叫脉厥；手足厥冷，甚至全身冰凉，这叫体厥。这就是张仲景所说的阳厥，厥轻热也轻，厥深热也深的道理。攻下之法决不可迟疑。不是那些见识真切、坚守原则又能通权达变的人，不足以谈论这个问题。（吴锡璜说：王士雄认为：沉细的脉象，也有因热邪闭塞导致的，形体症状实者，攻下可以存活，不可一概以见到阴脉就断定必死。凡是热邪壅遏，脉象多细实迟涩，按照症状清热解表，脉象自然会变为滑数，不像内伤病服用凉药后脉象加快就是虚证。另外马元仪说：三阳症也有脉微弱不起的情况，是因为邪热抑遏，不能外达，等到清除了热邪，脉象自然升起，不要说是阳气衰微脉象微弱。两位先生论脉，与栗山前面的说法都吻合，是经过长久经验积累、确切不易的理解，作为医生应当牢记。）
凡是温病的脉象，中取时洪大滑数的是轻症，重症则脉象沉，极重则脉象闭绝。这是辨别温病与伤寒脉象浮沉不同治法的关键要点。
凡是温病的脉象，洪大滑数兼缓的容易治疗，兼弦脉的难治。
凡是温病的脉象，沉涩小急，四肢厥逆，全身如冰的，病情危重。
凡是温病的脉象，两手脉象闭绝，或一手脉象闭绝的，病情危重。
凡是温病的脉象，沉涩而微，状如屋漏滴水般的，预后不良（死）。
凡是温病的脉象，浮大而散，状若釜中沸水翻滚般的，预后不良（死）。
按：伤寒和温病，必须通过诊脉来施治。有脉象与症状相应的，就容易识别；如果脉象与症状不相应，却应该审察病情的缓急，是该依据脉象还是该依据症状，务必做到脉证兼顾。就像表证脉象不浮的，可以通过发汗解除；里证脉象不沉的，可以通过攻下解除。这是因为邪气微弱，不能牵引抑郁正气，所以脉象不相应。下利病脉象实的，有病愈的，只要症状减轻，复现实脉，那是天年脉（正常寿命之脉）。另外脉法的辨别，以洪滑为阳为实，以微弱为阴为虚，是不言自明的。然而张仲景说：如果脉象浮大，是气实血虚；《内经》说：脉大四倍以上，叫关格。这些都是真虚证；陶氏说：不论脉象浮沉大小，只要指下无力，重按全无，就是阴脉。这说明洪滑未必全是阳证实证。景岳说：其脉如有如无，附骨才可见到，沉微细脱，是阴阳潜伏闭塞的征候；陶氏说：凡是内外有热，其脉沉伏，不洪不滑，指下沉涩而小急，这是伏热。这说明微弱未必全是阴虚证。
Pulse floating and tight with aversion to cold is termed Cold Damage (Shanghan); pulse rapid with less cold sensation and more heat sensation is termed Warm Disease (Wenbing); pulse slow with aversion to wind is termed Wind Injury (Shangfeng); pulse full and vigorous with high fever is termed Heat Disease (Rebing); pulse deficient with body heat is termed Summerheat Injury (Shangshu). Physicians must not fail to distinguish these.
Regarding the pulse of Warm Disease, it is neither floating nor sunken; at medium pressure, it appears surging (Hong), long, slippery, and rapid. The right-hand pulse is often fuller than the left-hand pulse. This is generally due to stifling heat (Fure) stagnating, causing the pulse qi to knot in the middle. If the left-hand pulse is full, or floating and tight, it is naturally a disease of contracting wind-cold, not Warm Disease.
Regarding the pulse of Warm Disease, stifling heat resides internally, mostly manifesting in the muscle layer, without being particularly superficial. If heat stagnates in the Shaoyin channel, the pulse becomes sunken, faint, and nearly imperceptible; this is not a true Yin pulse, but rather Yang pathogenic factors closing off the pulse vessels.
Cold Damage originates from the exterior moving inward, entering through the Qi level. Initially, it presents with fever and aversion to cold, without irritability or thirst within one or two days. The pulse is mostly floating and tight, does not transmit to the Three Yin channels, and the pulse does not appear sunken. Warm Disease originates from the interior reaching the exterior, emerging from the Blood level. Initially, there is no aversion to cold but rather fever; as soon as fever occurs, there is dry mouth and throat with thirst. (Yang Ruhou stated: This discusses latent Qi [Fuqi]. If it is an externally contracted Warm Disease, there may also be slight aversion to cold.) The pulse is mostly surging and slippery, and in severe cases, even sunken. This explains the difference between releasing the exterior and clearing the interior treatments.
When floating and medium palpation reveal a pulse that is large and forceful, or long and forceful, if a patient with Cold Damage has such a pulse, sweating therapy should naturally be employed; this indicates indications for Mahuang Tang (Ephedra Decoction) or Guizhi Tang (Cinnamon Twig Decoction). However, at the onset of Warm Disease, even if such a pulse exists, sweating must absolutely not be used; this indicates indications for Baihu Tang (White Tiger Decoction) or Xiexin Tang (Drain the Epigastrium Decoction). The critical juncture of life and death lies entirely in this distinction.
In Warm Disease, when there is heat both internally and externally, the pulse may be sunken and faint, neither surging nor rapid, but feeling sunken, small, and urgent under the fingers. It must absolutely not be mistaken for deficiency-cold. Using acrid-warm herbs will only exacerbate the heat. Therefore, Cold Damage diagnosis relies more on the pulse, while Warm Disease diagnosis relies more on symptoms. This is because Cold Damage involves wind-cold entering from outside and transmitting along the meridians, whereas Warm Disease involves stifling heat blazing internally and overflowing into the meridians.
If Cold Damage begins in the Taiyang stage with fever and headache, but the pulse is unexpectedly sunken, although it is called Taiyang, it actually reveals a Shaoyin pulse. Thus, Sini Tang (Frigid Extremities Decoction) is used to warm it. If Warm Disease begins with fever and headache, but the pulse is sunken, choppy, small, and urgent, this indicates latent heat toxin stagnating in the Shaoyin channel, unable to emerge into the Yang level. Consequently, the body is very hot while the four limbs are cold; this is termed Jue (Cold Extremities), caused by miscellaneous Qi stagnation and fire pathogen closing the pulse vessels, causing them to hide. One must urgently use salty-cold and bitter-cold substances to clear and purge vigorously. One must absolutely not mistake this for early-stage Taiyang Cold Damage presenting with a sunken Shaoyin pulse and use Sini Tang to warm it. Warming it will lead to disastrous complications. Nor should it be mistaken for Yang Jue in Cold Damage where purgatives are contraindicated and Sini San (Frigid Extremities Powder) is used to harmonize. Harmonizing it will worsen the disease. This is because heat stagnation is hyperactive and closed, preventing Yang Qi from connecting to the four limbs, resulting in a sunken and choppy pulse, or even all six pulses disappearing; this is Pulse Jue. When hands and feet are cold, or even the whole body is ice-cold, this is Body Jue. This corresponds to Zhang Zhongjing's description of Yang Jue: shallow Jue means shallow heat, deep Jue means deep heat. Purgative therapy must not be delayed. Only those with true insight, firm principles, and the ability to adapt flexibly can discuss this matter. (Wu Xihuang said: Wang Shizhong stated: A sunken and fine pulse can also result from heat pathogen blockage. In cases with substantial physical symptoms, purgation can save the patient; one cannot assume death simply upon seeing a Yin pulse. Whenever heat pathogen obstructs, the pulse is often fine, solid, slow, and choppy. Clearing and resolving according to symptoms will naturally make the pulse surging and slippery, unlike internal injury diseases where taking cooling herbs causes the pulse rate to increase indicating deficiency. Additionally, Ma Yuanyi stated: There are also cases in Yangming/Yang channels where the pulse is weak and unarisen, because heat pathogen suppresses it, preventing external release. Once heat is cleared, the pulse rises naturally; do not attribute it to Yang Qi decline and weak pulse. Both gentlemen's discussions on pulse align with Li Shan's previous statements, representing understanding gained from long experience that is accurate and unchangeable. Physicians must remember this well.)
Regarding the pulse of Warm Disease, if medium palpation reveals surging, long, slippery, and rapid qualities, the condition is mild; in severe cases, the pulse is sunken; in extreme cases, the pulse is closed and absent. This is the key principle for distinguishing different treatments based on floating versus sunken pulses in Warm Disease versus Cold Damage.
Regarding the pulse of Warm Disease, if surging, long, slippery, and rapid are accompanied by slow, it is easy to treat; if accompanied by wiry (Xian), it is difficult to treat.
Regarding the pulse of Warm Disease, if sunken, choppy, small, and urgent, with cold extremities and a body like ice, the condition is critical.
Regarding the pulse of Warm Disease, if both hands' pulses are closed/absent, or one hand's pulse is closed/absent, the condition is critical.
Regarding the pulse of Warm Disease, if sunken, choppy, and faint, resembling drops from a leaking roof, the prognosis is fatal.
Regarding the pulse of Warm Disease, if floating, large, and scattered, resembling boiling water in a cauldron, the prognosis is fatal.
Note: For both Cold Damage and Warm Disease, treatment must be administered based on pulse diagnosis. When pulse and symptoms correspond, identification is easy. When they do not correspond, one must examine the urgency, deciding whether to follow the pulse or the symptoms, ensuring both are considered. For example, if exterior syndrome presents without a floating pulse, it can be resolved by sweating; if interior syndrome presents without a sunken pulse, it can be resolved by purgation. This is because the pathogenic factor is weak and cannot restrain the righteous Qi, so the pulse does not correspond. In diarrhea, a solid pulse may indicate recovery; if symptoms subside and a solid pulse returns, it is a natural longevity pulse. Furthermore, regarding pulse differentiation, surging and slippery are Yang and Excess, while weak and faint are Yin and Deficiency, which is self-evident. However, Zhang Zhongjing stated: If the pulse is floating and large, it indicates Qi excess and Blood deficiency. The *Neijing* states: If the pulse is more than four times normal size, it is called Guan-Ge (Obstruction and Repletion). These represent true deficiency. Tao stated: Regardless of floating/sunken or large/small, if the pulse feels powerless under the fingers and vanishes completely upon heavy pressure, it is a Yin pulse. This shows that surging/slipping are not necessarily always Yang/Excess. Jingyue stated: If the pulse seems present yet absent, visible only when pressed to the bone, appearing sunken, faint, fine, and depleted, it is a sign of Yin-Yang lying dormant and blocked. Tao stated: Whenever there is heat internally and externally, if the pulse is sunken and hidden, neither surging nor slippery, but feeling sunken, choppy, small, and urgent under the fingers, it is latent heat. This shows that weak/faint are not necessarily always Yin/Deficiency.