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When diagnosing Shanghan (Cold Damage), to determine whether the pathogenic factor is transmitting or not, first observe the eyes and tongue, then ask the patient if there is pain or distension in the chest. If there is no pain or fullness in the chest, it indicates that the pathogen remains at the exterior (Biao). If there is distension and the patient has not undergone purgation, this is a Shaoyang syndrome (Half-Exterior Half-Interior syndrome). If purgation has already been performed and chest pain is severe, it is feared that Jie Xiong (Chest Binding) may have formed. Thus, the chest can indicate whether the pathogen is transmitting.

The abdomen belongs to the Extreme Yin. Within Interior syndromes, one can distinguish between Excess and Deficiency by examining the abdomen. After clarifying the chest condition, press the abdomen with the hand. If there is no pain or distension upon pressing, it indicates the pathogen has not entered the interior; once inside, it must cause pain and distension. How could the abdomen be painful and distended if the pathogen is at the exterior or half-exterior half-interior? If abdominal distension does not decrease and internal pain persists, this is an Excess Interior syndrome, and purgation may be applied. If abdominal distension decreases intermittently and pain is lingering, the Interior syndrome is not yet Excess, and only clearing methods should be used. If there is direct attack abdominal pain, it did not transmit from the Yang meridians; this is cold qi residing internally, with a deep and slow pulse, requiring urgent warming treatment.

The lower abdomen belongs to Yin within Yin, the deepest part of the Interior, indicating whether the pathogen has become solidified. After assessing the chest and abdomen, press the lower abdomen. Since the lower abdomen stores waste, when the pathogen reaches here, it must solidify. If the lower abdomen is not hard and painful, it is not an Interior Excess syndrome. If the pathogen has entered the interior, the lower abdomen must be hard and painful. If the lower abdomen is hard and painful with free urination and black stool, this is Blood Stasis Syndrome (Xu Xue Zheng), treatable with Tao Ren Cheng Qi Tang (Peach Kernel Decoction for Bowel Purging). If there is hard and painful sensation around the umbilicus with frequent and scanty urination, this is Dry Feces Syndrome, treatable with Da Cheng Qi Tang (Major Order the Qi Decoction). If the lower abdomen is distended but stool is normal, it may be due to difficult and obstructed urination, treatable by promoting urination.

In general diagnosis, first observe the complexion and form, then examine the ears, eyes, mouth, nose, lips, tongue, and body, then inquire about the chest, abdomen, and lower abdomen, thereby understanding the disease pattern and condition.

Shanghan (Cold Damage) is the proper disease caused by contracting cold during winter. Lei Shanghan (Shanghan-like diseases) are similar to Shanghan but essentially different. People often see fever and immediately say it is Shanghan, rashly using diaphoretic (sweating) methods. If the exterior pathogen is not expelled, they follow with harmonizing or cooling methods. Some recover immediately because the treatment matches the syndrome; some do not recover because it does not match; some survive by chance despite being critical. All these result from unclear differentiation at the beginning of treatment. For every disease, there is a specific syndrome. Mistreatment at the beginning turns mild cases into severe ones, and severe ones into critical ones. Even if life is spared by chance, it hangs by a thread, which is terrifying. Therefore, I wrote "Discourse on Differentiating Mixed Six Qi" to remind the world. Now, I repeat and elaborate, listing them below, so that practitioners may differentiate clearly before treating. Initial correct treatment is far better than correcting errors later. Students should ponder this carefully.

1. After Frost's Descent, when the weather is severely cold, illness occurring immediately after contraction is Zheng Shanghan (True Cold Damage). Symptoms include fever and aversion to cold, headache and stiff neck, stiffness of the waist and spine, and body ache. Pulse floating and tight without sweat indicates Shanghan; pulse floating and relaxed with sweat indicates Shang Feng (Wind Injury). Shanghan uses Ma Huang Tang (Ephedra Decoction); Shang Feng uses Gui Zhi Tang (Cinnamon Twig Decoction). I substitute them with Jia Wei Xiang Su San (Perfumed Cabbage Powder with Additions), which cures promptly.

2. Contracting cold in winter without immediate onset, lying dormant in the skin and muscles, and erupting in spring due to warm air contact is called Wen Bing (Warm Disease). If not erupting in spring, but erupting in summer due to heat contact, it is called Re Bing (Heat Disease). Symptoms of headache and fever are the same as True Shanghan, but unlike True Shanghan, there is no aversion to cold but thirst exists. Treat with Chai Ge Jie Ji Tang (Bupleurum and Kudzu Decoction to Release the Muscle Layer).

3. Throughout the four seasons, sudden aversion to cold and cold limbs, cold breath from mouth and nose, vomiting, abdominal pain, diarrhea, cyanotic face, and slow pulse indicate Zhong Han (Cold Stroke/Attack). Treat with Jiang Fu Tang (Ginger and Aconite Decoction).

4. When winter should be cold but is warm, leading to thin clothing and subsequent cold contraction, this is Dong Wen (Winter Warmth). Symptoms of Dong Wen involve exterior cold and interior heat. Treat with Xiang Su San (Perfumed Cabbage Powder) added with clearing herbs.

5. Between summer and autumn, sudden cold weather causing immediate illness is Shi Xing Han Yi (Seasonal Cold Epidemic). Sometimes, it is not a cold epidemic, but the person catches wind and seeks coolness, resulting in headache and fever, named Gan Mao (Common Cold). Symptoms are slightly milder than True Shanghan. Treat with Xiang Su San (Perfumed Cabbage Powder).

6. In summer, illness with headache, fever, spontaneous sweating, restlessness, and thirst is Shang Shu (Summerheat Injury). Treat with Jia Jian Xiang Ru Yin (Modified Elsholtzia Decoction). Summerheat patterns resemble Heat Disease, but Heat Disease begins without sweat, while Summerheat begins with sweat; Heat Disease has a surging pulse, while Summerheat has a deficient pulse. There are distinctions among Shang Shu, Zhong Shu (Severe Summerheat), and Bi Shu (Blocked Summerheat); treatments are detailed in this section.

7. In summer, illness with headache, fever, heavy body, abdominal fullness, delirium, spontaneous sweating, and cold legs from knees down is Shi Wen (Damp-Heat). The person is often injured by dampness, then contracts summerheat; summerheat and dampness contend, named Shi Wen. Diaphoresis is strictly contraindicated. Though named "sweating," it is difficult to treat. Use Cang Zhu Bai Hu Tang (Atractylodes and White Tiger Decoction). Note: In Shanghan cold extremities, both calves and arms are cold; in Shi Wen cold extremities, calves are cold but arms are not. This distinguishes them.

8. Headache and fever similar to Shanghan, but with heavy body, silence, desire to sleep, snoring breath, difficulty speaking, and inability to control limbs, is Feng Wen (Wind-Heat). Diaphoresis is forbidden. Use Jia Jian Wei Rui Tang (Modified Polygonatum Decoction).

9. Fever and aversion to cold resembling Shanghan, but with fine pulse, heavy body, inability to turn over, or head sweat, is Feng Shi (Wind-Damp). Without vomiting or thirst, use Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction with Added Aconite).

10. Vomiting and diarrhea, or headache, abdominal pain, aversion to cold, and fever, constitute Huo Luan (Cholera-like disorder). Use Huo Xiang Zheng Qi San (Patchouli Powder to Rectify the Qi).

11. Fever, red face, red eye vessels, stiff neck, isolated head shaking, sudden jaw lock, and opisthotonos (back arching) constitute Jing Bing (Spasm Disorder). No sweat indicates Gang Jing (Rigid Spasm); sweat indicates Rou Jing (Flaccid Spasm). Use Jia Jian Xu Ming Tang (Modified Life-Prolonging Decoction). Jing Bing differs in external/internal causes and Three Yang/Three Yin classifications; see this section for details.

12. Fever resembling Shanghan, but without body pain, tight pulse at the right Cun Kou (Radial artery), epigastric stuffiness, belching with rotten smell, and acid regurgitation, is Shang Shi (Food Injury). Use Bao He Wan (Preserve Harmony Pill).

13. Restless heat resembling Shanghan, but with weak and powerless pulse, intermittent headache, limb fatigue, and reluctant speech, is Xu Fan (Deficiency Restlessness). Use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction).

14. Phlegm-wheezing resembling Shanghan, but with chest fullness, shortness of breath, and string-taut slippery pulse, is Tan (Phlegm). Use Er Chen Tang (Two-Aged Decoction). Phlegm may also arise with Wind-Cold, requiring addition of dispersing agents.

15. Aversion to cold and fever resembling Shanghan, but starting from the feet with swollen calves, is Hong Kong Jiao (Hong Kong Foot / Beriberi). Hong Kong Jiao involves dampness. Use Bing Lang San (Areca Nut Powder). However, if both feet suddenly become emaciated, commonly called Dry Hong Kong Jiao, it is Wind-Dryness. Use Si Wu Tang (Four Substance Decoction) added with Niu Xi (Achyranthes Root) and Mu Gua (Chaenomeles Fruit).

16. Floating rapid pulse, fever, aversion to cold, fixed pain, and normal diet indicate accumulation of pus. This appears in both External and Internal Abscesses. What is Internal Abscess? Generally, coughing with hidden chest pain and foul-smelling sputum indicates Fei Yong (Lung Abscess). Distended and tense abdominal skin, pain on pressure, frequent urination like strangury, and water sounds upon turning indicate Chang Yong (Intestinal Abscess). Hidden epigastric pain, tenderness to touch, and occasional vomiting of pus indicate Wei Yuan Yong (Stomach Wall Abscess). Text says: If vomiting contains pus, do not treat the vomiting; it heals spontaneously when pus is exhausted. Do not err.

17. Fever resembling Shanghan, but with history of falling from height, trauma, excessive anger/shouting, emotional excess, or overwork, leading to fixed, unmovable pain in chest, abdomen, or hypochondrium, intolerable to touch, is Xu Xue (Blood Stasis). Use Ze Lan Tang (Lycopus Decoction). This differs from abscesses.

Among the above patterns, some are similar to Shanghan but have different treatments; some are similar but essentially different categories; some are mixed Shanghan and miscellaneous disorders. One must differentiate clearly at the onset of illness before prescribing, so that one dose brings recovery, avoiding the disaster of "treating excess as excess and deficiency as deficiency."