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[Outline] Zhang Zhongjing said: On the first day of Shanghan (Cold Damage), the Taiyang channel is affected. If the pulse remains calm, it indicates that the pathogen has not transmitted. If the patient feels a strong urge to vomit, or exhibits restlessness and irritability with a rapid and urgent pulse, it indicates that the pathogen has transmitted.

[Commentary] Zhang Yunqi said: Ou (vomiting with sound) refers to vomiting accompanied by sound; colloquially called "yue". Tu (spitting out/vomiting without sound) refers to expelling the contents of the stomach. Therefore, there is Gan Ou (dry heaving) but no Gan Tu (dry spitting). Thus, for Ou, we say "urge to vomit after eating"; for Tu, we say "food and drink are vomited immediately upon entering the mouth". This shows that Ou and Tu have differences in severity. The Ou caused by Shanghan may be attributed to Heat or Cold. As for Tu, it is entirely due to Deficiency-Cold. The Classics state: "In Taiyin disease, abdominal fullness with vomiting, inability to eat, worsening diarrhea, and spontaneous abdominal pain." It also states: "Deficiency-Cold in the Stomach causes vomiting." From this, the general principle can be understood.

Shen Jin'ao's Note: This passage discusses the initial invasion of Cold pathogen, affecting the Taiyang channel on the first day. On the day of initial invasion, the intention to vomit is already present, indicating a latent mechanism for vomiting and reflux, hence accompanied by symptoms of restlessness and an urgent, rapid pulse. The character "Jiang" (will/soon) implies a state of being about to happen but not yet happened.

[Outline] Zhang Zhongjing said: In Taiyang disease, whether fever has already appeared or not, aversion to cold is inevitable. With body pain, vomiting and reflux, and a tight pulse at both Yin (Cun/Ren) and Yang (Chi) positions, it is named Shanghan (Cold Damage).

[Commentary] Wang Lü said: For patients suffering from vomiting, if the condition is due to rebellious Qi, it must be treated with dispersing methods; if due to Phlegm-Fluids, it must be treated with purging methods. The *Qianjin Fang* states: Patients with vomiting should frequently consume Sheng Jiang (Fresh Ginger Rhizome); this is the sacred medicine for vomiting, intended to disperse rebellious Qi.

The *Jin Gui Yao Lue* further states: Use Ban Xia (Pinellia Tuber) to eliminate Fluids in vomiting patients; once the Fluids are eliminated, vomiting stops. This aims to purge Phlegm-Fluids downward. If vomiting is frequent, even if Yangming syndrome symptoms are present, purgation is contraindicated because the Qi is rebellious and has not yet consolidated into Excess. If vomiting is accompanied by a weak pulse, free urination, slight body heat, and cold extremities, it is difficult to treat, indicating severe Deficiency-Cold.

Pang Anchang said: Although there is a distinction between fever having appeared or not, the presence of aversion to cold, body pain, vomiting, and a tight pulse at both Yin and Yang positions allows one to diagnose Taiyang Shanghan rather than Feng Shang (Wind Strike). Body pain is caused by Cold pathogen binding externally; vomiting and reflux are caused by Cold pathogen invading internally.

[Outline] Zhang Zhongjing said: After six or seven days of Shanghan, with slight fever and aversion to cold, vexing pain in the limbs and joints, slight vomiting, subcostal support and accumulation (Zhi Jie), and unresolving exterior symptoms, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) is the primary treatment.

[Commentary] Shen Jin'ao's Note: This represents a state where interior and exterior symptoms are both mild, indicating the pathogen is about to resolve but has not yet left. Hence, "slight aversion to cold" indicates mild Cold; "vexing pain in limbs/joints" indicates it is not back/waist pain; "slight vomiting" indicates the sign of frequent vomiting; "Zhi Jie" indicates it is not Pi Man (epigastric fullness/stuffiness), but rather heat predominance causing fever and vexation. Therefore, a mild formula is formulated to harmonize the interior and exterior.

[Outline] Zhang Zhongjing said: In patients habitually consuming alcohol, Gui Zhi Tang (Cinnamon Twig Decoction) is contraindicated. Taking it will cause vomiting because alcohol-consumers dislike Sweet flavors. Anyone who vomits after taking Gui Zhi Tang will subsequently vomit pus and blood.

[Commentary] Wei Litong said: Alcohol-consumers presenting with floating pulse and spontaneous sweating resemble Wind damaging the Ying-Wei defense, but it is not actually Wind damaging the Wei. However, alcohol-consumers do exhibit spontaneous sweating and a rapid, large pulse, though not necessarily floating. A floating pulse indicates Wind damaging the Wei. Moreover, alcohol-consumers lack the symptom of aversion to wind. While fever and sweating are common in alcohol-consumers, aversion to wind only occurs after contracting Wind. Thus, Wind strike in alcohol-consumers should be considered the standard case. Therefore, when using Gui Zhi Tang, careful consideration is required for efficacy. If a person with Damp-Heat contracts Wind, although the pulse may be floating, it will likely be soggy and choppy with rapidness, indicating Heat. Although there is stiffness and pain in the head and neck, it will be accompanied by heavy body, vexing pain in bone joints, pulling pain making flexion/extension impossible, and worsened pain upon touch. Although sweating occurs, shortness of breath accompanies it. Although aversion to wind exists, difficulty in urination accompanies it. These symptoms indicate Dampness. Once differentiation is clear, why wait until vomiting to realize the error of taking Gui Zhi Tang? Thus, for Wind strike in Damp-Heat constitutions, Wuling San (Five-Ingredient Poria Powder) methods should be added to Gui Zhi Tang.

Shen Jin'ao's Note: Alcohol-consumers inevitably have Damp-Heat; thus, they vomit upon encountering Sweet flavors, and Gui Zhi Tang is contraindicated. Ke Yunbo suggested using Ge Gen Qin Lian Tang (Kudzu, Scutellaria, and Coptis Decoction) to release the muscle layer, which is correct. The second clause extends from alcohol-consumers to illustrate that all cases of Dampness obstructing the Interior and Heat flooding the Interior strictly prohibit Gui Zhi Tang. Otherwise, Damp-Heat may surge upward, damaging the Yang collaterals, leading to vomiting pus and blood. Old editions placed the clause on vomiting pus and blood before the alcohol-consumer clause, which may lack logical coherence.

[Outline] Zhang Zhongjing said: If a patient with existing Cold syndrome undergoes diaphoresis again, causing Cold in the Stomach, they will inevitably vomit Ascaris (roundworms).

[Commentary] Ke Qin said: "Existing Cold" means the patient had Cold prior to illness. In individuals with Internal Cold who contract external pathogens, the Middle Jiao should be warmed to expel Cold. If diaphoresis is induced, sweat is generated from Grain Qi; as Grain Qi scatters outward, the Yang Qi of the Stomach epigastrium becomes deficient. Without Grain Qi to nourish the Ascaris, they become agitated and move upward, exiting through the mouth. If many Ascaris are vomited and do not stop, death ensues. If Ascaris are vomited and the patient cannot eat, death also ensues.

Shen Jin'ao's Note: Ke Yunbo's argument applies not only to Shanghan but to any condition where Stomach Deficiency causes Ascaris agitation.

[Outline] Zhang Zhongjing said: In concurrent diseases of Taiyang and Yangming, if there is no diarrhea but only vomiting, Ge Gen Jia Ban Xia Tang (Kudzu Decoction with Added Pinellia) is the primary treatment.

[Commentary] Ke Qin said: Concurrent diseases of Taiyang-Yangming, Taiyang-Shaoyang, and Yangming-Shaoyang typically present with spontaneous diarrhea; thus, diarrhea seems inherent to concurrent diseases. Now, without diarrhea but with vomiting, it resembles Shaoyang concurrent disease. Ge Gen Tang with Ban Xia simultaneously resolves the semi-interior pathogen of Shaoyang, so it cannot be classified as concurrent disease of the Three Yang channels.

[Outline] Zhang Zhongjing said: In Shanghan, if the Exterior is unresolved and there is Fluid retention in the Heart (Epigastrium), presenting with dry heaving, fever, and cough, or alternatively thirst, diarrhea, dysphagia/choking sensation, difficulty in urination with hypogastric fullness, or wheezing, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is the primary treatment.

[Commentary] Li Zhongzi said: Ou (vomiting with sound) involves both sound and matter; Tu (spitting out) involves matter without sound; Yue (hiccups/belching) involves sound without matter.

Shen Jin'ao's Note: The dry heaving in this clause is caused by Fluid retention. Since the Fluids have not entered the Stomach, it presents as dry heaving.

[Outline] Zhang Zhongjing said: In Taiyang Wind Strike with diarrhea and vomiting/reflux, if the Exterior is resolved, purgation may proceed. If the patient has continuous sweating occurring at intervals, headache, epigastric stuffiness and hardness, pain radiating to the hypochondrium, dry heaving, shortness of breath, sweating without aversion to cold, this indicates the Exterior is resolved but the Interior is disharmonious. Shi Zao Tang (Ten Date Powder) is the primary treatment.

[Commentary] Pang Anchang said: Regarding this clause and the thirst in Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) cases, the absence of vomiting and thirst indicates no Heat in the Interior. Therefore, the presence of vomiting clearly indicates Heat in the Interior.

Shen Jin'ao's Note: The text mentions "vomiting/reflux" and "dry heaving." Carefully analyzing the tone throughout, it ultimately indicates that the Wind pathogen of the Exterior has resolved, while the Fluids in the Interior are disharmonious.

[Outline] Zhang Zhongjing said: After Shanghan is resolved by sweating, if the Stomach is disharmonious, presenting with epigastric stuffiness and hardness, dry heaving, foul food odor, Fluid retention under the costal region, borborygmus (rumbling in abdomen), and diarrhea, Sheng Jiang Xie Xin Tang (Fresh Ginger Drain the Epigastrium Decoction) is the primary treatment.

[Commentary] Ke Qin said: Yang pathogens residing at the upper opening of the Stomach cause epigastric stuffiness and hardness, dry heaving, and food odor. Water pathogens residing at the lower opening of the Stomach cause borborygmus and diarrhea. Failure of Fire function to circulate leads to stuffiness and hardness; failure of Water function to circulate leads to dry heaving. Pathogenic Heat failing to digest food leads to food odor; Spleen Earth deficiency failing to control Water leads to intestinal rumbling.

[Outline] Zhang Zhongjing said: In Taiyang disease on the second day, if restlessness appears and the back is mistakenly moxibusted/heated to induce profuse sweating, great Heat enters the Stomach, depleting Stomach fluids. Restlessness will lead to delirious speech. After more than ten days, if chills and shaking occur followed by spontaneous diarrhea, this indicates the disease is about to resolve. Consequently, sweating may not occur below the waist, the urge to urinate may be present but unsuccessful, vomiting may occur instead, urge to lose stool may arise, feet may feel aversive to wind, stools may become hard, urination frequency may increase but volume small, and finally, when urine volume increases and stool passes, sudden head pain may occur, and the soles of the feet will feel hot. This is because Grain Qi flows downward.

[Commentary] Lou Ying said: This is a mild case of Fire Reversal. The urge to urinate fails accompanied by vomiting, and the urge to lose stool arises; this does not mean there is no urine, but rather that Body Fluids are in the Upper Jiao and attempting to return to the Stomach area.

[Outline] Zhang Zhongjing said: After inducing sweating, if fluids cannot enter the mouth, it is a reversal pattern. If sweating is induced again, vomiting will not cease.

[Commentary] Ke Qin said: In individuals with excessive Yang, excessive sweating leads to ascending without descending, causing rejection of water and medicine. If mistaken for Wind Strike dry heaving or Shanghan vomiting/reflux and sweating is induced again, vomiting will persist, severely damaging Stomach Qi. This indicates Heat at the Stomach opening, requiring Zhi Zi Tang (Gardenia Decoction).

[Outline] Zhang Zhongjing said: In Wind Strike with fever, if unresolved after six or seven days with restlessness, presenting with Exterior and Interior symptoms, thirst wanting to drink, and vomiting immediately after drinking water, it is named Shui Ni (Water Reversal). Wu Ling San (Five-Ingredient Powder with Poria) is the primary treatment. Drinking plenty of warm water induces sweating and cures the disease.

[Commentary] Zhao Xianke said: Vomiting immediately after drinking water is due to Fluid retention in the Heart (Epigastrium). Due to insufficiency of True Water in the Li (Heart/Fire), the Fire function in Dan Zhong (Chest) fails to circulate. Evil Water condenses internally, rejecting external fluids. It cannot transport outward to the pores, upward to the mouth/tongue, or downward to the Bladder. This is the origin of the name "Water Reversal."

[Outline] Zhang Zhongjing said: In Shanghan originally presenting with spontaneous sweating or diarrhea, if the physician erroneously uses emesis or purgation, causing Cold-Heat Gridlock, where food is vomited immediately upon entering the mouth, Gan Jiang Huang Lian Huang Qin Ren Shen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction) is the primary treatment.

[Commentary] Ke Qin said: A minor treatment error results in mild transformation. The formula uses half the principles of Xie Xin Tang (Drain the Epigastrium Decoction). For Cold Gridlock in the Upper Jiao, Gan Jiang (Dried Ginger) and Ren Shen (Ginseng) are used; for Heat accumulation in the Heart (Epigastrium), Huang Qin (Scutellaria Root) and Huang Lian (Coptis Rhizome) are used. Vomiting patients dislike Sweet flavors, so Gan Cao (Licorice Root) is removed. No vomiting without eating indicates no Fluid retention in the Heart, so Gan Jiang and Ban Xia are omitted. One must know that Cold and Heat blocking each other forms a Ge (Gridlock) syndrome; Cold and Heat knotting together forms a Pi (Stuffiness) syndrome.