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Pulse is choppy, complexion is white with an expression of sorrow, accompanied by panting and coughing, and epistaxis: this indicates a concurrent dryness in the Lung. Pulse is faint, complexion is black, prone to fear, ear congestion, rebellious Qi leading to diarrhea: this indicates a concurrent cold in the Kidney. Generally, when pathogenic factors emerge outward, they affect the Fu organs and the Exterior; when they enter inward, they affect the Zang organs and the Interior. Regardless of which Zang or Fu organ is involved, Exterior syndromes invariably belong to the Taiyang (Greater Yang) channel, and Interior syndromes invariably belong to the Yangming (Bright Yang) channel. Alas! Treatment methods are not fixed, but diseases have definite characteristics. Understanding this allows one to comprehend the mechanisms of all diseases with a single insight, and why should one doubt that the Hand channels do not receive disease?
The preceding paragraph discusses the primary diseases of the Six Channels.

Exterior syndromes can be treated with sweating, and Interior syndromes with purgation.
Exterior syndromes belong to the Taiyang channel. Whenever headache, fever, aversion to cold, normal bowel and bladder functions, stiffness of the waist, neck, and spine, and a floating-tight pulse are present, it is an Exterior syndrome. Regardless of the number of days since onset, exterior-releasing measures should be taken promptly, and purgative or draining methods should be avoided. Sweating indicates an Exterior deficiency syndrome, suitable for muscle-relieving methods; no sweating indicates an Exterior excess syndrome, suitable for sweating methods. However, sweating methods vary in intensity. The ancients stated that sweating is appropriate in spring and summer, using the seasonal climate as an analogy for yang pathogens being on the exterior. In reality, in spring, yang Qi is still weak; in autumn, yang Qi is about to converge; thus, heavy sweating should be avoided in both seasons. In summer, the weather is hot, and the xuankou (sweat pores) are open, so heavy sweating is unnecessary. In winter, yang Qi is hidden and stored; for mild colds, sweating is particularly inappropriate. Only in severe cases of Shanghan (Cold Damage), when the season is bitterly cold and the skin and hair follicles are tight, can heavy sweating disperse the pathogen; this is a necessary expedient. For Yin syndromes, if there is only cold extremities without sweating, reckless sweating will disturb the meridians and cause death. If there is an exterior pathogen, mild sweating with pungent-warm herbs can disperse it. Interior syndromes initially present with a floating and large pulse, now becoming deep and rapid; initially clear-minded and quiet, now restless and agitated; initially headache, fever, and aversion to cold, now no longer averse to cold but rather averse to heat, with doubled restlessness and irritability, distension and pain extending from the chest to the umbilicus and abdomen, spontaneous sweating in the axillae and palms, leading to dry stomach and hardened stool, constipation, dark and scanty urination, thirst, mania, delirium, throwing off clothes and blankets, flinging hands and legs, and strong pulses in all six positions: this is a transmitted heat syndrome. It is also said that misusing sweating in Yang excess leads to death. If these symptoms appear at the onset of illness, regardless of the duration, prompt purgation is required; failing to purge will lead to obstruction of Qi and blood and result in cold extremities. Furthermore, if the syndrome is purely Exterior with no trace of Interior involvement, do not attack the Interior when treating the Exterior; if it is purely Interior with no trace of Exterior involvement, do not release the Exterior when attacking the Interior. If both Exterior and Interior signs are present, or if Exterior is predominant and Interior is minor, or if Exterior is urgent and Interior is slow, treat the Exterior first and then the Interior. If Interior is predominant and Exterior is minor, or if Interior is urgent and Exterior is slow, attack the Interior first and then rescue the Exterior. Additionally, for Exterior deficiency and Interior excess, use pungent-cool herbs; for Interior deficiency and Exterior excess, use pungent-warm herbs. In both cases, focus on the Interior; once the internal Qi is rectified, the Exterior can be treated. Although addressing the Interior is most urgent, releasing the Exterior cannot be delayed. The distinction between Exterior/Interior and Deficiency/Excess makes medical principles clear.

When Exterior and Interior are equally involved, use emesis and harmonizing methods.
In any illness, whether thirsty or not, whether vexed in the chest or not, whether vomiting or not, whether abdominal or hypochondriac pain exists or not, whether coughing occurs, whether palpitations in the epigastrium are present, or whether urination is difficult, or other various symptoms arise, these are governed by the Shaoyang (Lesser Yang) channel. Pathogens in the Exterior tend to cause cold; pathogens in the Interior tend to cause heat; pathogens in the Half-Exterior/Half-Interior cause alternating chills and fever. Pathogens in the Exterior do not cause fullness in the heart and abdomen; pathogens in the Interior cause fullness in the heart and abdomen; pathogens in the Half-Exterior/Half-Interior cause fullness in the chest and hypochondrium. Pathogens in the Exterior cause groaning and restlessness; pathogens in the Interior cause wild talk and confusion; pathogens in the Half-Exterior/Half-Interior cause a desire to speak but inability to do so. Pathogens in the Exterior result in clear and easy urination; pathogens in the Interior result in turbid and difficult urination; pathogens in the Half-Exterior/Half-Interior may cause diarrhea or normal urination. Pathogens in the Exterior cause no vexation, thirst, or vomiting; pathogens in the Interior cause vexation, fullness, and thirst. Therefore, if vexation or vomiting appears, it indicates the pathogen is transmitting from the Exterior to the Interior. If deafness, hypochondriac pain, alternating chills and fever, vomiting with bitter taste, tight fullness in the chest and hypochondrium, and a string-taut and rapid pulse are observed, it is a Half-Exterior/Half-Interior syndrome. A large pulse with chest fullness and much phlegm, or retention of undigested food, may be treated with emesis. *Baiwen* states: Qi floating in the upper part, blocking the chest and heart, headache with excessive saliva—this is an indication for emesis. *Neijing* states: "Where the pathology is high, induce vomiting to expel it." If the pulse is large but there is no stubborn phlegm, emesis is contraindicated; harmonizing is appropriate. The ancients said spring is suitable for emesis to follow the rising of Yang Qi; autumn and winter are suitable for purgation to follow the converging of Yang Qi inward. This describes the general rule, but treatment must adapt to specific conditions.

Yang syndromes can be treated with cold, and Yin syndromes with warm.
Generally, diseases of the Three Yang channels are Yang syndromes; the Hand Three Yang channels run from head to foot, hence symptoms like headache and body heat. Diseases of the Three Yin channels are Yin syndromes; the Foot Three Yin channels run from foot to abdomen, hence symptoms like abdominal pain and spontaneous diarrhea. However, both Yin and Yang have Exterior and Interior syndromes. Yang syndromes' Exterior and Interior both manifest as heat. Yin syndromes' Exterior stagnation may resemble Yang, but upon entering the Interior, there is a distinction between transmitted disease and direct transmission. Generally, Yang Exterior syndromes present with fever and aversion to cold, normal bowel/bladder function, bright complexion and loud voice, normal nasal respiration, and warm hands and feet. Yang Interior syndromes present with cracked lips and dry tongue, ruddy nails, ease of movement, restlessness and thirst, throwing off clothes, flinging limbs, constipation or hard stools, dark or scanty urine, and a floating, surging, rapid pulse; treat with sweating, emesis, purgation, and harmonizing methods. Yin Exterior syndromes present with no fever but aversion to cold, pale complexion and short voice, cold nasal respiration, and cold extremities. Yin Interior syndromes present with purple lips and curled tongue, cyanotic/black nails, heaviness of body and difficulty moving, no thirst, pulling clothes over oneself, sleeping curled up, diarrhea, clear and profuse urine, and a fine, deep, faint pulse; these are often opposite to Yang syndromes. Yang syndromes develop from bottom to top, so headache appears early; Yin syndromes do not have headache. Yang syndromes transmit from outside, causing stagnation and heat; Yin syndromes have no body heat but instead cold extremities. Yang syndromes involve flinging limbs; Yin syndromes involve sleeping curled up. Yang syndromes have internal heat and thirst; Yin syndromes have no thirst. Yang syndromes have closed bowels and bladder; Yin syndromes have clear and loose bowels and bladder. Abdominal pain and vomiting occur in both, but Yin pulse is deep and faint. Yang syndromes are mostly caused by wind, cold, summerheat, and dampness, originating from the Taiyang channel. Yin syndromes are mostly caused by diet, lifestyle, and emotions, originating from the Shaoyin channel. Thus, it is said that eight or nine out of ten cases of Shanghan involve internal injury; these are the primary diseases of Yin and Yang.

When Yin and Yang reach extremes, following treatment is not an error.
If Yang pathogen is not deep, it cannot cause cold extremities; if Yin pathogen is not severe, it cannot cause restlessness. This is "water extreme resembling fire, fire extreme resembling water," called reverse transformation, meaning extreme exuberance causes harm. Yang syndromes with tidal sweating, constipation, dark urine, fullness, thirst, mania, and delirium, or even petechiae, bleeding, and panting, may suddenly have heat concealed internally due to extreme heat, resulting in cold body and cold extremities, resembling Yin syndromes. However, although the body is cold, the patient does not desire warmth; although confused, the complexion is lustrous; the pulse is deep, slippery, and forceful. This is Yang extreme resembling Yin; treat with Da Chai Hu Tang (Major Bupleurum Decoction) for purgation, or Bai Hu Tang (White Tiger Decoction), or Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction). Yin syndromes with cold extremities, vomiting, and diarrhea, no thirst, quietness, and curling up, or even sore throat and monotonous speech, may suddenly have fire floating externally due to extreme cold, causing restlessness and agitation, resembling Yang syndromes. However, although restless, the patient pulls clothes over their eyes; although mouth is dry and thirsty, they cannot swallow water; the pulse is deep, fine, and weak. This is Yin extreme resembling Yang; treat with Tong Mai Si Ni Tang (Pulse-Restoring Four Reversal Decoction). Following treatment involves counteracting treatment: taking warm medicine cold, cold medicine hot, warm medicine as sovereign with cool ministers, or cool medicine as sovereign with warm ministers. This is not as clearly erroneous as common physicians might think. If a heat disease is cured by warm medicine, it is because too much cold medicine was taken previously; if a cold disease is cured by cold medicine, it is because too much warm medicine was taken previously. Using cold to treat heat and warm to treat cold is called contrary treatment (Ni Zhi). Contrary treatment is actually correct treatment (Zheng Zhi). Who does not know the method of correct treatment?

When neither Exterior nor Interior is involved, do not attack the upper or lower.
Shanghan with headache, chills, and fever is Exterior. Loss of taste, abdominal discomfort, constipation or diarrhea is Interior. If after four or five days, or even thirteen days past the channel cycle, there are neither Exterior nor Interior signs, but slight fever remains, it is deficient heat; treat with Xiao Chai Hu Tang (Minor Bupleurum Decoction) to harmonize. Do not use sweating or emesis to damage the clear Qi of the Upper Jiao; do not use drastic purgation to damage the Stomach Qi of the Lower Jiao. If there is body heat, unclear vision, unresponsive pupils, and hard stool, then Da Chai Hu Tang or Xiao Cheng Qi Tang (Minor Order the Qi Decoction) can be used for purgation. If purgation has already been performed, the pulse is rapid, food is digested quickly, and there is no bowel movement for six or seven days, it is a blood stasis syndrome.

When both Exterior and Interior are present, examine which is less and which is more.
When Exterior and Interior signs coexist, determine their proportion before treating. Floating and large pulse indicates Exterior; vexation, thirst, and red urine indicate Interior; treat with Wu Ling San (Five-Ingredient Powder with Poria). Headache, body heat, and constipation indicate Interior; clear and free urination indicates Exterior; treat with Gui Zhi Tang (Cinnamon Twig Decoction). Chest fullness, loss of appetite, and constipation indicate Interior; aversion to cold and sweating on the head indicate Exterior; treat with Xiao Chai Hu Tang. If Taiyang disease is treated with premature purgation leading to協熱下利 (diarrhea with accompanying heat) and epigastric hardness, it is called unresolved Exterior and Interior; treat with Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction). If premature purgation causes abdominal pain with accumulation, it is called Taiyang-Taiyin syndrome, or Interior transmitting to Exterior; treat with Gui Zhi Jia Shao Yao Tang (Cinnamon Twig Decoction plus Peony Root), adding Da Huang (Rhubarb) for severe cases. If premature purgation causes persistent diarrhea, hurried pulse, panting, and sweating, indicating the Exterior is not resolved, treat with Ge Gen Qin Lian Tang (Kudzu, Scutellaria, and Coptis Decoction). String-taut pulse with chest fullness: treat with Zhi Chi Tang (Gardenia and Fermented Soybean Decoction) via emesis. For predominantly Exterior, use Bai Hu Tang or combine with Xiao Chai Hu Tang. For predominantly Interior, use Wu Ling San or combine with Xiao Chai Hu Tang. For simultaneous urgency of Exterior and Interior, use Fang Feng Tong Sheng San (Saposhnikovia Decoction to Unblock the Whole Body) or Da Chai Hu Tang.

Misusing purgation when sweating is indicated leads to blood stasis, ao nao (restlessness), pi qi (stagnant qi), and jie xiong (chest binding).
For Taiyang syndrome with a floating-tight pulse, sweating is indicated. If sweating fails to resolve it, repeat sweating. If the opportunity to sweat is missed, the cold pathogen transmits through the channels; observe which channel it has entered and what disease has emerged. If sweating is indicated but purgation is mistakenly used, the exterior pathogen sinks inward due to deficiency, heat accumulates in the Interior, and transforms into blood stasis, ao nao, pi qi, jie xiong, and other syndromes.

Misusing sweating when purgation is indicated leads to palpitations, fright, loss of Yang, delirium, and exhaustion of cold extremities.
When Interior signs are complete and the pulse is deep and solid, purgation is indicated. If fever persists and the pulse remains unharmonized after purgation, assess deficiency and excess and purge again if necessary. If purgation is missed, the pathogen has no outlet. If purgation is indicated but sweating is mistakenly used, internal fluids are exhausted, transforming into palpitations and other syndromes.

Contraindications for sweating: all deficiencies, throat ulcers, strangury, bleeding disorders, ruined syndromes, moving Qi, wind-warmth, wind-dampness, and slow pulse.
Sweating is indicated when pulse and signs are entirely in the Exterior. However, if done too early or excessively, fluids are exhausted and complications arise. Contraindications include all deficiency consumptions with dry throat and mouth, sore throat and ulcers, strangury, menstruation just beginning, all hemorrhages, retching/coughing ruined syndromes, moving Qi around the umbilicus (up, down, left, right), wind-warmth, wind-dampness, damp-warmth, slow/fine/choppy pulse, or cold extremities with a tight pulse. These should be harmonized, not sweated. Forcing sweating in mild cases leads to difficult recovery; in severe cases, confusion and dizziness lead to death.

Contraindications for purgation: all deficiencies, throat swelling, vomiting, cold extremities, chest binding, moving Qi, floating/virtual pulse, and Exterior signs.
Purgation is indicated when pulse and signs are entirely in the Interior. However, if done too early or excessively, water and grain are depleted and complications arise. Contraindications include all deficiencies, throat swelling, vomiting, cold extremities, chest binding without passing gas, moving Qi around the umbilicus, fine/virtual/faint/choppy pulse, and Exterior signs like aversion to cold. Purgation here is dangerous; rescue with warm herbs as appropriate.

Yin deficiency with fire and rapid pulse: moxibustion is contraindicated as it consumes Yin.
Yin-Yang dual toxins, Shaoyin syndrome with vomiting and diarrhea, and mouth comfort with back aversion to cold and fine/choppy pulse belong to Yang deficiency and are suitable for moxibustion. Yin deficiency with fire and fine/rapid pulse is unsuitable for moxibustion. External fire aids internal fire; if fire blazes, the lower body becomes severely numb, bones burn, and flesh wastes away. This may lead to seminal emission, tidal cough, and hemoptysis, all caused by fire Qi. *Huo Ren* states: After moxibustion or burning needles, if symptoms resemble fire-pathogen mania, treat with Xiao Chai Hu Tang plus Long Gu (Dragon Bone) and Mu Li (Oyster Shell).

Cold in the diaphragm, cold extremities, and faint pulse: emesis is contraindicated as it causes death.
Cold fluid in the diaphragm with dry retching is a Shaoyin disease; cold extremities indicate Stomach deficiency; faint pulse indicates lower deficiency. Mistaken emesis causes internal vexation and damages Yuan Qi, potentially leading to untreatable conditions. If emesis is indicated but warming is used instead, toxic vapors stagnate in the Stomach, causing mania and other syndromes.

Urgent purgation to save Kidney Water: the opportunity to preserve fluids is critical.
In Shanghan, heat enters the Zang and flows into the Shaoyin channel, scorching the throat, causing dry mouth and thirst, indicating dried-up Kidney Water. In heat diseases, persistent heat with unresponsive eyes also indicates dried-up Kidney Water; both require urgent purgation to save Kidney Water. In Yangming, fever with profuse sweating, or sweating that fails to resolve the condition, abdominal fullness and pain, mania, delirium, and constipation all require urgent purgation to preserve Stomach fluids. In Shanghan, string-taut and slow pulse: taut indicates cold, slow indicates Zang involvement; large and tight pulse: large indicates Yang, tight indicates cold; both are called "Yang containing hidden Yin," requiring urgent purgation to differentiate Yin and Yang. Diarrhea with level pulses in all three positions and hardness under the heart indicates interior excess. Diarrhea with slow and slippery pulse, or large and floating pulse that feels choppy on pressure, with food aversion, indicates retained food in the Stomach. Retained food contraindicates croton seed (Ba Shuang); only Da Huang (Rhubarb) should be used to cleanse.

Urgent warming to harmonize Yang: its anti-emetic effect is significant.
Deep pulse with cold extremities, cold fluid in the diaphragm with dry retching, or occasional headache indicates attacking cold Qi; warm urgently with San Wei Can Yu Tang (Three-Ingredient Ginseng and Cornus Decoction). Extreme internal cold with cold extremities, vomiting, diarrhea, no thirst, quietness, curling up, impending loss of Yang-harmonizing Qi, and imperceptible pulses requires urgent warming with Si Ni Tang (Four Reversal Decoction). "Urgent" means the disease is severe and liable to change, unlike other diseases that can be treated slowly. Other examples: Taiyang non-stop sweating, aversion to wind after sweating, restlessness after sweating, palpitations and body pain—all require urgent addition of Fu Zi (Aconite) to Gui Zhi Tang (Cinnamon Twig Decoction) and Shao Yao (Peony Root). For Three Yang slow pulse and abdominal pain, Jian Zhong Tang (Build the Middle Decoction) should be applied first. Take one dose, stop when the disease is addressed; this applies to all Shanghan medicines.

After the channel cycle (unresolved), sweating and purgation should be mild.
Shanghan transmits through the channels in six days; it should resolve on the seventh day. If it continues beyond thirteen days without resolution, it is called "passing the channel." Improper sweating or purgation leaves pathogenic factors lingering, causing confusion, delirium, chest fullness, and tidal thirst. Adjust according to Exterior/Interior signs, possibly repeating mild sweating or purgation. Chaotic pulse with restlessness and sunken寸关尺 (cun, guan, chi) positions indicate danger. Slow pulse with peaceful sleep indicates residual pathogen and unrecovered Zheng Qi; treat with Shen Hu Shao Yao Tang (Ginseng, Bupleurum, and Peony Decoction). Diarrhea with harmonious pulse indicates previous purgation with pill medicine leaving residual heat. Qi deficiency after passing the channel, or mixed pathogenic factors, should be viewed alongside ruined syndromes.

Slow Chi pulse: temporary tonification is acceptable.
Slow and weak cun and chi pulses indicate blood deficiency. Regardless of initial wind-cold or miscellaneous diseases, sweating, emesis, and purgation are contraindicated. First use Xiao Jian Zhong Tang (Minor Build the Middle Decoction) or Huang Qi Jian Zhong Tang (Astragalus Build the Middle Decoction) to restore the pulse. If constitutionally robust, Xiao Chai Hu Tang is also good. Wait until the pulse is no longer slow before proceeding with treatment.

Formulas for releasing Exterior, attacking Interior, and warming Interior: the meaning of supporting Yang, assisting Yin, and suppressing Yin.
Here, Yin and Yang refer to Interior and Exterior. Disease represents deficiency; health represents excess. Exterior disease with Interior harmony means pathogen exits outward, resulting in Yang deficiency and Yin excess. Thus, releasing Exterior does not avoid heat, using pungent-sweet agents to support Yang. Interior disease with Exterior harmony means pathogen enters inward, resulting in Yin deficiency and Yang excess. Thus, attacking Interior does not avoid cold, using sour-bitter drugs to support Yin. If Yin channels directly receive cold pathogen, it is a Zang disease receiving Yin, with Yang Qi about to collapse; urgently use pungent-hot drugs to restore Yang and suppress Yin. Thus it is said: "Gui Zhi entering the throat, Yang excess leads to death; Cheng Qi entering the stomach, Yin excess leads to demise." Exaggerating excess and depleting deficiency, damaging the insufficient and benefiting the surplus—is killing by the physician. This is the key to sweating and purgation.

Methods value balance; insufficiency is better than excess.
Methods refer to sweating, emesis, purgation, warming, and harmonizing, each varying. Sweating includes heavy sweating to release Exterior and mild sweating to relieve muscles, distinguishing severity. Purgation includes urgent purgation, small doses, mild harmonizing, and draining, clarifying turbidity. Warming includes combined tonification. Emesis includes inducing vomiting and probing/guiding, or merely relieving fullness without daring to vomit. Harmonizing is singular. Some say Shanghan has no tonification method, as heat gains strength with tonification and requires further purgation, causing double distress; however, deficiency vexation, Interior cold, and Yin syndromes are exceptions. Balancing means the five methods hit the mark precisely; excess means rash advancement by crude practitioners; insufficiency means cautious slowness by intermediate practitioners. For Shanghan sweating/purgation drugs, stop after one dose if effective; do not finish the decoction, differing from miscellaneous diseases. Shanghan involves only sweating, emesis, and purgation; if used correctly, transmission is prevented. Success depends entirely on the physician's acuity and judgment.

Syndromes may seem similar yet be different; ignorance warrants abstaining from treatment.
When the Shanghan diagnosis is undecided, one may not know if wind-dampness, labor, phlegm, or food retention are concurrent. Similarity masking difference requires careful differentiation; thus, if unsure, it is better not to treat. Ban Gu said: "Not treating a disease yields a middle-class physician." One mistaken herb brings regret too late. Alas! Ancients used medicine to save lives from plague; today, medicine is used to sustain life. Sustaining life is good, but mistaking someone for death is akin to robbery! Be cautious! Be cautious!
The preceding paragraph discusses methods for Exterior/Interior, Yin/Yang, sweating, emesis, purgation, warming, and harmonizing.