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(Annotation by Chen Kunzai of Shanyin)
When the pulse at the cunkou (radial artery) is tight in both yin and yang positions, according to medical principles, this indicates that clear pathogenic factors attack the upper jiao, while turbid pathogenic factors attack the lower jiao. Clear pathogens attacking the upper part are called "Jie" (pure); turbid pathogens attacking the lower part are called "Hun" (turbid). When the yin aspect is attacked by pathogens, internal shivering must occur. This is because the exterior qi is slightly deficient and the interior qi fails to maintain its post, thus allowing pathogens to invade the yin aspect. When the yang aspect is attacked by pathogens, fever, headache, stiffness of the neck and nape, soreness and pain in the lower back and calves must occur; this is referred to as the yang aspect being attacked by mist and dew. Hence it is said that clear pathogens attack the upper part, and turbid pathogens attack the lower part. Yin qi affected by pathogens manifests as shivering, cold reversal of the feet and knees, and incontinence of urine and feces. The exterior qi is slightly deficient, the interior qi is slightly tense, the three jiaos are mixed and confused, and the internal and external pathways are obstructed. The upper jiao becomes stagnant, and the qi of the zang organs熏 (fumes upon) each other, leading to oral ulceration and inability to eat. If the middle jiao fails to regulate, stomach qi rebels upward, spleen qi fails to transform, turbidity forms in the stomach, Ying and Wei qi do not circulate smoothly, and blood coagulates and stagnates. If Wei qi flows freely first, urine will also be yellow; combing with heat, acting as a vehicle for heat, it wanders through the meridians, entering and exiting the zang-fu organs. Wherever the hot qi passes, abscesses and pus form. If Yin qi flows freely first, Yang qi becomes厥逆 (rebellious and weak), and Yin has no agent to act upon. Exogenous pathogens enter internally, expelled by sneezing, accompanied by hoarseness and throat obstruction. Cold reversal chases the pathogens, which are constrained by heat, causing blood to coagulate and flow downward, resembling pig liver. If both Yin and Yang qi experience reversal, Spleen qi becomes isolated and weak, the five fluids pour downward, the lower jiao fails to close, resulting in clear stools with a sensation of heaviness in the anus, frequent but difficult defecation, colic-like pain in the umbilical region, and a life-threatening condition.

This section discusses the origin of contracting epidemic diseases. Epidemic pathogens are formed by a mixture of cold, summer-heat, dryness, dampness, and wind, where clear and turbid distinctions are lost, and the three jiaos become mixed. The terms "attacking upper/lower" refer to the nature of the pathogens' clarity or turbidity; "yin/yang attack" refers to their invasion of the upper or lower parts. The key lies in restoring the function of the middle jiao. The middle jiao refers to the Spleen and Stomach. If the Qi of the Spleen and Stomach maintains its regulatory power, if Wei Qi flows freely first, pathogens can be resolved through sweating via the meridians; if Ying Qi flows freely first, pathogens can be resolved through purgation via the fu organs. However, if the Qi of the Spleen and Stomach is insufficient, pathogens will inevitably sink inward and damage the zang organs, causing the five fluids to pour downward, difficult defecation, and umbilical pain, leading to a life-threatening situation. The formation of abscesses and the passage of blood clots resembling pig liver refer to severe cases and may not always present exactly so. Therefore, the greatest fear in epidemic syndromes is pathogens lying dormant in the Mu Yuan (Omen Plain), causing internal blockage without resolution, making them difficult to treat. In Taiyang disease, when the pulse is tight in both yin and yang positions, with aversion to cold and fever, the pulse exhibits signs of Jue (reversal). The characteristic of Jue pulse is that it initially appears large, gradually becomes smaller, then gradually becomes larger again. Mr. Yang states: Epidemic diseases involve the diffusion of foul pathogens, and their pulses are usually indistinct and blurry; the gradual enlargement and contraction mentioned here precisely describe this sign. Such cases involve aversion to cold; in severe instances, there is slight sweating, sore throat, and excessive heat leads to red eyes and rapid pulses with dull vision. Mr. Yang notes: In all epidemic syndromes, the eyes appear dull. If the physician erroneously induces sweating, the throat will be injured. If erroneously purged, the eyes will close. Predominance of cold pathogens results in undigested food in stool; predominance of heat pathogens results in pus and blood in stool. Moxibustion/fumigation causes jaundice; ironing/pressing causes dry throat. If urination is free, the condition is salvageable; if urination is difficult, the condition is critical.

This section discusses the initial symptoms and pulse of epidemic pathogens. Tightness in both yin and yang pulses, along with aversion to cold and fever, are similar to Taiyang disease, but the Jue pulse that gradually contracts and enlarges distinguishes epidemics. Because pathogens lie deep and Zheng Qi cannot circulate freely, aversion to cold occurs initially, progressing to fever, sweating, sore throat, and red eyes. Inducing sweat due to aversion to cold aids heat and steams upward, injuring the throat. Purging due to internal heat causes Yang Qi to sink inward, closing the eyes. Excess Yin pathogens lead to undigested food in stool; excess Yang pathogens lead to pus and blood in stool. Fumigation causes damp-heat to stagnate and jaundice; pressing causes heat to dry fluids and injure the throat. The root cause is pathogens lying dormant in the Mu Yuan, rendering sweating, purging, fumigation, and pressing all erroneous treatments. Salvageability depends on the patency of urination. Mr. Yang states: Free urination in warm diseases indicates Yin Qi is not exhausted; free urination in epidemics indicates Fu organ Qi is still patent. With an exit for pathogens, both are treatable.

In Taiyang disease, presenting with fever, headache, and slight sweating, inducing sweating leads to confusion and inability to recognize people. Fumigation causes asthma, inability to urinate, and abdominal fullness. Purging causes shortness of breath, difficulty urinating, headache, and stiff back. Adding warm needle therapy causes epistaxis.

This section discusses clear pathogens attacking the upper jiao, hence predominantly Yang branch syndromes. Clear pathogens attacking the upper jiao enter directly into the Mu Yuan. Fever, headache, and slight sweating result from pathogenic heat steaming, indicating the pathogen is not in the exterior. Thus, sweating causes intense heat and coma. Mr. Yang states: Sweat is the fluid of the Heart; excessive sweating depletes Heart Qi, allowing pathogens to obscure the clear Yang. Fumigation causes heat congestion and asthma; Mr. Yang states: Fumigation adds heat to heat, damaging the upper source of water (Lung). Inability to urinate and abdominal fullness indicate Qi obstruction, not interior pathology. Shortness of breath, difficulty urinating, headache, and stiff back result from purging damaging body fluids. Epistaxis results from warm needles damaging collaterals. Mr. Yang states: Pathogenic heat enters the Ying level, causing epistaxis. Treatment should first unblock the Mu Yuan to prevent these complications.

In Taiyang disease, fever, forceful expulsion of Qi from the mouth, headache, yellow eyes, and uncontrollable epistaxis occur. Those desiring water will vomit. Mr. Yang states: Water accumulation without transformation causes vomiting. Those repulsed by water experience cold reversal. Mr. Yang states: Unchecked intense heat causes reversal. Purging causes ulcers in the throat. Mr. Yang states: Heat lingering in the upper jiao causes ulcers. If hands and feet are warm, heavy bearing down and pus/blood in stool will occur. Mr. Yang states: Extremities belong to the Spleen; warmth indicates heat pathogens filling the Spleen and Stomach, causing pus/blood in stool. For headache and yellow eyes, purging causes closed eyes. Mr. Yang states: Warm pathogens cannot be cleared by scouring; instead, it damages Zheng Qi, causing eye closure. Those desiring water have a Jue pulse, low voice, and throat obstruction.

Mr. Yang states: This is also a sign of water accumulation and overflow. Sweating causes shivering and deficiency of both Yin and Yang. Mr. Yang states: Pathogens are in the interior, not the exterior; sweating only depletes the exterior. Those repulsed by water, if purged, develop interior cold, anorexia, and undigested food in stool. Mr. Yang states: Repulsion of water indicates dampness predominance and mild heat; purging damages Middle Qi. Sweating causes oral injury and white tongue coating. Mr. Yang states: Exhaustion of fluids allows foul pathogens to steam upward. Restlessness and rapid, solid pulses indicate intense internal heat. Constipation for six to seven days leads to bloody stool. Sweating causes free urination. Mr. Yang states: The Taiyang Bladder governs fluids; sweating depletes Zheng Qi, losing control.

This section discusses turbid pathogens attacking the lower jiao, hence predominantly Yin branch syndromes. Turbid pathogens attacking the lower jiao do not mean infection from below; they still distribute from the Mu Yuan, meaning Yin pathogens return to the Yin aspect. Pathogens merging into Yin cause Yin excess and Yang deficiency, manifesting as forceful Qi expulsion, headache, yellow eyes, uncontrollable epistaxis, desire for water with throat ulcers, heavy bearing down with pus/blood in stool—this is Yin excess. Closed eyes, Jue pulse, low voice, throat obstruction, shivering, anorexia, undigested food in stool, and free urination constitute Yang deficiency. Excess is true excess; deficiency is false deficiency. Thus, treatment cannot focus solely on Yin or Yang.

Patients with no exterior or interior signs, febrile for seven to eight days, even with floating and rapid pulses, may be treated with purgation. If purged and the rapid pulse persists, combined heat causes polyphagia. By the eighth or ninth day, if constipation persists, blood stasis is present, requiring Dishui Tang. If the rapid pulse persists with unremitting diarrhea, heat-collateral dysentery with pus and blood ensues.

This section discusses the divergent transmission of epidemic pathogens. No exterior or interior signs indicate pathogens in the Mu Yuan (initial stage). Rapid pulse indicates intense internal heat; floating indicates heat steaming outward. Fever for seven to eight days without resolution via sweating indicates deep internal heat, warranting purgation (current state). If already purged and rapid pulse persists, heat transmitting to Yang causes polyphagia (Wei Qi flowing freely); heat transmitting to Yin damages blood forming stasis (Ying Qi flowing freely), requiring Dishui Tang (passing clots like pig liver). If rapid pulse persists with pus/blood in stool, Spleen Qi is isolated, five fluids pour downward, constituting an untreatable condition. Do not mistake this for ordinary heat-collateral diarrhea.

Disease in the Yang aspect should be resolved by sweating; erroneously spraying or pouring cold water suppresses the heat, preventing its release, increasing irritability, causing gooseflesh, thirst without actual desire to drink. Administer Wenli San. Mr. Yang states: This applies to both warm and heat diseases, not just epidemics.

If unresolved, administer Wuling San. For Cold-Excess Jie Xiong (Chest Binding) without heat signs, administer Sanwu Xiaoxianxiong Tang; Baisan may also be used.

This section discusses epidemic pathogens transmitting to the exterior. The character "Que" (retreat) is suspected to be a typo for "Jie" (rob/seize). Xu Yazhi argues: "Que" means unable to advance; heat suppressed by cold cannot exit, turning inward, causing increased irritability, so "Que" is likely correct. Mr. Yang agrees. Wenli San likely belongs to Wenli Decoction. Disease in the Yang aspect means epidemic pathogens have entered the Yang branch. Transmission to Yang requires sweating. "Pen" means spray; "Guan" means irrigate. Extreme epidemic heat could normally be resolved by drinking cold water to induce sweating; instead, spraying/irrigating the skin suppresses internal heat externally, worsening internal irritability and causing gooseflesh. Thirst without desire to drink indicates internal heat controlled by external water. Wenli (Clam Shell) is cold and drying; combined with Mahuang Xingren Shigan Tang, it removes external water and clears internal heat. Wuling San also promotes diuresis to eliminate heat. The phrase "Xiaoxianxiong Tang and Ke Yi Fu" (Seven characters) is suspected to be superfluous.

Taiyang disease with hiccups and abdominal fullness: Observe the anterior and posterior orifices to determine which is obstructed; unblocking it cures the condition.

This section discusses epidemic pathogens transmitting to the interior. Hiccups are often cold in Taiyang disease but heat in epidemics. Given abdominal fullness and obstruction of anterior/posterior orifices, pathogenic congestion is certain. Anterior/posterior refer to urination and defecation. Unblocking both is the method of draining the interior.

After six to seven days of illness, with slow, floating, weak pulses, aversion to wind/cold, and warm hands/feet, if the physician purges multiple times, leading to anorexia, hypochondriac fullness/pain, jaundice of face/body, stiff neck, and difficulty urinating, administering Chaihu Tang will cause heavy bearing down. If originally thirsty but vomiting after drinking water, Chaihu Tang is contraindicated; eating triggers hiccups.

This section discusses epidemic pathogens transcending the Three Yang branches. Six to seven days of illness with aversion to wind/cold and floating/weak pulses is not exterior deficiency. Warm hands/feet with slow pulse is not interior cold. Combined, this indicates epidemic pathogens lying dormant internally. Physicians focusing on draining the interior purge repeatedly, damaging Middle Qi, causing anorexia and difficulty urinating. Hypochondriac fullness/pain indicates Shaoyang; jaundice indicates Yangming; stiff neck indicates Taiyang. With pathogens transcending the Three Yangs, one should use heat-clearing and detoxifying formulas, adding meridian-guiding herbs based on syndrome. Clinging to hypochondriac pain as Shaoyang and using Chaihu Tang traps pathogens with Ginseng, Licorice, Ginger, and Dates, causing dysentery. Thirst followed by vomiting indicates internal fluid retention, not Shaoyang vomiting; Chaihu Tang is contraindicated. Hiccups after eating result from pathogenic obstruction, not interior cold. The final sentence likely has missing text.

Taiyang disease unresolved, with pulses appearing equalized/stopped in both Yin and Yang positions: Shivering and sweating precede resolution. If only Yang pulse is micro, resolve via sweating; if only Yin pulse is micro, resolve via purgation. If purging is indicated, Tiaowei Chengqi Tang is suitable.

This section discusses epidemic pathogens transcending Taiyang. Unresolved Taiyang disease here refers to floating epidemic pathogens, not Taiyang Meridian disease. "Ting" means uniform/equal. Equalized pulses in Yin/Yang positions (Chi/Cun, Floating/Sinking, Slow/Rapid, Large/Small) indicate sufficient Zheng Qi to transform pathogens, resolving via sweating. Shivering is Zhan Han (battle sweat). Micro pulse indicates declining pathogens. Yang pathogens retreating first resolve via sweating; Yin pathogens retreating first resolve via purgation. While sweating methods vary, purgation should use Tiaowei Chengqi Tang, as epidemic heat is not necessarily excess-solid.

Taiyang disease, purged without resolution, then sweated again, resulting in dual deficiency of exterior and interior, leading to Mao (vertigo/dizziness). Mao resolves spontaneously with sweating because the exterior harmonizes. Only after interior harmony is achieved should purgation be considered.

This section discusses the error of purging then sweating for epidemic pathogens transmitting to the exterior. Epidemics reaching the exterior require sweating; premature purging depletes interior Qi, failing to resolve. Subsequent sweating depletes exterior Qi, causing vertigo. One must wait for exterior harmony before addressing the interior. Post-sweat epidemics may require purgation, or post-purgation may require sweating to resolve, depending on divergent transmission, lacking a fixed method.

Taiyang disease purged: Pulse Cu (surging/interrupted) without Jie Xiong indicates impending resolution. Floating pulse indicates Jie Xiong; tight pulse indicates sore throat; wiry pulse indicates hypochondriac spasm; fine-rapid pulse indicates persistent headache; sinking-tight pulse indicates nausea; sinking-slippery pulse indicates heat-collateral diarrhea; floating-slippery pulse indicates bloody stool.

This section discusses complications of erroneous purgation in epidemics. Although draining the interior is suitable, once pathogens transcend Taiyang, treatment should target the exterior. Erroneous purgation causes numerous complications. Cu indicates Yang excess; purging leads to Jie Xiong. Absence of Jie Xiong indicates Yang pathogens dispersing outward (resolution). Floating indicates exterior; purging sinks pathogens inward causing Jie Xiong. Tight indicates pathogenic excess; purging pushes pathogens upward causing sore throat. Wiry indicates wind-carrying; purging draws wind into Liver causing hypochondriac spasm. Fine-rapid indicates internal heat stagnation; purging drives fire upward causing persistent headache. Sinking-tight indicates fluid retention; purging agitates fluids causing nausea. Sinking-slippery indicates heat-damp stagnation; purging directs damp-heat downward causing heat-collateral diarrhea. Floating-slippery indicates exterior heat excess; purging drives heat inward causing bloody stool.

Yang Du (Poison) presents with facial redness, mottled rash like brocade, sore throat, and expectoration of pus/blood. Treatable within five days; untreatable after seven days. Shengma Biejia Tang is indicated.

Yang Du involves epidemic pathogens invading the Yang aspect. Yang pathogens congesting upward cause facial redness. Intense heat damaging blood causes widespread mottled rash. Sore throat and pus/blood expectoration indicate pathogenic heat scorching fluids with imminent putrefaction. Within five days, Jing Qi has not fully circulated, toxin is not widespread, hence treatable. After seven days, pathogens are widespread and Zheng Qi depleted, hence untreatable. Shengma Biejia Tang clears Yang toxicity, thereby saving Yin blood.

Yin Du presents with blueish face/eyes, body pain like being beaten with a club, and sore throat. Treatable within five days; untreatable after seven days. Shengma Biejia Tang minus Xionghuang and Shujiao is indicated.

Yin Du involves epidemic pathogens entering the Yin aspect. Yin invaded by pathogens causes blueish complexion. Pathogens blocking meridians cause body pain like beating. Sore throat indicates Yin-level heat-toxin congesting upward. Days match Yang channels, but Xionghuang and Shujiao are removed because Yin levels already suffer heat pathogens and cannot tolerate further heating herbs.

Wang Shiong annotates: Wang Andao states: Yin does not mean Yin-cold disease, but rather contracting heaven-earth foul toxic異气 (strange Qi) entering Yin meridians, hence named Yin Du. Later generations equated extreme Yin-cold with Yin Du, citing Zhang Zhongjing's "blueish face, body pain like beating, sore throat," yet prescribing Fuzi San or Zhengyang San. I argue that while extreme Yin-cold can be named Yin Du, it contradicts Zhongjing's original intent. Later Yin Du descriptions differ fundamentally from Zhongjing's. Later Yin Du arises from internal injury to cold/raw foods, sudden cold exposure, overuse of cold-cooling herbs, or dual cold injury, not heaven-earth toxic Qi. Zhao Yangkui states: These Yin/Yang Dues stem from heaven-earth epidemic Qi, contagious within families, termed seasonal epidemics.

Further annotation: Regarding Xionghuang and Shujiao for Yang Du, commentators suggest using Yang herbs for Yang pathogens to disperse quickly. I consider Xionghuang a detoxifier, so its use is plausible. However, Shujiao seems inappropriate for red face, rash, sore throat, and hemoptysis. Likely textual errors exist; forced explanations are invalid. Mr. Yang states: A reasonable view. Such ambiguities abound in Shanghan Lun; do not force interpretations.

Further annotation: Ni Chongzhi's Shanghan Huiyan cites Yuan Yunlong: Zhongjing's text lacks consistency across Six Channels. The Yang/Yin Du sections are particularly puzzling. Both use Shengma Biejia Tang; Yin Du merely omits Xionghuang/Shujiao, suggesting a later forged edition. Song dynasty Pang Anchang used the full formula for both, omitting nothing, which aligns better with logic. Obtaining a Nanyang old edition in Wanli Yihai year, the Yin Du section reads: "Remove Xionghuang, add half dose of Shujiao," which makes more sense. Yang/Yin Dues arise from improper lifestyle, essence depletion, Qi/Blood chaos, suddenly contracting mountain/water/miasma toxic Qi. Traveling North to Yan/Liaoyang and South to Min/Guang/Qian/Jiaozhi, I observed more Yang Du in the South, Yin Du in the North. Contemporary physicians failed to cure them. Central Plains cases were also rare successes. Analyzing both syndromes, "sore throat" is common. My study of surgical texts reveals Suohou Feng, Chanhou Feng, Tie'e Chan, similar in presentation: red rash-like face, blue miserable face, pus/blood expectoration, clubbed body pain, asthma, delirium. All share throat obstruction/pain as primary suffering. Acute onset: treatable in 3-5 days; if unchanged by day 7, fatal. Are these not variants of Yang/Yin Du? Pulse analysis: slow-large indicates survival; fine-rapid-tight-interrupted indicates death. Treating both regardless of type with throat remedies (Borax 2 qian, Fire Nitrate 6 fen, Rice Vinegar 1 liang, Ginger Juice small half liang), probing throat with goose feather to expel phlegm, saved hundreds. According to Mr. Yuan, Yang Du is Yang pathogen, Yin Du is Yin pathogen. Yin pathogens suit doubled Shujiao; applying Shujiao to Yang pathogens is questionable. Changing to throat-induced vomiting is safer. I speculate Yang Du corresponds to modern Lanhou Sha (Rotten Throat Sand), termed Wendu by Shuhe. Treatment forbids warm-dispersing; prefers clearing-transforming. Chen Jixuan's Yisha Cao specializes in this.

Discourse: Baihe Bing (Lily Disease) involves all vessels originating from one source, collectively diseased. Desire to eat but unable; constant silence; desire to sleep but unable; desire to walk but unable. Diet varies between palatable and rejected. Medication causes severe vomiting/diarrhea, as if possessed. Body shape appears normal; pulse is micro-rapid. Headache during urination heals in 60 days; non-headache with chilliness heals in 40 days; dizziness after smooth urination heals in 20 days. Symptoms may appear pre-onset, 4-5 days into illness, or after 20 days/months. Treat according to syndrome. Mr. Yang states: Jin Gui treats this syndrome most clearly and completely.