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Zhu Danxi stated: Zhang Zhongjing discussed Shanghan (Cold Damage) but did not cover Zhonghan (Cold Stroke). Ancient sages, when treating severe cold in the stomach leading to coma, used Fuzi Lizhong Tang (Aconite and Poria Decoction for Regulating the Middle) to bring peace; their discussion on medication was appropriate. However, they only mentioned "Shang" (Injury) and not "Zhong" (Stroke), and it is unheard of that anyone discussed the similarities and differences between them. I reflect that Shanghan has cases that manifest immediately and those that do not; it necessarily involves high fever, with pathogenic factors entering via the meridians and gradually deepening. Zhonghan, however, results from sudden exposure, causing immediate and violent onset. Patients with Shanghan have pre-existing stagnant heat within; when wind-cold invades externally, the muscle interstices become dense, leading to stagnation and transformation into heat. In the initial stage, using Ma Huang (Ephedrae Herba) and Gui Zhi (Cinnamon Twig) to release the exterior is appropriate because the patient's constitution is not significantly deficient. Patients with Zhonghan, taking advantage of open and loose skin pores, suffer from pathogenic invasion throughout the body, making it difficult to distinguish meridians; there is no heat to release, so warming and tonification are required for resolution, indicating a severe deficiency of Stomach Qi. Although Shanghan involves severe fever, it is not fatal; if Zhonghan is not treated urgently, death is imminent. Thus, the distinction between deficiency and excess is evident.

Note: Zhang Zhongjing’s discussion of Shanghan extends to the Three Yin syndromes, where cases can be treated with sweating methods, belonging to external contraction. Han Zhihe listed warming methods, which target Zhonghan. Zhang Jiegu argued that Three Yin syndromes could be treated with purgatives, and Wang Haizang listed methods suitable for tonification; all refer to internal injury. However, Han Shi did not directly point out Zhonghan but established examples based on Yin syndromes, listing methods for warming the middle, differing from Zhang Zhongjing’s argumentation for Three Yin diseases. He established separate formulas, implying Zhonghan but lacking clarity. Therefore, Mr. Zhu Danxi re-emphasized this meaning. Nevertheless, these texts should be studied in detail, and clinical treatment should be adapted appropriately.

The Neijing states: "Yang deficiency leads to external cold." This is because Yang Qi receives its energy from the Upper Jiao to warm the skin and muscle spaces. If cold pathogen remains outside, the Upper Jiao becomes obstructed. Obstruction of the Upper Jiao causes cold pathogen to remain exclusively outside, resulting in chills. "Yin excess leads to internal cold." This occurs due to rebellious Qi moving upward, causing cold pathogen to accumulate in the chest without being discharged. Without discharge, warming Qi departs, leaving cold pathogen alone. Blood coagulates and stagnates; stagnation blocks the vessels. The pulse is large and forceful yet choppy, thus causing internal cold. According to this, cold caused by Yin-Yang deficiency or excess originates from emotional disturbances, as explained in the Tiaojing chapter.

Li Dongyuan stated: Chills at night and tranquility during the day indicate that Yin Blood is flourishing in the Yin aspect. Chills at both night and day indicate excessive Yin with absent Yang; one should urgently drain the Yin and vigorously tonify the Yang. Tranquility at night and chills during the day indicate that Yin Qi overflows into the Yang aspect.

Note: This is also caused by Yin excess; the root disease is not an external factor of contracting cold. In Shanghan caused by external factors, chills in the Three Yang syndromes indicate unresolved exterior pathogens. In Taiyin syndrome, the hands and feet are warm, so there are no chills. In Shaoyin and Jueyin syndromes, the hands and feet are cold and there are chills, which is due to Yin excess. This differs slightly from the aforementioned conditions.