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The aversion to cold (Ehan) in plague-epidemic diseases differs from that caused by wind, cold, summerheat, and dampness. In other conditions, aversion to cold occurs without specific timing and is not severe; whereas in plague-epidemics, it occurs at specific times and is severe. Following aversion to cold, fever must appear. During fever, one feels only heat without cold; during chills, one feels only cold without heat. This is unlike other conditions where aversion to cold and fever occur simultaneously.

In plague-epidemics, aversion to cold rarely transmits inward but often remains on the exterior. The differentiation relies on observing qi, complexion, spirit, pulse, and tongue coating, similar to differentiating fever, with differences only in depth, superficiality, deficiency, and excess. When the pathogen is shallow and on the exterior, the duration of aversion to cold is shorter than that of fever. The treatment method and formulas are the same as for fever, but primarily focus on releasing the exterior (Jiebiao). When the pathogen is in the half-exterior half-interior stage, alternating chills and fever resembling malaria occur; the treatment method and formulas are also the same as for fever.

When the pathogen penetrates deeply into the interior, and purgation is delayed, deep heat leads to deep extremity cold (Re Shen Jue Shen), manifesting as a desire to cover oneself with blankets and approach fire, presenting as aversion to cold without fever, or with only slight fever, and even cold extremities. Although this presents as aversion to cold, it is not true cold; rather, it is yang qi constrained and blocked by the pathogen. Treatment should focus on unblocking the constraint, selecting Da Yuan Yin (Origin-Reaching Decoction), Da Chai Hu Tang (Major Bupleurum Decoction), or the three Cheng Qi Tangs (Three Order-Regulating Decoctions). This allows the interior qi to flow freely and the constrained yang qi to disperse, potentially resulting in high fever, restlessness, and thirst. This condition is most difficult to identify as heat during the phase of aversion to cold; one must examine the nine orifices. Signs include red eyes, dry nostrils, ruddy lips, yellow-black dry tongue coating, tinnitus or deafness, yellow/red/astringent/painful urination, dry constipation, or loose yellow foul-smelling stool, bloody stool, or tenderness and inability to press from the epigastrium to the lower abdomen. These are all signs of deep heat and constrained yang. Generally, if the whole body shows cold signs but one or two areas show heat signs, one should prioritize the heat diagnosis; conversely, if the whole body shows heat but one or two areas show cold, one should prioritize the cold diagnosis. This is the key to distinguishing between true and false cold and heat. Among the thousands of plague cases I have treated, only one or two out of a hundred presented with interior aversion to cold. Even those with cold extremities and cyanotic nails reported no subjective feeling of cold when asked about their discomfort. This provides a general overview.

However, if the original condition was a heat-type plague, but due to the patient's inherent deficiency, old age, or excessive use of purgative and cooling drugs after a major illness, leading to incessant sweating, simultaneous vomiting and diarrhea, mild cold extremities, fine and soggy pulses throughout, and aversion to cold, this is Yang Deficiency caused by excessive attacking. Treatment should prioritize Ren Shen (Ginseng Radix et Rhizoma), Fu Ling (Poria), and Bai Zhu (Atractylodis Macrocephalae Rhizoma). If the cunkou (radial artery at wrist) pulse is faint, assist with Sheng Ma (Cimicifugae Rhizoma) and Chai Hu (Bupleuri Radix); if the chi (distal radial artery) pulse is faint, assist with Gui Zhi (Cinnamomi Ramulus) and Fu Zi (Aconiti Lateralis Radix Praeparata). Note that although this is Yang Deficiency, it originated from a heat condition, so yin must be deficient. Therefore, Gui Zhi and Fu Zi should not be overused; it is advisable to assist with yin-nourishing herbs such as Bai Shao (Paeoniae Radix Alba), Mai Dong (Ophiopogonis Radix), and Wu Wei Zi (Schisandrae Chinensis Fructus). The warming and tonifying action here should be gradual. If warming and tonifying are insufficient, death ensues; if overused, although yang may return, yin exhaustion will cause death. Thus, careful deliberation is essential. There are also cases of aversion to cold resulting from deficiency due to excessive purgation/dispersal, or aversion to cold resulting from excess due to premature use of cold/cooling drugs.

When the epidemic pathogen is just latent in the Mu Yuan (Membrane Source) and has not yet transmuted, there is often phlegm stagnation in the chest and diaphragm. Some physicians, seeing irritability, hastily use Zhi Mu (Anemarrhenae Rhizoma), Shi Gao (Gypsum Fibrosum), Huang Qin (Scutellariae Radix), and Lian Qiao (Forsythiae Fructus - *Note: Text says 'Gao', likely referring to Gao or similar bitter cold herbs, usually interpreted as Gao Ben or similar in context of Qing Re, but strictly 'Gao' might be a typo for 'Shi Gao' or generic term. Given context 'Zhi, Gao, Qin, Lian', 'Gao' likely refers to Shi Gao or similar. I will translate as Gypsum or similar cold herb*). Others, seeing thirst, hastily use Sheng Di Huang (Rehmanniae Radix) and Mai Dong. Patients who self-diagnose fire syndromes and consume cold water, watermelon, pear, or shepherd's purse too early can also suppress yang qi and obstruct pathogenic heat. This traps heat in the middle and lower jiao, while cold substances and retained phlegm stagnate in the upper jiao, frequently causing aversion to cold. In such cases, treatment must focus on promoting the dispersion and guidance of phlegm stagnation. Once phlegm stagnation clears, aversion to cold ceases. Do not over-warm, lest it cause lower jiao blood stasis, heat accumulation, macules, jaundice, and hiccups leading to death; do not over-cool, lest it cause chest and abdominal fullness and danger. Suitable herbs include Cao Guo (Tsaoko Fructus), Hou Po (Magnoliae Officinalis Cortex), Bing Lang (Arecae Semen), Mu Xiang (Aucklandiae Radix), Ban Xia (Pinelliae Rhizoma), Cang Zhu (Atractylodis Rhizoma), Lai Fu Zi (Radish Seed), Fu Ling (Poria), and Ze Xie (Alismatis Rhizoma) to guide phlegm, open stagnation, and drain water. Once phlegm, stagnation, and water are removed, aversion to cold stops and heat signs emerge. Subsequently, apply cooling, resolving, or purgative formulas according to the transmission pattern for effectiveness. This method specifically treats iatrogenic errors, not the primary disease itself.

In summary, in wind-cold diseases, aversion to cold is heavy; in plague-epidemics, it is light. Many cases start with aversion to cold, which resolves spontaneously after one or two days as the pathogen transmutes if untreated. It is better to wait than to mistreat. Mistaking aversion to cold for true cold and using acrid-warm dispersing drugs will invariably exacerbate the condition.