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Then Yin has already been exhausted first, how can Yang be restored? Therefore, seeing cold extremities and removing heat, to preserve one-tenth or one-hundredth of the body fluids and Yuan Qi (Original Qi), is already too late; how much more dare one assist Yang by robbing Yin? (Yu Jiayan)

In "Zhi Zhong" (Direct Invasion) Shanghan (Cold Damage), the Yin fluids are not damaged, so urgent rescue of Yang is required; thus formulas such as Zhenwu Tang (True Warrior Decoction) and Sini Tang (Reverse the Extremities Decoction) are used. In Shanghan characterized by Heat Disease, where scorching heat damages the Yin fluids, only rescuing Yin is appropriate; therefore, Ginger (Sheng Jiang, 生姜) and Aconite (Fu Zi, 附子) must not be used. (Xu Xuanzhi)

When Shanghan pathogens transmit inward: if Stomach Qi is Excess, there will be constipation; if Stomach Qi is Deficient, there will be diarrhea. Why does Excess Stomach Qi lead to constipation? Because the patient's Stomach Qi was originally Excess, and when pathogenic heat enters the Stomach, it steams and agitates, drying up the body fluids, leading to hard and constipated stools. This is like firing clay in a kiln; naturally, it becomes hard. It is appropriate to use Chengqi Tang (Major/Minor Order the Qi Decoction) to purge it. Why does Deficient Stomach Qi lead to diarrhea? Because the patient's Stomach Qi was originally Deficient, and when pathogenic factors enter the Stomach, the pathogen and righteous Qi contend; the pathogen wins and righteous Qi loses, causing righteous Qi to sink downward and resulting in diarrhea. This is like mud becoming slushy; adding rain causes it to flow and scatter. It is appropriate to use Lizhong Tang (Regulate the Middle Decoction) to warm and tonify. This is a fixed method based on the Excess or Deficiency of the patient's Yuan Qi combined with external pathogens. (Yu Fushan)

I have repeatedly treated Shanghan diseases, which are essentially Heat patterns. When treated with Cold medicines for several days, they suddenly transform into Cold patterns. This is because the Middle Jiao Qi is severely deficient and cannot tolerate cold and cool substances; switching to warm agents yields results. Alternatively, in a Yang pattern that requires purgation, if the physician purges too excessively, it also transforms into a Cold pattern. This is a "Huai Zheng" (Damaged Pattern). Switching to hot agents is necessary for recovery. The proverb says, "An official beats you for being present; a clerk beats you for being liable." Thus, the flexible method for treating Shanghan is: today, if a Heat pattern is seen, use cool medicines; tomorrow, if a Cold pattern is seen, use hot medicines; the day after, if a Heat pattern appears again, reuse cool medicines. It all lies in adaptability; one must not be rigid or dogmatic. (Wu Huangchi)

Question: What does it mean that "entering Yin allows for purgation"? Answer: When Yang enters Yin, purgation is allowed. This does not refer to entering Taiyin, Shaoyin, or Jueyin, but rather entering the Three Yang. Here, "Three Yang" does not refer to the Taiyang, Shaoyang, and Yangming meridians, but to the Stomach, Large Intestine, and Small Intestine. These three Yang organs are Fu (Hollow Organs); because they receive and hold food and drink, and conduct有形 (form/substance), they are called "entering Yin" (here Yin refers to the interior/Fu organs). Zhang Zhongjing said: "Once entered the Fu, purgation is allowed." This is what is meant. ○ Sweating inherently causes loss of Yin; because excessive sweating causes Yang to follow Yin and leave. Purging inherently drains Yang; because excessive purging causes Yin to follow Yang and leave. Therefore it is said: Excessive sweating leads to loss of Yang; excessive purging leads to loss of Yin. ○ In *Ping Re Lun* (Discussion on Fever), the character "Zang" (Storehouse/Organ) here refers to the storehouse of food, not the Five Zang (Solid Organs). When disease of the Three Yang meridians enters the "Zang" (storehouse/Fu), which stores food, it can be drained/purged. The Yellow Emperor asked about treatment; Qibo replied that treatment should unblock the pulses of each Zang, and the disease will decline daily. He further stated that if less than three days have passed, sweating can cure it; if more than three days have passed, purging can cure it. For disease affecting the Three Yang, if it has not entered the Zang (Fu), sweating is appropriate; if it has entered the Zang (Fu), purging is appropriate. If one interprets "Zang" as the Five Solid Organs, the preceding and following text becomes contradictory and illogical; if one interprets "Zang" as the storehouse of food, the logic flows smoothly throughout. Zhang Zhongjing said: "Once entered the Fu, purgation is allowed." The *Jiaozheng* (Correction) states: The character "Fu" should be read as "Zang". What is there to doubt? (*Ci Shi Nan Zhi*)

The key to treating Shanghan initially is fearing transmission through the meridians; transmission brings changes. Later, one fears non-transmission; non-transmission means the condition becomes severe. (*Shanglun Pian*)

For Exterior patterns, sweating is indicated: if the pulse is floating and rapid, sweat; if floating and slow, sweat. For Interior patterns, purging is indicated: if floating and slow, purge; if deep and rapid, purge. For the Three Yang, sweating should be urgent, while purging should be slow; for the Three Yin, sweating should be slow, while purging should be urgent. Sweating differs between profuse sweating to release the exterior and mild sweating to resolve the muscle layer. Purging differs between urgent purging with small doses and mild harmonizing with moistening/diuresis. (Wang Haogu)

General Principles of the Five Methods

Zhang Zhongjing treats diseases with both Exterior and Interior patterns using methods that simultaneously resolve both; methods that only resolve the Exterior allowing the Interior to harmonize itself; methods that only harmonize the Interior allowing the Exterior to resolve itself; and methods of rescuing the Interior first then the Exterior, or resolving the Exterior first then attacking the Interior. Thus, five methods are formed. (Ke Yunbo)

1. Fa (Elicit/Disperse): Medicines use Pungent and Sweet flavors. Because the outermost layer of the Exterior, the Cou Li (interstices/skin pores), is dense, only Pungent and Sweet can disperse it; hence it is called "Fa". "Fa" refers to the true Exterior. ○ 2. Jie (Resolve): Resolution is lighter than elicitation; medicines use Pungent and Cool flavors. Because the Cou Li is already open and aversion to cold has ceased, and pathogens are transforming into heat, only Pungent can resolve the muscle layer, and only Cool can resolve heat; hence it is called "Jie". "Jie" refers to resolving the muscles. ○ 3. He (Harmonize): Harmonizing is lighter than resolving; medicines use light Pungent and heavy Cool flavors. Because the Exterior pathogen is fading but wants to enter the Interior without deeply penetrating, it is neither purely Exterior nor purely Interior, but Semi-Exterior/Semi-Interior, making both Fa and Jie difficult; hence it is called "He". "He" refers to harmonizing the Exterior and Interior. ○ 4. Gong (Attack): Attacking is heavier than harmonizing; medicines use Bitter and Cold flavors. Because the Exterior pathogen has ceased, and pathogens have entered the Fu, knotting in the intestines and stomach, only Bitter and Cold can attack; hence it is called "Gong". "Gong" refers to attacking Excess Heat. ○ 5. Jiu (Rescue): Rescue is different from attack; Heat is attacked, Cold is rescued; medicines use Warm and Hot flavors. Because pathogens do not enter via the Yang meridians but directly strike the Three Yin, named "Zhi Zhong" (Direct Strike), internal Cold is extremely severe, and Yang Qi is critically deficient; hence it is called "Jiu". "Jiu" refers to rescuing critical Yang. ○ Among the five methods, the so-called "Exterior" is sweating, and "Attack" is purging. However, Zhang Zhongjing’s treatment of Shanghan includes Sweating, Vomiting, and Purging methods. Why is Vomiting excluded now? Because all three methods expel pathogens: if pathogens are in the Exterior, sweat them; if in the upper epigastrium of the Stomach, vomit them; if in the Interior, purge them. Sweating, vomiting, and purging all expel pathogens. The term "Vomit" was originally set for pathogens in the upper epigastrium. Pathogens in the Exterior prohibit vomiting; pathogens in the Interior prohibit vomiting; at Semi-Exterior/Semi-Interior, all three methods are prohibited. Modern formularies treat vomiting as the method for Semi-Exterior/Semi-Interior, causing much harm to later generations. Vomiting succeeds in one or two cases out of ten, and harms in eight or nine. Physicians can speak of it but dare not use it lightly, so it is not listed among the five methods. (Chen Yanghui)

Note: Emetic drugs are not limited to Gardenia (Zhi Zi); various drugs can induce vomiting. One must accurately diagnose whether the pathogen in the chest and stomach is Cold, Heat, Food retention, Water retention, Phlegm, or Qi stagnation? What obstruction prevents the Chest-Stomach Yang Qi from extending? Then use the appropriate drug to induce vomiting, and recovery will naturally occur. To vomit Cold, use Dried Ginger (Gan Jiang, 干姜) and Cinnamon Bark (Gui Pi, 桂皮); to vomit Heat, use Gardenia (Zhi Zi, 栀子) and bitter tea; to vomit Food, use Pingwei San (Calm the Stomach Powder) and salt; to vomit Water, use Wuling San (Five Ling Powder) and fresh ginger; to vomit Phlegm, use Xixian San (Slippery Saliva Powder) and tangerine peel; to vomit Qi, use Liuqi Yin (Flowing Qi Decoction), Zhi Shi (Immature Bitter Orange, 枳实), and Hou Po (Magnolia Bark, 厚朴). For those with weak constitution, the dose should be small, supplemented with Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) and other ascending drugs for safety; for those with strong constitution, the dose should be larger, supplemented with potent drugs like Melon Sprout (Gua Di, 瓜蒂) and Veratrum (Li Lu, 藜芦) for better effect. When decocting emetic soups or mixing powders, use sour rice soup, plain water, or thin rice gruel. Prepare over ten cups. Have the patient gulp down one cup, then stimulate the throat with a finger to induce vomiting. After vomiting, take another cup, stimulate again, and repeat until vomiting is smooth and rapid. At this point, slight sweat will appear on the forehead and body, symptoms will lessen, indicating the medicine has hit the mark. There is no need to finish the remaining medicine. Over-vomiting may damage Chest Yang even if the disease is cured. Modern physicians have long considered vomiting an obsolete ancient method. This is because Zhang Zhongjing’s principles are obscure and the method lost, so no wonder they dare not use it. Not knowing its efficacy and daring not to use it is understandable. But dismissing it as "ancient methods are unusable" is wrong. Pathogens in the Upper Jiao cannot be cured without vomiting. If, as vulgar practitioners claim, patients fear taking the medicine, leading to delay and complications, turning mild cases severe and severe cases fatal, whose fault is it? Moreover, if Sweating, Vomiting, and Purging are used appropriately, effects are immediate. How can future physicians only discuss Sweating and Purging, leaving Vomiting unused, causing ancient methods to perish? (*Yizong Jinjian*)

Contraindications of the Six Meridians

Foot-Taiyang Bladder Meridian prohibits purging. If purged too early, myriad transformation patterns will emerge. Foot-Yangming Stomach Meridian prohibits sweating and diuresis. Violating this severely damages body fluids, and the pulse will likely show intermittent (Dai, 代) or knotted (Jie, 结) qualities. Foot-Shaoyang Gallbladder Meridian prohibits sweating, purging, and diuresis. Sweating violates Yangming; purging violates Taiyang; diuresis traps the generating Qi in Yin. Taiyang has one prohibition, Yangming has two, Shaoyang has three; these are fixed prohibitions. As for the Three Yin meridians, there are no fixed prohibitions, except that purging is still prohibited unless there is Stomach Excess. (Yu Jiayan)

Correct Interpretation of the Six Meridians

Zhang Zhongjing divides the Exterior/Interior and Yin/Yang of various diseases into Six Meridians, clarifying differences in pulses and symptoms, and Excess/Deficiency of Cold/Heat, so that treatment focuses solely on the Six Meridians. Diseases of the whole body are encompassed by the Six Meridians, just as the Rites of Zhou divided six offices to manage all duties. If speaking of Shanghan, it is merely one pattern within the Six Meridians. Wang Shuhe did not understand that Zhang Zhongjing’s Six Meridians refer to strategic regions, not meridian pathways. He wrongly cited the *Neijing*'s *Re Bing Lun* (Treatise on Fever Diseases) as a preface, confusing the diagnosis and treatment of the Six Meridians. The Six Meridians of Fever Diseases focus specifically on meridian pathology, involving only Excess Heat in the Exterior/Interior, with no Deficient Cold. Although originating from Shanghan, it has transformed into a Fever Disease (also known as Warm Disease), possessing only methods for sweating and purging, with no examples of warming or tonifying. Zhang Zhongjing’s Six Meridians divide geographical regions, covering a wide range: Wind-Cold-Damp-Heat, Internal Injury, External Contraction, from Exterior to Interior, Cold-Heat, Excess-Deficiency, all included. Thus, the Six Meridians outlines stand independently, not constrained by meridians, nor defined strictly by Wind-Cold. Taiyang is Opening, thus governing the Exterior, with floating pulse, aversion to cold, and stiffness/pain of the head and neck as the outline. Yangming is Closing, thus governing the Interior, with Stomach Excess as the outline. Shaoyang is Pivot, and Shaoyin is also Pivot, so both have Semi-Exterior/Semi-Interior patterns. Shaoyang is the Yang Pivot, focusing on Semi-Exterior, with bitter taste, dry throat, and vertigo as the outline; Shaoyin is the Yin Pivot, with desire to sleep but inability, desire to vomit but inability, also Semi-Exterior/Semi-Interior, focusing on Semi-Interior. Does only Yangming govern the Interior? The Three Yin also govern the Interior, but due to different Yin/Yang positions, their governance differs. Yangming governs the Yang aspect of Interior patterns; the Yang pathway is Excess, so Stomach Excess belongs to Yangming. Taiyin governs the Yin aspect of Interior patterns; the Yin pathway is Deficient, so spontaneous diarrhea belongs to Taiyin. Taiyin is Opening and the Ultimate Yin within Yin, thus governing Interior Cold and spontaneous diarrhea. Jueyin is Closing and Yang within Yin, thus governing Interior Heat and rebellious Qi. Shaoyin is the Pivot within Yin, so its governance varies between Cold/Heat and Exterior/Interior, similar to Shaoyang. Let us use geography as a metaphor: the Six Meridians are like feudal states. Above the waist is the Three Yang region; Three Yang govern the Exterior but originate from the Interior. The Heart is the borderland of the Three Yang. Internally from the chest/heart, externally from the vertex, anteriorly to the forehead, posteriorly to the shoulders/back, inferiorly to the feet, internally connecting to the Bladder—this is the Taiyang region. This meridian manages Ying and Wei Qi, governing Exterior patterns of the whole body, like a border state defending against enemies. Internally from the chest/heart to the Stomach/intestines, externally from the head to the face/abdomen, inferiorly to the feet—this is the Yangming region. From the heart to the throat, back to the cheeks, up to the eyes/ears, diagonally to the vertex exterior, internally to the hypochondrium connecting to the Gallbladder—this is the Shaoyang region, like the capital vicinity. Below the waist is the Three Yin region; Three Yin govern the Interior and do not extend to the Exterior. The abdomen is the borderland of the Three Yin. From the abdomen via the Spleen to the intestines/anus—Taiyin region; from the abdomen to the kidneys/bladder urinary tract—Shaoyin region; from the abdomen via the Liver up through the diaphragm to the heart, from the hypochondrium down to the small intestine/genitals—Jueyin region. This meridian connects the San Jiao, governing Interior patterns of the whole body, like a vassal state near the capital. Taiyin and Yangming reside together but are treated differently, like the shared governance of Zhou and Shao. The presence of Correct Pathogens, Guest Pathogens, Combined Diseases, Concurrent Diseases, and involvement of Spleen/Stomach in the Six Meridians is like bandits filling the land, either in their own territory or spreading to neighbors. The Taiyang region is largest, adjacent internally to Shaoyin and externally to Yangming, so diseases are related. For example, difficulty urinating is originally a Bladder disease; if Shaoyin disease presents with difficulty urinating, the pathogen has entered the Taiyang boundary. Lower back pain is originally a Kidney disease; if Taiyang disease presents with lower back pain, the pathogen has reached the Shaoyin boundary. Constipation for 6-7 days with headache and fever indicates Yangming Heat pathogen invading the Taiyang boundary. Head/neck stiffness with nasal congestion and dry retching indicates Taiyang Wind pathogen invading the Yangming boundary. The chest/heart is the Yangming region but serves as the thoroughfare for Taiyang, because Taiyang manages Ying and Wei Qi, and the chest/heart is the root of Ying and Wei. Ying and Wei circulate endlessly, like border officials/citizens/soldiers gathering in the capital, coming and going constantly. Wheezing with chest fullness indicates Taiyang external pathogen entering the Yangming region and causing disturbance, hence called Taiyang-Yangming Combined Disease. If no headache/stiffness, but chest oppression/hardness, Qi rushing to the throat preventing breathing, this pathogen does not come from Taiyang but is Yangming Heat knotting in the chest, like rebels causing trouble in their own territory. The Heart is the master of the Six Meridians, so all Six Meridians have irritability. If no head/neck stiffness, irritability does not belong to Taiyang; if no alternating chills/fever, irritability does not belong to Shaoyang; if no Three Yin signs, irritability does not belong to the Three Yin. Thus, mental confusion, palpitations, inner restlessness, and all deficiency irritability belong to Yangming, because the Heart resides in the Yangming region. Yangming is like the capital, so Heart and Abdomen are in its territory. Pathogen in the Heart causes deficiency irritability; in the Abdomen causes Excess Heat. The Heart is Yang and formless; the Abdomen is Yin and substantial. Diseases of the human body often involve the Heart and Abdomen; Yang pathogens gather in the Heart, Yin pathogens gather in the Abdomen. The Liver is Yang within Yin, so it can cause Yin pathogens to rush upward to the Heart; Yangming is Yang within the Interior, so it can cause Yang pathogens to gather in the Abdomen. Using military strategy as a metaphor, the key to strategy is understanding terrain. One must first understand the paths of the Six Meridians to know where the enemy comes from, which direction is the approach to which prefecture, and which is the retreat. The approach is like the border pass (Three Yang); the retreat is the interior (Three Yin). The approaches of the Six Meridians differ: Taiyang is the main road, Shaoyang is the remote path, Yangming is the direct road, Taiyin is the nearby road, Shaoyin is the rear road, Jueyin is the irregular path. Guest pathogens mostly come from the Three Yang; Correct pathogens (internal imbalances) mostly arise from the Three Yin, like external invaders coming from borders and rebels rising from the interior. Understanding the terrain of the Six Meridians allows one to grasp the pivot of all diseases; detailing the approaches allows one to control the rules of treatment. Regarding patterns: Shanghan is a great invader, disease from outside; Stroke is a roaming bandit, disease from side involvement; Miscellaneous diseases are chaotic locals, disease arising from within. Once identified as what kind of enemy and known where it originates, if it arises in its territory, defend there; if it shifts disaster to neighboring counties, attack from two routes. If pathogen enters Taiyang region, sweat and disperse it, like deploying elite troops at key points to strike before they settle. Light pathogens are in Wei (Defensive Qi), heavy in Ying (Nutritive Qi), especially heavy in Chest/Diaphragm, like enemies shallow outside the pass, deep inside the pass, especially deep within. Mahuang (Ephedra) is the army outside the pass; Guizhi (Cinnamon Twig) and Gegen (Kudzu Root) are the army at the pass; Da Qinglong Tang (Major Green Dragon Decoction) is the army within the pass. Whenever external unrest occurs, internal thieves rise to respond; thus solutions are established, leading to Da/Xiao Qinglong Tang and modified Guizhi/Mahuang formulas. If the vanguard lacks discipline causing internal chaos, prioritize the interior over the exterior, hence Wuling San, Shizao Tang, Xiongxiong Tang, Xiexin Tang, Didang Tang. If pathogen enters Shaoyang region, mix Exterior/Interior, Cold/Heat, Attack/Tonify agents for defense and resolution. Like a remote path, suitable for short weapons, not spears; suitable for defense, not war. Light pathogens enter Cou Li, heavy enter Mo Yuan (Membrane Source), especially heavy enter Spleen/Stomach. Xiao Chaihu Tang (Minor Bupleurum Decoction) is the Cou Li agent; Da Chaihu Tang (Major Bupleurum Decoction) is the Mo Yuan agent; Xiaojianzhong Tang, Banxia Xiexin Tang, Huangqin, Huanglian are the Shaoyang Spleen agents; Chaihu Jia Mangxiao Tang, Chaihu Jia Muli Tang are the Shaoyang Stomach agents. If Taiyang-Shaoyang combined disease, one army attacks Taiyang, one attacks Shaoyang; Chaihu Guizhi Tang is the two-route dividing force. Even San Yang Combined Disease, facing enemies on three sides, the method is to exclusively target Yangming. If the Yangming region is clear and orderly, the Yang pathogens of Tai/Shaoyang resolve without attack; once internal rebels are pacified, external threats cease. This is why Baihu Tang achieves victory. If Yang pathogens are not contained internally, use Dachengqi Tang for urgent purging to attack pathogens and protect the host; if Yin pathogens strike directly inward, use Sini Tang to urgently rescue the interior to strengthen the host and drive out invaders. Yangming is the interior; its boundaries are the Taiyang/Shaoyang regions. If pathogen enters Yangming boundary, even if not violating Taiyang, Taiyang forces cannot ignore it; thus Yangming Ying/Wei diseases borrow Guizhi/Mahuang formulas to sweat. If pathogen nears Shaoyang region, Shaoyang forces cannot hide behind walls without fighting; thus Yangming Cou Li diseases borrow Chaihu to resolve. Knowing Yangming’s failure to hold implies either Taiyang is not solid or Shaoyang is unprepared, so often Two Yangs combine to cause disease. If pathogen is already in Yangming region, must send out troops to vigorously chase pathogens, leaving none, hence using Goudi/Zhichi emetic method to sweep quickly. If penetrating deep into the interior, cannot be driven out, then practice scorched earth policy, denying plunder; this is where Baihu Tang excels. If pathogen is at the gate, must clean the palace and roads; this is why the three Chengqi formulas succeed. Drugs like Yinchen and Zhuling legislate for undisciplined armies. Taiyin is also interior; Shaoyin/Jueyin are borderlands. Taiyin occupies the Central State; though externally connected to Three Yang, Yin and Yang take different paths, and Heart/Abdomen have diaphragmatic barriers. Thus, Cold-Water pathogens attaching externally from Taiyang are light; those internally transmitted from Shaoyin are heavy. Wind-Wood pathogens invading from Shaoyang are light; those襲 (attacking) from Jueyin are heavy. If the primary pathogen of the meridian transfers to Yangming becoming Excess, like an old army with exhausted momentum, it can be purged to heal. If Yangming Excess pathogen transfers to the primary meridian becoming Deficient, then Excess pathogen and Deficient righteous Qi make warm-tonifying recovery very difficult. Although Taiyin and Yangming regions are distinct, there is no barrier. If Yuan Qi is sufficient, pathogen enters Yangming; if insufficient, pathogen enters Taiyin. In Yangming, one can deploy troops and fight behind the city walls, winning quickly; in Taiyin, supplies are burned and granaries empty, unable to resist enemies. Jueyin region is the area where Minister Fire wanders; its original Qi is Minor Fire. If Wind/Cold/Dryness/Dampness pathogens enter, they all transform into Heat, becoming Major Fire. Minor Fire is the life force of the body; Major Fire is the great disaster of Heart/Abdomen. Its region connects the San Jiao. Pathogen attacking Upper Jiao causes Qi rushing to the Heart, burning pain in the Heart, thirst, mouth ulcers, sore throat, throat obstruction. Pressing on Middle Jiao causes cold extremities, faint/almost imperceptible pulse, hunger but no desire to eat, vomiting roundworms upon eating. Shifting disaster to Lower Jiao causes dysentery with heaviness, or pus/blood in stool, leading to...