Library

Shanghan (Cold Damage) theory exclusively venerates Zhang Zhongjing. Anyone reading Zhang Zhongjing's works must distinguish between Shanghan (Cold Damage) and Zhonghan (Direct Strike of Cold) as two separate categories to facilitate understanding. Due to the passage of time, the original texts have suffered from fragmentation; those who added supplements and annotations often introduced chronological errors and mistakes. Fortunately, successive generations of scholars gradually clarified these issues. It was only after the publication of Tao Jie'an's *Liu Shu* (Six Books) and Wu Shou's *Yun Yao* (Essential Collection) that the principles of Shanghan became prominent. I do not have the leisure to debate the profound truths in detail at this moment; instead, I will first clarify Shanghan and Zhonghan one by one to prevent the confusion of Yin and Yang syndromes. Treating Shanghan is not difficult if one grasps the general outline; however, seeking too many divergent paths leads to a fragmented approach.

Let us first discuss Yang syndromes. Since it is called Shanghan, cold pathogenic factors enter from the exterior and damage the interior. The entry has degrees of depth and sequence: from the surface to the interior, first affecting the skin and hair, then muscles, and subsequently bones, sinews, stomach, and intestines. This is the gradual trend of deepening invasion. When wind-cold initially enters, it must first invade the Taiyang (Greater Yang) Bladder meridian, presenting symptoms such as aversion to wind, aversion to cold, headache, and spinal pain. Cold stagnating in the skin and hair constitutes an Exterior Syndrome. Other meridians would not present these specific symptoms. If the pulse is floating and tight without sweating, it is Shanghan, treated with Mahuang Tang (Ephedra Decoction) to induce sweating for resolution. If the pulse is floating and relaxed with sweating, it is Wind Injury, treated with Guizhi Tang (Cinnamon Twig Decoction) to disperse pathogens, resolving when sweating stops. If there is no headache or aversion to cold, and the pulse is not floating, this indicates the Exterior Syndrome has ceased and the pathogen is in the "Middle" (half-exterior/half-interior). What is the Middle? It is the boundary between exterior and interior, specifically the realms of Yangming (Stomach) and Shaoyang (Gallbladder). The pulse is neither floating nor sinking, located between the muscles, beneath the skin. There are two variations here: if the pulse is slightly flooding and long, it is a Yangming pulse; external signs include dry nose and insomnia, treated with Gegen Tang (Kudzu Decoction) to release the muscles. If the pulse is wiry and rapid, it is a Shaoyang pulse; symptoms include hypochondriac pain, deafness, alternating chills and fever, and bitter taste in the mouth, treated with Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize. This is because Yangming and Shaoyang do not follow the root or branch but are treated via the middle. If even a slight aversion to cold remains, indicating the pathogen is still on the exterior, even if entering the half-exterior/half-interior, dispersing methods should be combined. Beyond this point, the pathogen enters the interior, becoming Excess Heat. The pulse is neither floating nor sinking; if sinking, pressing reveals it between bones and sinews. If the pulse is sinking, solid, and forceful, and external signs show aversion to wind/cold is absent but aversion to heat, delirium, and extreme thirst are present, along with constipation for six to seven days, this clearly indicates heat entering the interior causing dryness and excess in the stomach and intestines. Mild cases use Dahuang Huanglian Xixin Tang (not explicitly named here but implied contextually as intermediate) or rather, mild cases use Da Chaihu Tang (Major Bupleurum Decoction), while severe cases use the Three Chengqi Decoctions (Tiaowei Chengqi Tang, Xiao Chengqi Tang, Da Chengqi Tang). Once stool passes, heat dissipates.

Now let us discuss Yin syndromes. If from the onset there is fear of cold, cold limbs, or shivering and curling up without thirst, accompanied by abdominal pain, vomiting, diarrhea, salivation, a face pale as if scraped by a knife, no fever, and a sinking, slow, and weak pulse, this is a Yin Syndrome. It does not follow the treatment examples of heat syndromes transmitted from Yang meridians. One must further observe external signs. Mild cases use Lizhong Tang (Regulate the Middle Decoction); severe cases use Jiangfu Tang (Ginger and Aconite Decoction) or Sini Tang (Recover the Extremities Decoction) to warm. From this, we see that Shanghan proceeds from skin/hair to organs/viscera. Initially虽有 aversion to cold and fever, it ultimately becomes a heat syndrome; such individuals must inherently possess Fire. Zhonghan (Direct Strike of Cold), however, goes directly into the viscera, maintaining constant aversion to cold without fever, etc.; such individuals lack Fire. One approach releases the exterior and attacks the interior; the other warms the middle and dispels cold. The two categories are distinct. How could they be mixed, causing confusion for later generations?

Cold damages Ying (Nutritive Blood); Wind damages Wei (Defensive Qi). Wei is Yang; Wind is also Yang. Like attracts like, so Wind damages Wei. Blood is Yin; Cold is also Yin. Like attracts like, so Cold damages Ying. Pungent and Sweet flavors that disperse belong to Yang. Wind should be dispersed with Pungent herbs; Cold should be released with Sweet herbs. Guizhi (Cinnamon Twig) is pungent and hot, thus dispersing Wind pathogens in the Wei level. Mahuang (Ephedra) is sweet and hot, thus dispersing Cold pathogens in the Ying/Blood level. Furthermore, Guizhi and Mahuang have light aromas and flavors, representing Yang within Yang, allowing them to enter the Taiyang meridian and disperse wind-cold in the skin. These two formulas are the precise prescriptions for treating Zheng Shanghan (True Cold Damage) in winter. From Frost Descent to Spring Equinox, the Taiyang Cold Water phase is dominant. Individuals who engage in sexual activity excessively or endure hard labor have deficient Taiyang Cold Water Qi, which allows pathogens to enter the Taiyang meridian due to resonance of similar energies, making injury easy. Zhang Zhongjing detailed this because the killing energy of cold is heaviest then. In other seasons, there is no Shanghan, and these two formulas should not be used. Today, medical signs often claim treatment for "Four Seasons Shanghan," which is improper nomenclature. The *Huoren Shu* states that for headache like splitting, use Lianxu Congbai Tang (Green Onion White Decoction); do not immediately give Shengma Gegen Tang, lest Taiyang pathogens flow into Yangming, pulling Taiyang pathogens into Yangming where they cannot be resolved. Before reaching Shaoyang, do not immediately give Chaihu Tang. If aversion to cold exists, add Mahuang to the base formula; if aversion to wind, add Guizhi. For true Yangming Fu organ disease, with no aversion to cold, sweating, and thirst, use Baihu Tang (White Tiger Decoction).

Taiyang meridian governs the exterior of the body, running along the back. Yangming meridian governs the interior of the body, running along the front. Shaoyang meridian governs half-exterior/half-interior, running along the sides of the ribs. Beyond these, Shaoyin, Taiyin, and Jueyin all enter the Zang organs, becoming Interior.

Generally, when Shanghan pathogenic heat transmits to the interior and forms accumulation, one must judge the depth of heat to prescribe medication. Current physicians fail to distinguish between cases requiring urgent purgation and those needing only mild regulation of Stomach Qi, indiscriminately using Dahuang (Rhubarb) and Mangxiao (Mirabilite) in decoctions, leading to many wrongful deaths. I argue that Shanghan pathogens transmit in various ways, requiring different treatments. If pathogens injure all three Jiaos, resulting in fullness, distension, dryness, excess, and hardness, Da Chengqi Tang (Major Order the Qi Decoction) is appropriate. Houpo (Magnolia Bark) is bitter and warm to remove distension; Zhishi (Immature Bitter Orange) is bitter and cold to drain fullness; Mangxiao is salty and cold to moisten dryness and soften hardness; Dahuang is bitter and cold to drain excess and clear heat. The disease resolves. If pathogens are in the Middle Jiao, presenting dryness, excess, and hardness, Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) is used. Gancao (Licorice) harmonizes the middle; Mangxiao moistens dryness; Dahuang drains excess. Zhishi and Houpo are omitted to avoid damaging Upper Jiao Yuan Qi; hence the name "Regulate the Stomach." If the Upper Jiao is injured, presenting distension and excess, Xiao Chengqi Tang (Minor Order the Qi Decoction) is used. Zhishi and Houpo remove distension; Dahuang drains excess. Mangxiao is omitted to avoid damaging Lower Jiao True Yin, preserving the root. As for Da Chaihu Tang, it is used when exterior signs remain unresolved but interior signs are urgent, requiring simultaneous resolution of exterior and interior. It is also suitable for the elderly, weak, and those with dual deficiency of Qi and Blood. Thus, the classics state: regarding the urgency of medication transformation, those containing Mangxiao are most urgent. Da Chengqi is most urgent, Xiao Chengqi is next, Chaihu Tang is next. Da Chaihu Tang plus Mangxiao qualifies as transforming medication, intended for milder illnesses. Zhang Zhongjing stated that to sweep away Shanghan heat accumulation, decoctions must be used; pills are unsuitable. This must be known. To use these three Chengqi formulas, one must press the patient's abdomen from chest to lower abdomen; if there is hardness that cannot be touched, then one dares to administer. However, the subtlety lies in examining the tongue coating for dryness or slipperiness. The *Jing Jian Lu* (Record of Tongue Mirrors) describes thirty-six tongue types, which must be studied carefully.

If initial illness presents no fever but cold limbs, or chest/abdominal fullness, vomiting, abdominal pain, and diarrhea, with a fine and weak pulse, this is Cold contracted from a Yin syndrome, i.e., True Yin Syndrome, not transmitted from Yang meridians. Immediate warming is required, without delay. The classics state: Fever with aversion to cold originates in Yang; no fever with aversion to cold originates in Yin. Treatment should use Sini Tang. Abdominal fullness and pain are Yin syndromes, differing only in severity, making treatment non-uniform. Abdominal pain with constipation uses Guizhi Shaoyao Tang (Cinnamon Twig and Peony Decoction); severe abdominal pain uses Guizhi Dahuang Tang (Cinnamon Twig and Rhubarb Decoction). If spontaneous diarrhea with abdominal pain and clear urine, warm the middle using Lizhong Tang or Sini Tang based on severity. Mild cases use Wuji San (Five Accumulations Powder); severe cases use Sini Tang. Pulseless conditions use Tongmai Sini Tang (Pulse-Returning Sini Decoction) to make Yin retreat and Yang recover.

Yin Du (Yin Toxin) disease presents with blue fingernails/toenails, sinking, fine, and rapid pulse; treat with Sini Tang. Pulseless: Tongmai Sini Tang. Also consider Yindu Gancao Tang (Yin Toxin Licorice Decoction), moxa application on the navel with scallion, and moxibustion on Qihai and Guanyuan acupoints (200-300 moxa cones), followed by mild Qi-tonifying herbs to open interior/exterior and restore Yang Qi. If ineffective, it is a death case.

Above are True Yin Syndromes, which people know. Anomalous cases are harder to understand. Some present with fever, red face, restlessness, removing clothes/blankets, drinking cold fluids, and large pulse, mistaken for Yang syndrome and treated with cold herbs, leading to many deaths. One must rely on pulse diagnosis. Regardless of floating/sinking or large/small, if the pulse feels weak under the finger and completely powerless when pressed to bone/sinew, there must be hidden Yin. Do not give cooling herbs. If cooling herbs were already taken, the pulse may become forceful and striking, making pulse diagnosis unreliable. If all teas and medicines are vomited, this is Yin Excess repelling Yang. Urgently use Baotong Tang (Unblock the Yang Decoction) with human urine and pig bile to overcome the repelling cold. Thus, Zhang Zhongjing discusses both transmitted and direct-strike patterns in *Shanghan Lun* precisely because Yang syndromes can resemble Yin, and Yin syndromes can resemble Yang, requiring careful differentiation. Due to textual corruption over time, later compilations caused confusion. For example, Taiyang syndrome headache/fever should have a floating pulse but presents sinking, resembling Shaoyin; thus, Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) is used. Shaoyin syndrome pulse sinking should have no fever but presents fever, resembling Taiyang; thus, Ganjiang Fuzi Gancao Tang (Dried Ginger, Aconite, and Licorice Decoction) is used. Yin syndrome cold limbs vs. Yang syndrome cold limbs differ: Sini Tang vs. Sini San (Bupleurum Powder). Yin syndrome diarrhea vs. Yang syndrome leakage (undigested food): Lizhong Tang vs. Huanglong Tang (Yellow Dragon Decoction). Such ambiguities were clarified by Tao Jie'an's *Liu Shu*. I have another point: Reading Shanghan books without Li Dongyuan's works leaves Internal Injury unclear, causing many deaths. Reading Li Dongyuan without Zhu Danxi's works leaves Yin Deficiency unclear, causing many deaths. Reading Zhu Danxi without Xue Ji's works leaves True Yin/True Yang unclear, causing many deaths. Li Dongyuan said: Where pathogenic factors gather, Qi is necessarily deficient. Internal injuries are common; external contractions are rare. The word "rare" implies "one in five hundred years," emphasizing the absence of external contractions. Li Dongyuan's *Pi Wei Lun* (Treatise on Spleen and Stomach) and *Nei Shang Wai Gan Bian* (Differentiation of Internal Injury and External Contraction) clarify that fevers from hunger/fullness or fatigue are internal injuries, similar to Shanghan, forbidding sweating and purging. He argued internal injuries are common, external few; thus, warm tonification is needed, not dispersion. If external contraction is common and internal injury rare, add mild dispersion to warm tonification, primarily using Buyi Zhongqi Tang (Tonify the Middle and Augment the Qi Decoction), modified. For internal injury with Shanghan, add Mahuang; with Wind, add Guizhi; with Summerheat, add Huanglian; with Dampness, add Qianghuo. This offers eternal benefit. Li Dongyuan elucidated Yang Deficiency Fever. However, 60-70% of fevers in the world are due to True Yin Deficiency, indistinguishable from Shanghan, yet rarely discussed. People see fever and assume Shanghan requiring dispersion; if dispersion kills, they say Shanghan treatment is exhausted. Do they not know Zhu Danxi's deeper insights? I once treated Yin Deficiency fever with high doses of Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia), curing it instantly. For lower body cold/cold feet with upper body extreme thirst/dryness or vomiting upon drinking, I added Rougui (Cinnamon Bark) and Wuweizi (Schisandra) to Liuwei Dihuang Tang, or Fuzi (Aconite) in severe cases, served cold, curing instantly. I saved many with this method. Why keep it secret? I wrote *Bu Tian Yao Lun* (Essential Discourse on Supplementing Heaven) to supplement predecessors' shortcomings, hoping for expert review. Consider thirst in Shanghan: Pathogenic heat in Stomach consumes fluids, causing thirst. To save Stomach juice, urgent purging preserves fluids. For mild thirst, give water but not much, with no specific formula. Those who treat it use Huangqin, Huanglian, Zhimu, Huangbai, Maidong, Wuweizi, Tianguafen, or Shigao/Zhimu to stop thirst. These are tangible waters trying to extinguish intangible fire, unable to nourish Kidney True Yin. High-dose Liuwei Dihuang Tang cures thirst instantly, preventing transmission to Shaoyin and formation of dryness/excess/hardness. If formed, Zhang Zhongjing reluctantly uses Chengqi Tang, a temporary measure, warning against use in weak/elderly, substituting Da Chaihu Tang. Tao substituted Liuyi Shunqi Tang. Did he think these were mild? Even if effective, losses are great; 80-90% fail. If Liuwei Dihuang Yin was used heavily, effect might be slower but benefits infinite. Yin Deficiency fever presents scant urine and constipation, with thirst/restlessness like Shanghan. Their Chengqi Tang acts to descend rebellious Qi to support True Yin. I explore the source of True Yin and tonify it, like rain in drought, instantly cooling. Why not? After purging deficient Kidney Water, survival is impossible. Be cautious. I elaborate in *Bu Tian Yao Lun*.

Tao Jie'an understood this: From Qi to Blood, Blood to Qi: Da Chengqi Tang. From Blood to Qi, Qi to Blood: Shengdihuang Huanglian Tang. Both with constipation are counterparts to Chengqi Tang, related to Sanhuang Shigao Tang, treating Empty Fire in Three Jiao and Bao Luo. In critical illness, these cool blood-fire. Tao viewed Blood as Yin, hence his theory, but missed True Yin/True Yang principles.

In summary: True Yang Deficiency -> Buyi Zhongqi Tang. True Yang Deficiency Direct Strike -> Fuzi Lizhong Tang. True Yin Deficiency -> Liuwei Shenqi Tang. True Yin Deficiency without Fire -> Bawei Shenqi Tang (Eight-Ingredient Pill with Rehmannia). For pseudo-Yin/Yang signs, use "treat cold with hot" method following the false appearance, never erring. Focus on tonifying Righteous Qi, never attacking Evil. Strong Righteous Qi expels Cold naturally, inducing sweat and cure. "Attack" is abhorrent to benevolent men. Winning every battle is good; winning without fighting is best. Thus, skilled warriors deserve punishment.