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At the onset of Shanghan (Cold Damage), fever appears first, followed by aversion to cold; at the onset of Yi (Epidemic Disease), aversion to cold appears first, followed by fever. After one or two days, there is only fever without aversion to cold. This indicates that while the symptoms of fever and aversion to cold are the same, their sequence of appearance differs. Some cases resemble Taiyang disease (disease pattern caused by pathogenic factors invading the Taiyang channel) and Yangming disease (disease pattern caused by pathogenic factors invading the Yangming channel); however, in Taiyang and Yangming diseases, headache does not feel as severe as being split open, whereas in Yi disease, the headache feels like splitting, and the head is so heavy it cannot be lifted. Shanghan presents with no sweating, whereas Yi presents with no sweating on the lower body but sweating on the upper body, with sweating on the head being particularly profuse. The head is the meeting point of all Yang channels; fire has a nature of flaming upward. When toxic heat stagnates internally, it boils the fluids of the five zang organs, causing hot qi to rise upward, similar to dew condensing from steaming under a cover. Thus, sweating is concentrated solely on the head. This further illustrates that although the pain is similar, the sweating pattern is uniquely different. Some cases resemble Shaoyang disease (disease pattern caused by pathogenic factors invading the Shaoyang channel) with vomiting, and some resemble Taiyin disease (disease pattern caused by pathogenic factors invading the Taiyin channel) with spontaneous diarrhea. In Shaoyang vomiting, the hypochondrium must be painful, and the ears must be deaf; in Yi vomiting, the hypochondrium is not painful, and the ears are not deaf, because latent toxins within the body cause evil fire to harass the Stomach, with toxic vapors rushing upward, causing frequent episodes. In Taiyin spontaneous diarrhea, the abdomen must be full; in Yi spontaneous diarrhea, the abdomen is not full. The Large Intestine is the official responsible for transmission and excretion. When heat pours into the Large Intestine, some patients pass foul-smelling feces, some have clear liquid flowing out alongside normal stool, and some defecate dozens of times a day. This again shows that while the symptoms differ, the underlying pathology is the same. Such distinctions clarify that this is Yi disease; why persist in treating it using methods for Shanghan?

Zhang Zhongjing discussed that Zheng Shanghan (True Cold Damage) occurs after the Winter Solstice. This implies that if it does not occur after the Winter Solstice, its treatment can only be inferred by analogy. His emphasis on Shanghan lies in the three characters "after the Winter Solstice." Scholars discussing Zhang Zhongjing's works focus intently on the seventy-two syndromes but completely neglect the significance of "after the Winter Solstice." Consequently, regardless of whether it is Spring, Summer, Autumn, or Winter, they treat all conditions as Shanghan. In essence, among the Qi of the four seasons, cold is merely one type. Because illness contracted in winter is due to cold, it is called Shanghan. However, when it becomes warm in spring and hot in summer, it is still incorrectly termed Shanghan, ignoring where the cold injury originated. I often argue that Re Yi (Heat Epidemic) is not Shanghan, and Shanghan does not manifest with macules and papules. Someone asked me: "You state that Re Yi is not Shanghan, which I understand. But you say Shanghan does not develop macules and papules. Why did the ancients say that if heat in Shanghan has not yet entered the Stomach, premature purgation allows heat to enter the empty Stomach, causing macules; and if heat has already entered the Stomach but purgation is delayed, preventing heat release, macules also appear? What does this mean?" I replied: "This is an error in the ancients' reasoning. Take the character 'heat' itself to prove it is not Shanghan; heat and cold are opposites and do not coexist. If it is Shanghan, how can heat enter the Stomach? If heat has entered the Stomach, why is it still called Shanghan? Even when using formulas such as Baihu Tang (White Tiger Decoction), Sanhuang Tang (Three Yellows Decoction), Huaban Tang (Macule-Transforming Decoction), and Jiedu Tang (Detoxification Decoction), all treatments address heat, never cold. Why do modern practitioners fail to realize the ancients' error, thereby misleading themselves and others? Regarding the distinction between macules and papules: large lesions are macules, small ones are papules. Red color indicates extreme Stomach heat, with a prognosis of ten deaths to one survival; purple-black color indicates rotting of the Stomach, with nine deaths to one survival. However, my judgment of life and death does not depend on the size or purple-black color of the lesions, but solely on whether their morphology is loose and floating or tight and bound. If macules appear loose, lively, and floating on the skin surface, red like cinnabar dots on paper or black like ink on skin, this indicates toxic heat manifesting loosely outwardly; even if purple-black and confluent, survival is possible. If lesions appear small like millet grains but are tight, bound, and rooted, like a needle penetrating the sole of a shoe or an arrow hitting the target, this indicates toxic heat deeply rooted and knotted; even if not purple-black, death is inevitable. If one can carefully examine and weigh these signs, applying divine discernment between loose-floating and tight-bound states, and deciding life and death at the moment of clinical presentation, one will believe my words are not erroneous."