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Taiyang disease (Disease of the Taiyang/Bladder channel). There may be fever already, or there may be no fever yet. There will invariably be aversion to cold (aversion to cold), body pain, and vomiting with a sensation of qi rushing upward. If the pulse is tight at both the cun (distal) and chi (proximal) positions on both hands, it is named Shanghan (Cold Damage).

In the previous general discussion of pulses and syndromes, the pulses and syndromes common to Fengzhong (Wind Strike) and Shanghan were already listed together, but it was not yet distinguished which constitutes Fengzhong and which constitutes Shanghan. This chapter, starting from the general pulse and syndrome of "floating pulse, stiffness and pain in the head and neck," adds "fever present or absent," "aversion to cold, headache, vomiting," and the "tightness of the pulse at yin and yang positions" to differentiate these as the pulses and syndromes manifested by Shanghan. Such is the situation. Shanghan refers to cold pathogen damaging the Ying (Nutrient) level. The Ying level resides within the Wei (Defensive) level and belongs to Yin. Cold is originally a Yin pathogen, with a sharp nature, thus penetrating deeply to damage the Ying level. When the cold pathogen enters the Couli (interstices/skin pores), the Xuanfu (pores) become tightly closed, preventing Yang Qi from venting. It is inevitable that stagnation will generate heat. The statement "either fever has already appeared or has not yet appeared" indicates that although the timing of fever onset may vary (early or late), aversion to cold, body pain, and vomiting are invariably present. The term "aversion to cold" is used rather than "aversion to wind" because the focus is on cold damaging the Ying level. Although subsequent texts mention aversion to wind and absence of sweating, this is likely because the Ying and Wei levels are interconnected internally and externally; as the cold pathogen moves from the Wei to the Ying, damage to the Ying implies prior damage to the Wei, hence aversion to wind also occurs. Body pain results from cold damaging the Ying division. Ying Qi is the refined and concentrated Qi within the blood. Blood flows within the vessels, circulating with Ying Qi to nourish the entire body. The *Suwen: Shengqi Tongtian Lun* states, "The sage harmonizes Yin and Yang so that sinews and vessels are peaceful, and Qi and blood follow smoothly." This is because when the cold pathogen enters the blood vessels, Ying Qi becomes sluggish and fails to circulate freely, causing pain throughout the body and joints. Vomiting and upward rushing of Qi result from rebellious Qi. The chest and diaphragm constitute the boundary area of the Taiyang channel; when pathogens reside here, Qi rebels upward causing vomiting.

However, vomiting occurs in various channels. Only vomiting accompanied by aversion to cold, fever, tight pulse, and absence of sweating constitutes the primary syndrome of Taiyang. One must distinguish it based on accompanying syndromes of other channels to clarify the diagnosis. For instance, if vomiting is frequent in Shanghan, even if Yangming syndromes are present, purgation should not be used. This is because the Taiyang exterior syndrome has not resolved, so it still belongs to Taiyang vomiting. If, in Shanghan characterized by fever and absence of sweating, there is vomiting, inability to eat, and profuse sweating, this indicates a transformation into Yangming vomiting. Similarly, desire to vomit after eating belongs to Yangming. Furthermore, vomiting accompanied by alternating chills and fever belongs to Shaoyang, and so forth. A "tight" pulse feels like a twisted rope. The *Maijing* states that the tight pulse resembles the wiry pulse. The *Bianmai Pian* says: "The wiry pulse resembles a bowstring, firm and unyielding upon pressure; the tight pulse resembles a turning rope, shifting constantly." "Tightness at yin and yang positions" means that upon superficial palpation (floating position), the pulse is indeed tight, and upon deep palpation (sinking position), it is also tight. In the case of Fengzhong, the pathogen is Yang, thus only damaging the Yang of the Wei level, resulting in a floating Yang pulse and weak Yin pulse. Here, due to the sharp nature of the cold pathogen penetrating deeply into the Ying level, and moving from Wei to Ying, both Ying and Wei are damaged, resulting in a tight pulse at both yin and yang positions. The *Jingji Jiuyao* states, "All conditions of contraction and pulling due to cold belong to the Kidney." Since the Kidney and Bladder are interior-exteriorly related, cold in the Taiyang channel manifests as a tight pulse. Tightness indicates injury by cold Qi, hence the name Shanghan. However, this is not exclusive to winter; changes in the Six Qi occur in all four seasons, though they are more prevalent in winter. Henceforth, whenever Shanghan is mentioned with the use of Mahuang Tang, it refers to this specific pulse and syndrome pattern. As damaging the Ying level by cold constitutes the second layer, this section is placed as the middle chapter of Taiyang diseases.

[Correction of Errors] Although Cold is one of the Six Qi, it is essentially the storing energy of severe winter cold and desolation. Heaven and Earth's Yang Qi rises in spring, emerging from the earth to generate all things, reaching full flourishing and growth in summer. At its peak, it declines, thus enacting autumn's command to converge and mature. This is called "Western Completion." Once completed, winter energy stores it, serving as the root for next spring's generation. Therefore, the cold energy stored in winter is the righteous energy for the beginning and end of all things in heaven and earth. It must not be injured; injury leads to disease. Why does injury cause immediate illness? By the tenth lunar month, Yin Qi is at its extreme, corresponding to the hexagram Kun (Pure Yin). In the eleventh month, one Yang arises amidst extreme Yin, corresponding to the hexagram Fu (Return), with the image of Kan (Water). One Yang resides between two Yin lines, using cold water as its womb, deeply hidden and firmly nurtured, cultivating the initial Yang—this is what is meant by "Hidden Dragon, do not act." Waiting until it gradually emerges above ground to become the master of generation in East Zhen (Thunder), its hexagram becomes Tai (Peace), marking the time of Lichun (Start of Spring). By the second lunar month, Yang Qi strengthens, rising above ground becoming Wind. From this primordial time, thunder, rain, and wind generate all things, allowing plants to grow vigorously. If the womb of cold water is injured, the stored Yang leaks and depletes. By spring, it cannot flourish freely, causing the Six Qi to be out of season, leading to droughts and floods, and successive famines.

In the human body, the Kidney is the organ of winter. The True Yang of the Mingmen (Gate of Life) resides within the two kidneys, mirroring the image of the Kan hexagram. It is the Yuan Qi (Original Qi) contained within the Great Ultimate. It is the root of generating Qi and the source of the Sanjiao (Triple Burner). One Yang hides within the cold water of the two kidneys, nurtured securely and densely. When Yuan Yang is sufficient, clear Yang Qi rises and ascends, steaming grain Qi to reach the exterior, becoming Wei Qi. It roams the body and distributes via the Sanjiao. If this Fire is damaged, the Sanjiao cannot distribute Yang Qi. Without it in the Upper Jiao, hearing and vision lose clarity; without it in the Middle Jiao, food and drink cannot be transformed; without it in the Lower Jiao, Qi transformation fails, and the openings of the Yin organs are obstructed. Moreover, it cannot steam the pungent, slippery, and rapid grain Qi to defend the skin externally, leading to loose Couli, allowing wind, cold, warmth, and summer-heat pathogens to invade through deficiency. Thus, it is said, "If one is injured by cold in winter, one will suffer from Warm Disease in spring." This refers to injury by cold before the manifestation of disease. "Winter injury by cold" means injuring the root of hibernation and storage governed by the Winter organ. Cold water fails to secure and nurture Yuan Yang, causing the Yang Qi of the Sanjiao, Liver, and Gallbladder to be weak, unable to distribute the spring-like generating Wei Qi. This leaves Couli loose and Xuanfu open, allowing external pathogens to invade and cause Warmth. However, the "Shanghan" discussed in this chapter specifically refers to Zhang Zhongjing's designation of cold pathogen invading Ying and Wei, stagnating in the Couli, preventing Yang Qi from venting, manifesting as aversion to cold and fever—an already manifested Shanghan. Wang Shuhe failed to understand Yin and Yang and did not grasp the profound principles. He did not perceive the teachings of Xuanyuan and Qibo, nor comprehend the mysteries of Zhongjing. He erroneously equated the *Neijing*'s "winter injury by cold" with Zhongjing's "Shanghan," failing to distinguish between pre-disease and post-disease states, or congenital and acquired factors. He cited the *Neijing* to justify the term "Shanghan" in Zhongjing's treatise, yet could not explain why "winter injury by cold" leads to Warm Disease only in spring, nor could he explain the *Relun* passage: "All diseases transforming from Shanghan into Warmth are called Wen if occurring before the Summer Solstice, and Shu if occurring after." How could an acquired cold pathogen remain dormant for half a year or three months before activating? Presumably, upon writing, he must have been greatly frustrated, forcing an explanation: "Those who do not immediately fall ill harbor cold toxicity in the skin and muscles, transforming into Warm Disease in spring and Heat Disease in summer." If cold pathogen could indeed remain peacefully in the skin and muscles for long, would the statement in *Suwen: Yuji Zhenzang Lun*—"When wind and cold invade humans, causing all hair to stand erect and skin pores to close, generating heat"—be false? Since Wang Shuhe's theory,千古 (eternal) confusion began. Unexpectedly, Wang Bing of the Tang Dynasty also failed to notice this error. He cited these sentences under "Winter injury by cold" in the *Suwen: Yin-Yang Yingxiang Lun* as commentary. Consequently, future generations believed this was the original intent of the scripture, unaware it was Wang Shuhe's error. They revered it as inscriptions on bronze tripods and carvings on stone, unhesitatingly believing and frequently citing it as evidence. Whether wise or foolish, few escaped falling into his trap. My exposition on the principles of the Four Qi is detailed in the annotations of *Suwen: Shengqi Tongtian Lun* and *Yin-Yang Yingxiang Lun*. This chapter does not reproduce them fully but briefly mentions one aspect to clarify the ambiguity of the term "Shanghan" and correct eternal errors.

Taiyang disease, characterized by headache, fever, body ache, lower back pain, joint pain, aversion to wind, absence of sweating, and wheezing, is treated primarily with Mahuang Tang.

Although the previous clause provided pulses and syndromes to define the name Shanghan, the symptoms of Shanghan were not fully enumerated. Therefore, this clause supplements various symptoms and provides the primary treatment method. The overlapping information between these two clauses serves to show that the manifestations of Shanghan need not be complete and may vary. Pathogens in the Taiyang channel inevitably cause headache. Although seen in the general syndrome earlier, it is reiterated here. "Body ache, lower back pain, joint pain" clarifies the meaning of "body pain" mentioned previously. The *Zhizheng Dayao Lun* states, "All conditions of contraction and pulling due to cold belong to the Kidney." The waist is the mansion of the Kidney, and bones are governed by the Kidney. The Kidney and Bladder are a zang-fu pair, interior-exteriorly related. The Foot-Taiyang Bladder Channel runs along both sides of the spine. With pathogens in the Taiyang channel, lower back and joint pain occur. Aversion to wind can sometimes be used interchangeably with aversion to cold, but ultimately indicates damage to both Ying and Wei. Why? Wei pathology causes aversion to wind. Ying resides within Wei; if cold has entered Ying, it must have passed through the Wei level. Hence, aversion to wind also occurs. Absence of sweating and wheezing occur because the Lung governs the skin and hair. Cold pathogens in the exterior connect internally to the Lung. Unable to vent, Lung Qi fails to diffuse, causing absence of sweating and wheezing. Cold pathogens cannot be resolved without sweating; thus, Mahuang Tang is used.

Mahuang Tang Formula
Ephedrae Herba (Mahuang, 麻黄) 3 liang, remove nodes
Cinnamomi Ramulus (Guizhi, 桂枝) 2 liang
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) 1 liang
Pruni Semen Armeniacae Amarum (Xingren, 杏仁) 70 seeds, remove skins and tips, grind

These four ingredients. Use 9 sheng of water. First boil Ephedrae Herba, reduce by 2 sheng, remove the foam on top. Add the remaining herbs. Boil to obtain 2.5 sheng. Remove dregs. Take 8 ge warm. Cover to induce a slight sweat. Do not consume porridge. Rest and care follow the method of Guizhi Tang.

Ephedrae Herba has a light and thin flavor, acrid and warm, dispersing. It is the specialized herb for opening the "Ghost Gates" (sweat pores) of the Lung Meridian. Pruni Semen Armeniacae Amarum is bitter and acrid, essential for smoothing Lung Qi. Zhang Zhongjing treats Taiyang Shanghan using herbs entering the Hand-Taiyin Lung Meridian because the Lung governs the skin and hair. Gancao is used because the classics state: "For excess cold, soothe with acrid-hot, assist with bitter-sweet." Among these herbs, only Cinnamomi Ramulus is a muscle-relaxing and exterior-releasing agent, yet it works with Ephedrae Herba to induce sweating from the Ying level. This is because Wei resides outside Ying; cold moves from Wei to Ying, causing tightness at yin and yang pulses. Tightness at the Yang pulse indicates Wei damage; tightness at the Yin pulse indicates Ying damage. To release cold pathogens from within Ying, one must first open the exit in Wei, guiding pathogens from Ying to Wei, resolving through sweating. Li Shizhen stated in the *Bencao Gangmu*: "Ephedrae Herba is the specialized herb of the Lung Meridian, hence often used for Lung diseases." Zhang Zhongjing used Ephedrae Herba for Shanghan with no sweat, and Cinnamomi Ramulus for those with sweat. Past physicians explained this merely by following the text, rarely exploring the essence. Li Shizhen pondered this, finding insight different from predecessors. Body fluids become sweat; sweat is blood. Within Ying, it is blood; exiting Wei, it is sweat. Severe cold damages Ying, causing Ying blood to stagnate internally, unable to communicate externally with Wei. Wei Qi closes and secures, body fluids fail to move, resulting in no sweat, fever, and aversion to cold. Wind damages Wei; Wei Qi receives pathogens, unable to protect Ying internally. Ying Qi becomes weak, body fluids insecure, resulting in sweat, fever, and aversion to wind. However, wind and cold pathogens enter via skin and hair, which are the exterior of the Lung. The Lung governs Wei Qi, encompassing the body, representing Heaven. Although the syndrome belongs to Taiyang, the Lung actually receives the pathogen. Symptoms often include red face, oppression, cough, phlegm, wheezing, and chest fullness—are these not Lung diseases? When skin and hair close externally, pathogenic heat attacks internally, causing Lung Qi stagnation. Thus, Ephedrae Herba and Gancao, assisted by Cinnamomi Ramulus, draw out Ying-level pathogens to the muscle surface. Pruni Semen Armeniacae Amarum assists in draining Lung Qi and promoting movement. Therefore, although Mahuang Tang is a heavy sweating formula for Taiyang, it is实质上 (substantially) a formula for dispersing Fire Stagnation in the Lung Meridian. Binhu (Li Shizhen)'s theory reveals a secret unknown for millennia. Regrettably, predecessors saw Zhongjing use it to induce sweating in Taiyang and assumed it was a Foot-Taiyang herb, viewing Ephedrae Herba as a sweating agent and Cinnamomi Ramulus as a stabilizing-Wei and stopping-sweat agent. If Cinnamomi Ramulus truly stopped sweat, why would Zhongjing use it to assist Ephedrae Herba in inducing sweat? Later practitioners used Ephedrae Herba monitored by Cinnamomi Ramulus, marveling at the moderation, comparing it to controlling six horses with reins, fearing loss of control. Is this logical?

A floating pulse indicates disease in the exterior; sweating may be induced, preferably with Mahuang Tang.

A floating and rapid pulse allows for sweating; preferably with Mahuang Tang.

These two clauses reiterate that floating and floating-rapid pulses can also be treated with sweating, not necessarily requiring a tight pulse. According to pulse methodology, floating indicates Wind, tight indicates Cold. Floating pulse with aversion to wind and spontaneous sweating requires Guizhi Tang. Tight pulse with aversion to cold and absence of sweating requires Mahuang Tang. Using Mahuang Tang for Fengzhong is erroneous sweating; using Guizhi Tang for Shanghan is strictly contraindicated. This clause states that a merely floating pulse allows for sweating with Mahuang Tang. Is this Zhongjing's error? Reasoning logically, although the pulse is floating and rapid without tightness, there must be accompanying symptoms of aversion to cold, body pain, and absence of sweating, justifying Mahuang Tang. A floating and rapid pulse resembles the floating and active-rapid pulse of Taiyang Fengzhong. However, Shanghan with existing fever can also present a floating-rapid pulse. Observing symptoms such as aversion to cold and absence of sweating confirms cold damaging Ying. Since the pulse is floating and rapid, the stagnant heat pathogen remains in the exterior. The classics state, "It can be resolved by sweating." Hence, "Sweating may be induced, preferably with Mahuang Tang."

[Correction of Errors] Cold pathogens in the exterior cause a floating pulse; existing fever causes a rapid pulse. This is the norm. Given the previous mention of tight yin-yang pulses, cold in the exterior can also be floating-tight. To prevent rigid adherence, these two clauses clarify that floating and floating-rapid pulses in Shanghan can also use Mahuang Tang, distinguished by presence or absence of sweat. Commentators, citing Zhongjing's "rapid and urgent pulse indicates transmission," argue that Mahuang Tang is used while the pathogen is about to disperse, scattering the rapidness to prevent transmission. Later scholars further speculated: "While the momentum is transmitting, strike it halfway with Mahuang Tang to drive it out." Logically, such interpretation is unnecessary.

On the first day of Shanghan, the Taiyang channel is affected. If the pulse is quiet, transmission has not occurred. If there is strong desire to vomit, restlessness, irritability, and a rapid-urgent pulse, transmission has occurred.

"First day of Shanghan, Taiyang affected" corresponds to the *Neijing: Relun* concept: "Day 1, Juyang (Taiyang) is affected; Day 2, Yangming is affected." Since Taiyang governs the exterior and commands Ying and Wei, it is affected first. In cold damaging Ying, the pulse is tight at yin and yang, or floating-tight. If after one day the pulse becomes calm and retreating, the pathogen is mild and resolves spontaneously, without transmitting to other channels. If symptoms include strong desire to vomit, the Shanghan vomiting syndrome persists. Vomiting implies pathogen entering the Stomach, a sign of internal invasion. Dry mouth, irritability, fever, and rapid-urgent pulse indicate pathogen has stagnated into heat, Qi is vigorous, and resolution is unlikely, signaling transmission.

On the second or third day of Shanghan, if Yangming and Shaoyang syndromes are absent, transmission has not occurred.

Days 2 and 3 correspond to "Day 2 Yangming affected, Day 3 Shaoyang affected" in the *Relun*. However, Taiyang pathogens do not necessarily transmit to Yangming first, then Shaoyang. They may enter Yangming or Shaoyang directly. By standard progression, Day 2 transmits to Yangming, Day 3 to Shaoyang. If on days 2-3, Yangming and Shaoyang syndromes are absent, the pathogen remains in one channel, hence no transmission.