此一卷论切脉。治伤寒先须识脉。若不识脉。则表里不分。虚实不辨。仲景犹诮当时之士。按寸
不及尺。握手不及足。必欲诊冲阳。按太溪而后慊。况于寸关尺耶。大抵问而知之以观其外。切而知
之以察其内。证之与脉不可偏废。且如伤寒脉紧。伤风脉缓。热病脉盛。中暑脉虚。人迎紧盛伤于寒。
气口紧盛伤于食。率以脉别之。非特此也。病患心下紧满。按之石硬而痛者。结胸也。结胸证于法当
下。虽三尺之童皆知。用大黄甘遂陷胸汤下之。然仲景云。结胸脉浮者。不可下。下之则死。以此推
之。若只凭外证。便用陷胸汤则误矣。况伤寒尤要辨表里。脉浮为在表。脉沉为在里。阳动则有汗。
阴动则发热。得汗而脉静者生。汗已而脉躁者死。阴病阳脉则不成。阳病阴脉则不永。生死吉凶。如
合龟镜。其微至于祸福休咎。修短贵贱。无不可考。然古人乃以切脉为下者。特以脉理精微。其体难
辨。而伤寒得外证为多故也。外证易见。切脉难明。弦紧之混淆。迟缓之参差。沉与伏相类。濡与弱
相似。非得之于心。超然领解。孰能校疑似于锱铢者哉。苟知浮芤滑实弦紧洪属于表。迟缓微涩沉伏
濡弱属于里。表里内外。阴阳消息。以经处之。亦过半矣。
（帝曰。气口何以独为五脏主。岐伯曰。胃者水谷之海。六腑之大源也。五味入口。藏于胃以养
五气。气口亦太阴也。是以五脏六腑之气味。皆出于胃。变见于气口。右手关前一分。气口之位）
\r气口脉\pt51a7.bmp\r
\r人迎脉\pt51a8.bmp\r
人迎在颈法象天地要会始终之门户。（人迎属太阴肺之经。而黄帝乃云。人迎亦胃脉何也。左手
关前一分者人迎之位。挟喉咙两旁者人迎之穴。人迎之位属手太阴肺之经。人迎之穴属足阳明胃之经。
故素问云人迎亦胃脉也）
\r太溪脉\pt51a9.bmp\r
伤寒何以须诊太溪脉耶。答曰。太溪穴是足少阴肾之经。男子以右肾为命门。女子以左肾为命门。
（三十六难曰命门者神精所舍。原气所系。男子藏精。女子以胞）主生死之要。病患有命门脉者活。
无者死。仲景云。少阴病手足逆冷发热者。不死。脉不至者灸太溪七壮。故伤寒必诊太溪以察其肾之
盛衰也。（太溪二穴。在足内踝后跟骨上动脉陷中）
\r冲阳脉\pt51a10.bmp\r
伤寒何以须诊冲阳脉耶。答曰。冲阳穴是足阳明胃之经。人受气于谷。谷入于胃。乃传与五脏六
腑。脏腑皆受气于胃。其清者为营。浊者为卫。营行脉中。卫行脉外。阴阳相贯。如环无端。胃为水
谷之海。主禀四时。皆以胃气为本。是谓四时之变病。死生之要会。故伤寒必诊冲阳。以察其胃之有
无也。（冲阳二穴。一名会源。在足跗上五寸骨间动脉上去陷骨三寸）
\r风池穴\pt51a11.bmp\r
\r风府穴\pt51a12.bmp\r
仲景云。太阳病初服桂枝汤。反烦不解者。先刺风池风府。却与桂枝汤。（正一）愈。谓服桂枝
汤后。其证尚自汗发热恶寒。脉尚寸浮尺弱而反烦。为邪痹在阳维经。故可先针风池。（风池二穴。
是足少阳阳维之会。在项后发际陷中。是穴。甲乙经云。风池穴在HT 后发际陷者。中是穴。针入一
寸一分）风府。（风府一穴。是督脉阳维之会。在项后入发际一寸。大筋穴中。不可灸。针入四分
留三呼）此二穴阳维之会。非太阳经也。太阳经穴在挟项后发际大筋外廉陷中。名曰天柱。不针此
者。桂枝已主太阳病故也。
\r期门穴\pt51a13.bmp\r
期门穴。在乳直下筋骨近腹处是也。凡妇人病。法当针期门。不用行子午法。恐缠脏膜引气上。
但下针令病患吸五吸。停针良久。徐徐出针。此是平泻法也。凡针期门。必泻勿补。可肥人二寸。瘦
人寸半深。
\r关元穴\pt51a14.bmp\r
脐下一寸五分。名气海。二寸名丹田。三寸名关元。关元穴。是小肠募足少阴任脉之会。针入八
分。留三呼泻五吸。灸亦良。然不及针。（气海穴。或作脐下一寸。按针灸经云。脐下一寸曰阴交穴。
阴交下五分曰气海）
（七）问三部之位
左右手去鱼一寸名曰寸口。去泽一尺名曰尺部。两境之间。名为关位。关位六分。阳部出三分。
阴部入三分。关前为阳。关后为阴。为阴阳之关津。寸脉下不至关为阳绝。尺脉上不至关为阴绝。阳
得寸内九分。取阳奇之数。阴得尺内一寸。取阴耦之数。是名寸关尺也。寸上一分为鱼际。关下一分
为神门。左关为人迎。右关为气口。三阳从地长。故男子尺脉常沉。三阴从天生。故女子尺脉常浮。
男子阳多而阴少。其脉在关
上。故寸盛而尺弱。女子阴盛而阳微。其脉在关下。故寸沉而尺盛。所以男子不可以久泻。女子不可
以久吐。男得女脉为不足。女得男脉为太过。所谓反也。（今人以男子尺脉常弱。女子尺脉常盛谓之
反。非也。男子阳有余。脉在上。尺脉必弱。女子阴有余。脉在下。寸脉必微。乃是正也。非反也。又
以男子以右尺为命门。女子以左尺为命门。谓之反亦非也。男子得阴以生。先生右肾。女子得阳以长。
先生左肾。乃是正也。非反也。所谓反者。只是男子尺脉当弱今反盛。女子尺脉应盛今反弱。谓之反耳）
圣人以察阴阳以决生死。虽经络流注。如环无端。岂能逃于三部者耶。
（八）问诊候之法
凡初下指。先以中指揣按得关位。乃齐下前后二指为三部脉。前指寸口也。后指尺部也。若人臂
长乃疏下指。若臂短乃密下指。先诊寸口。（男先左手。女先右手）浮按消息之。次。中按消息之。
次。重按消息之。次。上竟消息之。次。下竟消息之。次。推指外消息之。次。推指内消息之。（医
家责肥人脉浮为肌肉浓实。重取乃得。若举手而得。则其浮也甚矣。责瘦人脉沉为皮脉相附而易见。若
按之始应。则其沉也亦甚矣）凡诊脉以气息平定。方下指。以一呼一吸为一息。其一息之间。脉息
四至。或五至。不大不小。与所部分四时相应者。为平和脉也。过则为至。不及则为损。损至之脉。
难经言之详矣。（所属部分。谓心位洪。肺位浮。肾位沉。肝位弦。脾位缓也。四时谓春脉弦。夏脉
洪。四季脉缓。秋脉浮。冬脉沉也。假令心脉本位虽当见洪。得冬脉须微带沉下。是四时相应。余皆
仿此）
（九）问脉息之证
脉之字。从肉从HT 。又作HT 。盖脉以肉为阳。HT 以血为阴。华佗云。脉者气血之先也。气血盛则
脉盛。气血衰则脉衰。气血热则脉数。气血寒则脉迟。气血微则脉弱。气血平则脉缓。又长人脉长。
短人脉短。性急则脉急。性缓则脉缓。反此者逆。按内经云。形盛脉细。气少不足以息者危。形瘦脉
大。胸中气多者死。形气相得
者生。参伍不调者病。难经云。数者腑也。迟者脏也。数则为热。迟则为寒。诸阳为热。诸阴为寒。
王叔和云。脉沉为在里。脉浮为在表。迟则在脏。数则在腑。滑为实为下。数为虚为热。张仲景云。
脉大浮数动滑。此名阳也。脉沉涩弱弦微。此名阴也。阴病见阳脉者生。阳病见阴脉者死。大抵阳脉
常浮而速。阴脉常沉而迟。七表属腑。病在于阳。春夏见之易治。八里属脏。病在于阴。秋冬见之犹
轻。假令数在左寸。浮之得者热入小肠。沉之得者热入于心。余皆仿此。脉理精微。非言可尽。论其
梗概。不出于此矣。王叔和云。在心易了。指下难明。亦在乎人熟之而已矣。
（十）问七表
七表阳也。阳数奇。浮。按之不足。举之有余。（寸口浮。其人伤风。发热头疼。关上浮腹满。
尺中浮小便难。趺阳浮即为虚）芤。浮大而软。按之中央空两边实。（芤主失血。寸口芤主吐血。
微芤者衄。关上芤。大便血。尺中芤。小便血）滑。往来前却流利。替替然与数相似。（脉滑为阳。
寸口滑为阳盛。关上滑为呕逆。尺中滑小便赤。妇人经脉不利。然而尺脉滑者。亦本形也。趺阳脉滑
者。胃气实）实。脉大而长。按之隐指。 然。浮沉皆得。（寸口实。主上焦热。关上见之腹胀。
尺中有此。主小腹痛。并小便涩）弦。举之无有。按之如弓弦状。又曰。浮紧乃为弦。状如弓弦。
按之不移。（阳弦则头痛。阴弦则腹痛。大抵伤寒脉须弦。盖人迎紧盛伤于寒。人迎者少阳之分。少
阳脉主弦故也。寒邪中人。其脉必弦。弦则多兼洪数。为其先有邪热也。洪数甚者。正为阳证。若沉
细而弦疾。乃正阴证也）紧。按之实。数似切绳状。（紧则为寒。寸口紧头痛。关紧心中满痛。尺
紧脐下痛。阴阳俱紧。当清邪中于上。浊邪中于下）洪。极大在指下。举按满指。（寸口洪主胸膈
烦热。关洪主胃热口干。尺中洪。主大小便血。三部洪。三焦俱热）
（十一）问八里
八里。阴也。阴数耦。微。若有若无。极细而软。（微则为虚。寸口微为阳不足。阳微则恶寒。
阴微则下利）沉。举之不足。按之有余。（沉为在里。尺寸俱沉者少阴
受病也。然沉而迟者。乃阴证也。宜温之。沉而数者有热也。宜下之）缓。去来亦迟。小快于迟。
（缓则为虚。太阳病。其脉缓者为伤风。惟脾得之即是本形）涩。细而迟。往来难。时一止。（涩
则少血。寸口涩少气。上焦冷。关上涩胃冷脾痛。尺中涩小便数。小腹冷。三部俱涩。腹中气结。王
冰曰。阳有余则血少。故脉涩也。又曰。涩者阳气有余。阳气有余为身热无汗）迟。呼吸三至。去
来极迟。（迟则为寒。寸口迟则上焦冷。关上迟胃冷不欲食。吞酸吐水。尺中迟。小便多。并白浊）
伏。极重按之。指着骨乃得。（伏主物聚。寸口伏胸中逆气。关上伏有水气。溏泄。尺中伏。水谷不
化。大抵关前得之多为热。关后得之多为冷。关中得之阴阳结。或冷或热不定。当以余证参之）濡。
按之似无。举之全无力。（形与缓涩迟脉虽稍殊。其为冷证皆一也）弱极软而沉细。按之欲绝指下。
（弱为虚。寸口弱。阳气虚。汗自出。关弱无胃气。胃中有热。脉弱为虚热病作。不可大攻。热去寒
起。尺中弱。气少发热也）
（十二）问脉按之来缓。时一止复来。又脉来动而中止。不能自还。因而复动。
有结脉。有促脉。有代脉。结者。阴也。阴盛则结。脉来缓时一止复来曰结。主胸满烦躁。促者。
阳也。阳盛则促。脉来数时一止复来。曰促。主积聚气痞。忧思所成。太阳病。下之后。脉促胸满
者。桂枝去芍药汤主之。（正方七）若微寒桂枝去芍药加附子汤主之。（正八）太阳病桂枝证医反下
之。利遂不止。脉促者。表未解也。喘而汗出者。葛根黄芩黄连汤主之（正二十八）大抵结促之
脉。虽时一止为病脉。非死脉也。惟代脉者。真死矣。往来缓。动而中止。不能自还。因而复动。名
曰代也。代者。死也。仲景伤寒。脉结代。心动悸。炙甘草汤主之。（正五十六）
这一卷论述切脉。治疗伤寒必须先懂得诊脉。如果不识脉象，就无法分辨表里，无法辨别虚实。张仲景曾讥笑当时的医生，诊脉时只按寸部而不按尺部，只握手部而不按足部，一定要诊察冲阳穴和太溪穴的脉象，心里才感到满足，更何况是寸、关、尺三部呢？大抵通过问诊来观察外在表现，通过切脉来探查内在情况，证候与脉象不可偏废。例如，伤寒脉象紧，伤风脉象缓，热病脉象盛，中暑脉象虚。人迎脉紧盛是感受寒邪，气口脉紧盛是饮食积滞，大致都可以通过脉象来区别，不仅仅是这些情况。病人心下部位拘急胀满，按压像石头一样硬且疼痛的，是结胸证。结胸证依法应当用攻下法，即使是三岁孩童也知道这一点，使用大黄甘遂陷胸汤攻下它。然而张仲景说，结胸证如果脉象浮的，不可用攻下法，用了就会死亡。由此推断，如果只凭外在证候就使用陷胸汤，那就错了。况且伤寒尤其要辨别表里，脉浮表示病在表，脉沉表示病在里。阳气发动则出汗，阴气发动则发热。出汗后脉象平静的会生，出汗后脉象躁动的会死。阴病出现阳脉则病情难愈，阳病出现阴脉则寿命不长。生死吉凶，如同龟镜占卜一样准确。其细微之处至于祸福休咎、寿命长短贵贱，没有不可以考证的。然而古人把切脉看作低下的医术，只是因为脉理精微，脉体难以辨别，而且伤寒病外在证候较多的缘故。外证容易看见，切脉难以明了。弦脉与紧脉混淆，迟脉与缓脉参差，沉脉与伏脉相似，濡脉与弱脉相像，如果不是内心领悟，超然理解，谁能毫厘之间校正疑似之脉呢？如果知道浮、芤、滑、实、弦、紧、洪属于表，迟、缓、微、涩、沉、伏、濡、弱属于里，表里内外，阴阳消长，以经脉理论来处理，也就掌握了一半了。
（黄帝问：气口脉为什么独能作为五脏的主宰？岐伯答：胃是水谷之海，六腑的大源头。五味入口，藏于胃中以滋养五气。气口也属于太阴经。因此五脏六腑的气味，都出于胃，变化显现于气口。右手关前一分的位置，就是气口脉的位置。）
[图片：气口脉]
[图片：人迎脉]
人迎脉位于颈部，是效法天地、汇聚始终的关键门户。（人迎脉属于手太阴肺经，但黄帝却说人迎也是胃脉，为什么呢？左手关前一分是人迎脉的位置，挟持喉咙两旁的人迎穴，人迎脉位属于手太阴肺经，人迎穴位属于足阳明胃经，所以《素问》说人迎也是胃脉。）
[图片：太溪脉]
治疗伤寒为什么必须诊察太溪脉呢？回答说：太溪穴是足少阴肾经的穴位。男子以右肾为命门，女子以左肾为命门。（《难经·三十六难》说：命门是神精所居舍，原气所系连的地方。男子藏精，女子通过胞宫孕育。）这是主宰生死的关键。患有命门脉象存在的就能活，没有的就死。张仲景说，少阴病手足逆冷发热的，不会死；脉象摸不到的，灸太溪穴七壮。所以治疗伤寒必须诊察太溪脉以观察肾脏的盛衰情况。（太溪穴有两个，位于足内踝后方跟骨上方的动脉凹陷中。）
[图片：冲阳脉]
治疗伤寒为什么必须诊察冲阳脉呢？回答说：冲阳穴是足阳明胃经的穴位。人从谷物中获取气，谷物进入胃中，然后传送给五脏六腑。脏腑都接受胃的气血，其中清轻的部分成为营气，浑浊的部分成为卫气。营气行于脉中，卫气行于脉外，阴阳相互贯通，如圆环一样没有尽头。胃是水谷之海，主顺应四时变化，都以胃气为本，这叫做四时变病的规律，是生死的关键所在。所以治疗伤寒必须诊察冲阳脉，以观察胃气的有无。（冲阳穴有两个，又名会源，位于足背上方五寸骨间动脉处，距离陷骨三寸。）
[图片：风池穴]
[图片：风府穴]
张仲景说，太阳病初服桂枝汤后，反而出现烦闷不解的情况，先针刺风池、风府穴，然后再给予桂枝汤。（正方第七）即可痊愈。意思是服用桂枝汤后，症状仍然是自汗、发热、恶寒，脉象仍然是寸浮尺弱，却反而感到烦闷，这是因为邪气痹阻在阳维经，所以可以先针刺风池穴。（风池穴有两个，是足少阳经与阳维脉的交会穴，位于项后发际处的凹陷中。此穴，《甲乙经》说在风府穴后发际凹陷处，即为此穴，进针一寸一分。）风府穴。（风府穴有一个，是督脉与阳维脉的交会穴，位于项后入发际一寸，大筋中间的穴位，不可艾灸，进针四分，留针三次呼吸的时间。）这两个穴位是阳维脉的交会穴，不属于太阳经。太阳经的穴位在挟持项后发际大筋外侧的凹陷中，名叫天柱穴。不针刺这个穴位的原因，是因为桂枝汤已经主治太阳病了。
[图片：期门穴]
期门穴，位于乳头直下，肋骨近腹部的位置。凡是妇女患病，依法应当针刺期门穴，不使用子午流注补泻手法，恐怕缠绕脏膜引气上行。只需下针让病患吸气五次，停针很久，慢慢出针。这是平泻法。凡是针刺期门穴，必须用泻法不可用补法，胖人可以深刺二寸，瘦人深刺一寸半。
[图片：关元穴]
脐下一寸五分，名叫气海穴；两寸名叫丹田；三寸名叫关元穴。关元穴，是小肠募穴，也是足少阴肾经与任脉的交会穴。进针八分，留针三次呼吸的时间，泻法配合吸气五次。艾灸也很好，但不如针刺。（气海穴，有的说是脐下一寸。按《针灸经》说，脐下一寸叫阴交穴，阴交穴下五分叫气海穴。）
（七）问三部脉的位置
左右手距离大鱼际一寸的地方名叫寸口，距离鱼际一尺的地方名叫尺部，两处境界之间，名叫关位。关位宽六分，阳部向外延伸三分，阴部向内深入三分。关前为阳，关后为阴，这是阴阳的关津。寸脉向下不到关位叫阳绝，尺脉向上不到关位叫阴绝。阳脉得寸内九分，取阳奇之数；阴脉得尺内一寸，取阴偶之数，这就叫寸、关、尺。寸上一分为鱼际，关下一分为神门。左关为人迎，右关为气口。三阳经之气从地生长，所以男子的尺脉常沉；三阴经之气从天生成，所以女子的尺脉常浮。男子阳气多而阴气少，其脉象在关之上，所以寸脉盛而尺脉弱；女子阴气盛而阳气微弱，其脉象在关之下，所以寸脉沉而尺脉盛。因此男子不可以久泻，女子不可以久吐。男子出现女脉（尺盛寸弱）为不足，女子出现男脉（寸盛尺弱）为太过，这叫做反脉。（现在人们认为男子尺脉常弱、女子尺脉常盛叫做反脉，这是不对的。男子阳气有余，脉象在上，尺脉必然弱；女子阴气有余，脉象在下，寸脉必然微弱，这才是正常的，不是反脉。又有人认为男子以右尺为命门，女子以左尺为命门，称之为反脉也不对。男子得阴气而生，先生右肾；女子得阳气而长，先生左肾，这也是正常的，不是反脉。所谓反脉，只是指男子尺脉应当弱现在反而盛，女子尺脉应当盛现在反而弱，这才叫做反脉。）圣人通过诊察阴阳来决定生死，虽然经络流注如圆环一样没有尽头，难道能逃脱三部脉的范畴吗？
（八）问问诊候的方法
凡是用手指初次接触脉搏，先用中指揣按找到关位，然后齐着放下前后两个手指作为三部脉。前面的手指是寸口，后面的手指是尺部。如果人的手臂长就疏开手指放置，如果手臂短就紧密放置手指。先诊察寸口脉。（男子先诊左手，女子先诊右手）轻取以观察脉象，接着中取以观察脉象，接着重取以观察脉象，接着向上推至尽处以观察脉象，接着向下推至尽处以观察脉象，接着向外推以观察脉象，接着向内推以观察脉象。（医家指责肥人脉浮是因为肌肉浓密坚实，重按才能触及，如果举手轻按就能得到，那么这种浮脉就非常严重了；指责瘦人脉沉是因为皮肉紧贴容易看见，如果按下去才有反应，那么这种沉脉也非常严重了）凡诊脉要以气息平稳安定之后，才下指。以一呼一吸为一息，在这一息之间，脉跳四次或五次，不大不小，与所属部位和四时相应合的，称为平和脉。超过这个次数就是至脉，不够就是损脉。损脉和至脉，《难经》说得非常详细了。（所属部位，是指心位见洪脉，肺位见浮脉，肾位见沉脉，肝位见弦脉，脾位见缓脉。四时是指春脉弦，夏脉洪，四季末月脉缓，秋脉浮，冬脉沉。假如心脉本位应当见洪脉，但在冬季必须微带沉象，这就是四时相应，其余都仿照这个原则。）
（九）问脉息的证候
“脉”字，由“肉”和“血”组成。又写作“脈”。大概脉以肉为阳，血为阴。华佗说：脉是气血的先兆。气血盛则脉盛，气血衰则脉衰，气血热则脉数，气血寒则脉迟，气血微弱则脉弱，气血平和则脉缓。另外，身材高的人脉长，身材矮的人脉短，性情急躁则脉急，性情舒缓则脉缓。与此相反的则为逆证。按《内经》说，形体盛壮但脉细，气少不足以喘息的，危险；形体消瘦但脉大，胸中气多的，死亡；形气相得的，生；脉律参差不齐不调匀的，病。《难经》说：数脉属腑，迟脉属脏。数则为热，迟则为寒。诸阳脉为热，诸阴脉为寒。王叔和说：脉沉表示病在里，脉浮表示病在表。迟则在脏，数则在腑。滑脉为实为下部病变，数脉为虚为热。张仲景说：脉大、浮、数、动、滑，这名叫阳脉；脉沉、涩、弱、弦、微，这名叫阴脉。阴病见到阳脉者生，阳病见到阴脉者死。大抵阳脉常浮而快，阴脉常沉而慢。七表脉属腑，病在于阳，春夏见到容易治疗；八里脉属脏，病在于阴，秋冬见到还算轻微。假如数脉在左寸，轻取得到的，是热邪侵入小肠，重取得到的，是热邪侵入心脏，其余都仿照这个原则。脉理精微，不是言语可以穷尽的，论述其大概，不出于此了。王叔和说：在心很容易明白，在指下却难以明了，这也在于人熟练罢了。
（十）问七表脉
七表脉属阳。阳数为奇数。
浮脉：按之不足，举之有余。（寸口脉浮，其人伤风，发热头痛；关上脉浮，腹满；尺中脉浮，小便困难；趺阳脉浮即为虚证。）
芤脉：浮大而软，按之中央空两边实。（芤脉主失血，寸口芤主吐血，微芤者鼻衄；关上芤，大便出血；尺中芤，小便出血。）
滑脉：往来流利，替替然与数脉相似。（脉滑为阳，寸口滑为阳盛，关上滑为呕逆，尺中滑小便赤色，妇人经脉不利。然而尺脉滑者，也是正常形态。趺阳脉滑者，胃气实。）
实脉：脉大而长，按之隐指，坚实有力，浮沉皆可得。（寸口实，主上焦热；关上见此，腹胀；尺中有此，主小腹痛，并小便涩。）
弦脉：举之无有，按之如弓弦状。又说，浮紧才算是弦，状如弓弦，按之不移。（阳弦则头痛，阴弦则腹痛。大抵伤寒脉须弦，盖因寒邪伤人，人迎脉紧盛，人迎属少阳之分，少阳脉主弦，故寒邪中人，其脉必弦。弦脉多兼洪数，因为先前有邪热。洪数严重的，正是阳证；若沉细而弦疾，乃是正阴证。）
紧脉：按之实，数似切绳状。（紧则为寒，寸口紧头痛，关紧心中满痛，尺紧脐下痛。阴阳俱紧，当是清邪中于上，浊邪中于下。）
洪脉：极大在指下，举按满指。（寸口洪主胸膈烦热，关洪主胃热口干，尺中洪主大小便血，三部洪，三焦俱热。）
（十一）问八里脉
八里脉属阴。阴数为偶数。
微脉：若有若无，极细而软。（微则为虚，寸口微为阳不足，阳微则恶寒，阴微则下利。）
沉脉：举之不足，按之有余。（沉为在里，尺寸俱沉者少阴受病。然而沉而迟者，乃阴证，宜温之；沉而数者有热，宜下之。）
缓脉：去来亦迟，稍快于迟脉。（缓则为虚，太阳病，其脉缓者为伤风，只有脾脏得到缓脉即是本形。）
涩脉：细而迟，往来困难，时有一止。（涩则少血，寸口涩少气，上焦冷；关上涩胃冷脾痛；尺中涩小便频数，小腹冷；三部俱涩，腹中气结。王冰说：阳有余则血少，故脉涩。又说：涩者阳气有余，阳气有余表现为身热无汗。）
迟脉：呼吸三至，去来极迟。（迟则为寒，寸口迟则上焦冷，关上迟胃冷不欲食，吞酸吐水；尺中迟，小便多，并白浊。）
伏脉：极重按之，指着骨头才得到。（伏主物聚，寸口伏胸中逆气，关上伏有水气，溏泄；尺中伏，水谷不化。大抵关前得之多为热，关后得之多为冷，关中得之阴阳结，或冷或热不定，应当以其他证候参照判断。）
濡脉：按之似无，举之全无力。（形状与缓、涩、迟脉虽稍有不同，但它们都是冷证。）
弱脉：极软而沉细，按之欲绝于指下。（弱为虚，寸口弱，阳气虚，汗自出；关弱无胃气，胃中有热；脉弱为虚热病发作，不可大攻，否则热去寒起；尺中弱，气少发热。）
（十二）问脉按之来缓，时一止复来，又有脉来动而中止，不能自还，因而复动。
有结脉，有促脉，有代脉。
结脉：属阴。阴盛则结。脉来缓，时一止复来，叫作结脉。主胸满烦躁。
促脉：属阳。阳盛则促。脉来数，时一止复来，叫作促脉。主积聚气痞，忧思所成。太阳病，下之后，脉促胸满者，用桂枝去芍药汤主治。（正方第七）如果有轻微恶寒，用桂枝去芍药加附子汤主治。（正方第八）太阳病桂枝证，医生反而用下法，利遂不止，脉促者，表未解也，喘而汗出者，用葛根黄芩黄连汤主治（正方第二十八）。大抵结、促之脉，虽然时一止为病脉，但不是死脉。
惟代脉者，真是死脉。往来缓，动而中止，不能自还，因而复动，名叫代脉。代者，死也。张仲景治伤寒，脉结代，心动悸，用炙甘草汤主治。（正方第五十六）
This volume discusses pulse palpation. In treating cold damage (Shanghan), one must first understand the pulse. If one does not understand the pulse, one cannot distinguish between exterior and interior, nor differentiate between deficiency and excess. Zhang Zhongjing once mocked physicians of his time for palpating only the cun position without reaching the chi position, and holding the wrist without reaching the foot. They insisted on diagnosing the Chongyang and Taixi pulses to feel satisfied; how much more so for the cun, guan, and chi positions? Generally, inquiry observes the exterior, while palpation examines the interior. Both syndrome differentiation and pulse diagnosis are indispensable. For instance, in cold damage, the pulse is tight; in wind injury, the pulse is slow and relaxed; in heat disease, the pulse is vigorous; in summerheat stroke, the pulse is empty. A Renying pulse that is tight and full indicates cold pathogen invasion; a Qikou pulse that is tight and full indicates food retention. These can generally be distinguished by the pulse, not just these cases alone. If a patient has tightness and fullness below the heart, which feels hard as stone and painful upon pressure, this is Jie Xiong (Chest Binding Syndrome). According to the law, Jie Xiong should be treated with purgation; even a three-year-old child knows this, using Dahuang Gansui Xianxiong Tang to purge it. However, Zhang Zhongjing stated: if the pulse in Jie Xiong is floating, purgation is contraindicated; applying it will lead to death. From this, we deduce that relying solely on external syndromes to use Xianxiong Tang would be an error. Moreover, distinguishing exterior and interior is crucial in cold damage. A floating pulse indicates the exterior; a deep pulse indicates the interior. When Yang moves, there is sweating; when Yin moves, there is fever. Survival is indicated if the pulse becomes calm after sweating; death is indicated if the pulse remains restless after sweating. If a Yin disease presents with a Yang pulse, recovery is unlikely; if a Yang disease presents with a Yin pulse, longevity is compromised. Life and death, auspiciousness and misfortune, are as certain as divination with a tortoise shell or mirror. Its subtleties extend to fortune, misfortune, good and bad omens, lifespan length, and social status, all of which can be verified. Yet ancients considered pulse diagnosis a lower art because pulse theory is subtle and difficult to discern, and cold damage often presents with many external signs. External signs are easy to see, but pulse diagnosis is hard to clarify. Confusion between wiry and tight pulses, discrepancies between slow and relaxed pulses, similarity between deep and hidden pulses, and resemblance between soft and weak pulses—unless one understands them intuitively and comprehends them transcendentally, who can distinguish such similarities with precision? If one knows that floating, knotted, slippery, solid, wiry, tight, and flooding pulses belong to the exterior, while slow, relaxed, faint, choppy, deep, hidden, soft, and weak pulses belong to the interior, and applies meridian theory to analyze the changes of interior/exterior and Yin/Yang, one has mastered half of the knowledge.
(Huangdi asked: Why does the Qikou pulse alone serve as the master of the five Zang organs? Qibo answered: The Stomach is the sea of water and grain, the great source of the six Fu organs. Flavors enter the mouth and are stored in the Stomach to nourish the five Qi. The Qikou also belongs to the Taiyin Meridian. Therefore, the Qi and flavor of the five Zang and six Fu organs all originate from the Stomach and manifest at the Qikou. The position one-fen anterior to the Guan on the right hand is the location of the Qikou pulse.)
[Image: Qikou Pulse]
[Image: Renying Pulse]
The Renying pulse is located in the neck, serving as a gateway that models Heaven and Earth and gathers the beginning and end. (The Renying pulse belongs to the Hand Taiyin Lung Meridian, yet Huangdi said the Renying is also a Stomach pulse. Why? The position one-fen anterior to the Guan on the left hand is the location of the Renying pulse. The Renying acupoint, located beside the throat, belongs to the Foot Yangming Stomach Meridian, whereas the Renying pulse position belongs to the Hand Taiyin Lung Meridian. Thus, Suwen states that the Renying is also a Stomach pulse.)
[Image: Taixi Pulse]
Why must the Taixi pulse be diagnosed in cold damage? The answer is: Taixi is an acupoint of the Foot Shaoyin Kidney Meridian. In men, the right kidney is the Mingmen (Gate of Life); in women, the left kidney is the Mingmen. (Nanjing Chapter 36 states: The Mingmen is where spirit and essence reside, and where Yuan Qi is connected. Men store essence; women conceive via the Bao Palace.) It is the key to life and death. Patients with a palpable Mingmen pulse survive; those without it die. Zhang Zhongjing said: In Shaoyin disease, if hands and feet are cold but there is fever, death is avoided; if the pulse is unobtainable, moxa seven moxibustion cones on Taixi. Therefore, in cold damage, one must diagnose the Taixi pulse to observe the flourishing or declining state of the Kidneys. (There are two Taixi acupoints, located in the depression of the arterial pulse posterior to the medial malleolus and superior to the calcaneus.)
[Image: Chongyang Pulse]
Why must the Chongyang pulse be diagnosed in cold damage? The answer is: Chongyang is an acupoint of the Foot Yangming Stomach Meridian. Humans derive Qi from grain. Grain enters the Stomach and is transmitted to the five Zang and six Fu organs. All organs receive Qi from the Stomach. The clear part becomes Ying (Nutritive) Qi, and the turbid part becomes Wei (Defensive) Qi. Ying Qi circulates within the vessels, and Wei Qi circulates outside the vessels. Yin and Yang interpenetrate like a circle without end. The Stomach is the sea of water and grain, governing adaptation to the four seasons, with Stomach Qi as the foundation. This is called the variation of diseases according to the four seasons, the key meeting point of life and death. Thus, in cold damage, one must diagnose the Chongyang pulse to observe the presence or absence of Stomach Qi. (There are two Chongyang acupoints, also known as Huiyuan, located on the dorsum of the foot, five cun proximal to the web margin, in the depression of the arterial pulse between the bones, three cun distal to the ankle bone.)
[Image: Fengchi Acupoint]
[Image: Fengfu Acupoint]
Zhang Zhongjing said: In Taiyang disease, if Gui Zhi Tang fails to resolve symptoms and causes irritability, first puncture Fengchi and Fengfu, then administer Gui Zhi Tang again (Correct Formula 7). This means after taking Gui Zhi Tang, if symptoms such as spontaneous sweating, fever, aversion to cold persist, and the pulse remains floating at cun and weak at chi, accompanied by irritability, it indicates pathogenic obstruction in the Yangwei Vessel. Therefore, one can first needle Fengchi. (There are two Fengchi acupoints, intersections of the Foot Shaoyang Gallbladder Meridian and the Yangwei Vessel, located in the depression behind the nape at the hairline. As per Jiayi Jing, Fengchi is in the depression posterior to Fengfu at the hairline. Needle depth: 1.1 cun.) Fengfu. (There is one Fengfu acupoint, intersection of the Du Vessel and Yangwei Vessel, located one cun above the hairline at the nape, in the depression between large tendons. Moxibustion is contraindicated. Needle depth: 0.4 cun; retain for three breaths.) These two acupoints are intersections of the Yangwei Vessel, not belonging to the Taiyang Meridian. The Taiyang Meridian acupoint is located in the depression lateral to the large tendons at the nape, named Tianzhu. We do not needle this point because Gui Zhi Tang already treats Taiyang disease.
[Image: Qimen Acupoint]
Qimen is located directly below the nipple, near the ribs close to the abdomen. For female patients, according to the method, one should needle Qimen without using the Zi-Wu flow method, to avoid entangling organ membranes and drawing Qi upward. Simply insert the needle and have the patient inhale five times, retain the needle for a long time, and withdraw slowly. This is the Ping-Xie (Level Reducing) method. When needling Qimen, always reduce, never tonify. For obese individuals, needle 2 cun deep; for thin individuals, 1.5 cun deep.
[Image: Guanyuan Acupoint]
One cun five fen below the umbilicus is named Qihai; two cun is named Dantian; three cun is named Guanyuan. Guanyuan is the Mu-Alarm point of the Small Intestine and an intersection of the Foot Shaoyin Kidney Meridian and the Ren Vessel. Needle depth: 0.8 cun; retain for three breaths; reduce by having the patient inhale five times. Moxibustion is also effective, but needling is superior. (Qihai is sometimes described as one cun below the umbilicus. According to Zhenjiu Jing, one cun below the umbilicus is Yinjiao; five fen below Yinjiao is Qihai.)
(Seven) Inquiry into the Positions of the Three Sections
One cun distal to the Thenar Eminence on both hands is called Cun Kou (Radial Pulse). One chi distal is called Chi Bu (Distal Section). The area between these two boundaries is called Guan Wei (Guan Position). The Guan position is six fen wide; the Yang section extends three fen outward, and the Yin section extends three fen inward. Anterior to Guan is Yang; posterior to Guan is Yin. This is the pass between Yin and Yang. If the Cun pulse does not reach Guan, it is Yang Extinction. If the Chi pulse does not reach Guan, it is Yin Extinction. Yang obtains nine fen within Cun, taking the odd number of Yang. Yin obtains one cun within Chi, taking the even number of Yin. This is called Cun, Guan, and Chi. One fen above Cun is Yu Ji; one fen below Guan is Shen Men. Left Guan is Renying; Right Guan is Qikou. The three Yang meridians grow from the earth; thus, the Chi pulse in men is usually deep. The three Yin meridians are born from heaven; thus, the Chi pulse in women is usually floating. Men have abundant Yang and deficient Yin; their pulse is above Guan; therefore, Cun is strong and Chi is weak. Women have abundant Yin and deficient Yang; their pulse is below Guan; therefore, Cun is deep and Chi is strong. Hence, men should not undergo prolonged purgation, and women should not undergo prolonged emesis. If a man presents with a woman's pulse (strong Chi, weak Cun), it indicates insufficiency. If a woman presents with a man's pulse (strong Cun, weak Chi), it indicates excess. This is called a "Reverse" pulse. (Currently, people consider a weak Chi pulse in men and a strong Chi pulse in women as "reverse," which is incorrect. Men have surplus Yang, so the pulse is upper; Chi must be weak. Women have surplus Yin, so the pulse is lower; Cun must be weak. This is normal, not reverse. Also, considering the right Chi as Mingmen in men and left Chi as Mingmen in women as "reverse" is incorrect. Men are born from Yin, developing the right kidney first; women grow from Yang, developing the left kidney first. This is normal, not reverse. The term "reverse" specifically refers to a man whose Chi pulse should be weak but is actually strong, or a woman whose Chi pulse should be strong but is actually weak.) Sages examine Yin and Yang to determine life and death. Although meridians circulate endlessly like a circle, can they escape the scope of the three sections?
(Eight) Inquiry into Pulse Diagnosis Methods
When initially placing fingers, first use the middle finger to locate the Guan position, then place the index and ring fingers simultaneously for the three sections. The front finger is Cun Kou; the rear finger is Chi Bu. If the arm is long, space the fingers widely; if short, place them closely. Diagnose Cun Kou first. (For men, start with the left hand; for women, start with the right hand.) Lightly press to observe, then moderately press, then heavily press. Then push upwards to the limit, downwards to the limit, laterally outward, and laterally inward. (Physicians criticize floating pulses in obese patients as due to thick muscle requiring heavy pressure; if obtained lightly, the floating is severe. They criticize deep pulses in thin patients as skin adhering to vessels making them visible; if only felt upon pressure, the deepness is severe.) Always diagnose when respiration is calm. One exhalation and inhalation constitute one Xi (breath cycle). Within one Xi, the pulse beats four or five times, neither too large nor too small, corresponding to the organ position and season, is called a Harmonious Pulse. Exceeding this is Zhi (Excessive); falling short is Sun (Deficient). Nanjing details Sun and Zhi pulses extensively. (Organ positions refer to Heart-Hong, Lung-Floating, Kidney-Deep, Liver-Wiry, Spleen-Slow. Seasons refer to Spring-Wiry, Summer-Hong, Late Summer-Slow, Autumn-Floating, Winter-Deep. For example, although the Heart pulse should be Hong, in winter it must slightly show Deep qualities to correspond to the season. Others follow this principle.)
(Nine) Inquiry into Pulse Syndromes
The character "Mai" (Pulse) consists of "Rou" (Flesh/Yang) and "Xue" (Blood/Yin). Hua Tuo said: The pulse is the precursor of Qi and Blood. Abundant Qi and Blood mean a vigorous pulse; deficient mean weak; hot mean rapid; cold mean slow; minute mean weak; balanced mean slow and regular. Tall people have long pulses; short people have short pulses. Impatient temperaments have urgent pulses; patient ones have relaxed pulses. Deviations are adverse. Nei Jing states: Vigorous body with fine pulse, insufficient Qi to breathe—dangerous. Emaciated body with large pulse, excessive Qi in chest—death. Matching form and Qi—survival. Irregular pulse—disease. Nanjing states: Rapid pulses belong to Fu organs; slow to Zang organs. Rapid indicates Heat; Slow indicates Cold. All Yang pulses indicate Heat; all Yin pulses indicate Cold. Wang Shuhe said: Deep pulse indicates Interior; Floating indicates Exterior. Slow indicates Zang; Rapid indicates Fu. Slippery indicates Excess or Lower pathology; Rapid indicates Deficiency or Heat. Zhang Zhongjing said: Large, Floating, Rapid, Moving, Slippery are Yang pulses. Deep, Choppy, Weak, Wiry, Faint are Yin pulses. Yin disease with Yang pulse—survival; Yang disease with Yin pulse—death. Generally, Yang pulses are Floating and Fast; Yin pulses are Deep and Slow. Seven Tables belong to Fu, disease in Yang; seen in Spring/Summer, easier to treat. Eight Li belong to Zang, disease in Yin; seen in Autumn/Winter, still mild. For example, if a Rapid pulse is at Left Cun: obtained by light pressure, Heat enters Small Intestine; obtained by heavy pressure, Heat enters Heart. Others follow this. Pulse theory is subtle and cannot be fully expressed in words. The general principles are summarized here. Wang Shuhe said: Easy to understand in mind, hard to clarify under fingers. It depends on practice.
(Ten) Inquiry into the Seven Tables (Yang Pulses)
Seven Tables are Yang. Yang numbers are odd.
Floating (Fu): Insufficient on pressure, abundant on lifting. (Cun Floating: Wind injury, fever, headache. Guan Floating: Abdominal fullness. Chi Floating: Difficulty urinating. Duzi Floating: Deficiency.)
Knotted (Kou): Floating, large, and soft; empty in center, solid on sides. (Indicates blood loss. Cun Kou: Hematemesis. Slight Kou: Epistaxis. Guan Kou: Hematochezia. Chi Kou: Hematuria.)
Slippery (Hua): Smooth and fluent, resembling Rapid. (Yang pulse. Cun Hua: Yang excess. Guan Hua: Vomiting/reversal. Chi Hua: Dark urine, irregular menstruation in women. Note: Chi Hua can be normal constitution. Duzi Hua: Stomach Qi excess.)
Solid (Shi): Large and long, firm on pressure, obtainable in floating and deep. (Cun Shi: Upper Jiao Heat. Guan Shi: Abdominal distension. Chi Shi: Lower abdominal pain, dysuria.)
Wiry (Xian): Not felt on lifting, felt like a bowstring on pressure. Also, Floating-Tight is Wiry. (Yang Xian: Headache. Yin Xian: Abdominal pain. Generally, cold damage pulses are Wiry because Cold invades, causing Renying Tightness. Shaoyang governs Wiry. Cold invasion makes pulse Wiry, often combined with Hong/Rapid due to pre-existing Heat. Severe Hong/Rapid indicates Yang syndrome; Deep/Fine/Wiry-Rapid indicates Yin syndrome.)
Tight (Jin): Firm on pressure, resembling cut rope. (Indicates Cold. Cun Jin: Headache. Guan Jin: Chest/epigastric fullness/pain. Chi Jin: Umbilical pain. Both Yin/Yang Tight: Clear pathogen attacks upper, Turbid attacks lower.)
Flooding (Hong): Very large under fingers, filling the finger on lift and press. (Cun Hong: Chest/diaphragm irritability/heat. Guan Hong: Stomach Heat, dry mouth. Chi Hong: Hematochezia/Hematuria. All three sections Hong: Triple Burner Heat.)
(Eleven) Inquiry into the Eight Li (Yin Pulses)
Eight Li are Yin. Yin numbers are even.
Faint (Wei): As if present or absent, extremely fine and soft. (Indicates Deficiency. Cun Wei: Yang insufficiency, aversion to cold. Yin Wei: Diarrhea.)
Deep (Chen): Insufficient on lifting, abundant on pressing. (Indicates Interior. Both Cun/Chi Deep: Shaoyin disease. Deep-Slow: Yin syndrome, warm it. Deep-Rapid: Heat, purge it.)
Relaxed (Huan): Similar to Slow, slightly faster. (Indicates Deficiency. Taiyang disease with Huan pulse: Wind injury. Only Spleen presenting Huan is its natural state.)
Choppy (Se): Fine, slow, difficult movement, occasional stop. (Indicates blood deficiency. Cun Se: Qi deficiency, upper cold. Guan Se: Stomach cold, spleen pain. Chi Se: Frequent urination, lower cold. All three Se: Qi knot in abdomen. Wang Bing: Yang excess leads to blood deficiency, hence Se pulse. Also: Se indicates Yang excess, manifesting as body heat and no sweat.)
Slow (Chi): Three beats per breath cycle, very slow. (Indicates Cold. Cun Chi: Upper cold. Guan Chi: Stomach cold, anorexia, acid regurgitation. Chi Chi: Polyuria, white turbidity.)
Hidden (Fu): Obtained only with extreme pressure, touching bone. (Indicates accumulation. Cun Fu: Rebellious Qi in chest. Guan Fu: Water retention, loose stools. Chi Fu: Indigestion. Generally, Guan anterior Fu: Heat; Guan posterior Fu: Cold; Guan middle Fu: Yin-Yang knot, variable cold/heat, consult other symptoms.)
Soft (Ru): Absent on pressure, powerless on lifting. (Shape differs slightly from Huan/Se/Chi, but all indicate Cold.)
Weak (Ruo): Extremely soft, deep, and fine, almost imperceptible. (Indicates Deficiency. Cun Ruo: Yang deficiency, spontaneous sweating. Guan Ruo: No Stomach Qi, stomach heat. Weak pulse indicates deficieny-heat flare-up; do not purge heavily, or heat leaves and cold arises. Chi Ruo: Qi deficiency with fever.)
(Twelve) Inquiry into Intermittent Pulses
If the pulse comes slowly and stops occasionally before returning, or if it moves and stops, cannot return immediately, then moves again:
There are Jie (Knotted), Cu (Rapid-intermittent), and Dai (Intermittent) pulses.
Jie: Yin. Yin excess causes Jie. Pulse is slow with occasional stops. Indicates chest fullness and irritability.
Cu: Yang. Yang excess causes Cu. Pulse is rapid with occasional stops. Indicates accumulations, Qi痞 (fullness), caused by worry/thought. In Taiyang disease, after purgation, if Cu pulse and chest fullness occur, use Gui Zhi Qu Shao Yao Tang (Correct Formula 7). If slight chills occur, use Gui Zhi Qu Shao Yao Jia Fu Zi Tang (Correct Formula 8). In Taiyang Gui Zhi syndrome, if mistakenly purged leading to persistent diarrhea, Cu pulse indicates unresolved exterior. With wheezing and sweating, use Ge Gen Huang Qin Huang Lian Tang (Correct Formula 28). Generally, Jie and Cu are pathological but not fatal.
Dai is truly fatal. Pulse is slow, stops, cannot return immediately, then resumes. Dai means death. Zhang Zhongjing treats cold damage with Jie/Dai pulse and palpitations with Zhi Gan Cao Tang (Correct Formula 56).