Library

Difficulty in urination. One must distinguish between Yin and Yang. The classics state: "Yin deficiency leads to difficulty in urination." However, when Yin is deficient, Yang inevitably encroaches upon it, causing difficulty in urination, with the urine appearing dark yellow. This indicates encroachment by Yang heat, signifying internal heat. It is due to a deficiency of Yin blood, insufficient to restrain Yang Qi, resulting in Yang excess and difficult urination. Wuling San (Five-Ingredient Powder with Poria) added with Talcum powder (Huashi Mo) is appropriate.

In Taiyang disease, after sweating therapy, perspiration continues unceasingly. The patient experiences aversion to wind, slight stiffness of the four limbs making flexion and extension difficult, accompanied by difficulty in urination. This indicates Yang Qi deficiency, insufficient to secure Yin fluids, leading to fluid dryness and difficult urination. Guizhi Tang (Cinnamon Twig Decoction) added with one qian of Shu Fuzi (Prepared Aconite Root), or additionally Fu Ling (Poria), is appropriate.

There are cases of Yangming disease presenting with shortness of breath, abdominal fullness, pain under the hypochondrium and heart region, nasal dryness, absence of sweat, jaundice, difficulty in urination, tidal fever, and hiccups. Xiaochaihu Tang (Minor Bupleurum Decoction) added with one qian of Fu Ling (Poria) is appropriate. The classics state: "Tidal fever occurring around the Shen hour (3-5 PM) belongs to the excess syndrome of the Stomach organ." This belongs to Yangming disease requiring purgation. However, there are cases where fever occurs every evening but subsides at Wu Geng (3-5 AM), with spontaneous loose stools, cured using acrid-hot agents like Ginger and Aconite. How can one hastily conclude it is a Yang or Excess syndrome merely based on evening tidal fever? Other symptoms must be consulted for comprehensive judgment. I once treated the son of a patient surnamed Shen; this was personally witnessed and verified by me.

The Three Yang meridians present with headache; the Three Yin meridians do not. This argument is ancient. However, occasionally there is headache in the Yin meridians. The Jueyin meridian circulates behind the throat and meets the Du meridian at the vertex. If there is no headache, it seems not to be the standard method. I once treated an elderly neighbor, Mr. Fan, who had body heat but slight absence of headache. After taking eight doses of Xiaochaihu Tang (Minor Bupleurum Decoction), he recovered. This point should not be overlooked.

When various diseases have resolved without other symptoms, but only headache remains, decocting scallion whites with roots and fresh ginger is suitable. If excessive sweating led to severe headache, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) added with one qian of Xiong (Ligusticum Chuanxiong Rhizome) is appropriate.

Yang syndrome patients can eat; Yin syndrome patients cannot. Heat consumes grain, leading to easy hunger. If a Yin syndrome patient can eat, it signifies the return of Yang Qi and impending recovery. However, food intake should not be excessive, as the Spleen Qi may still be weak and unable to digest. For Yang syndrome patients, failing to regulate diet increases illness; overeating after recovery causes relapse. Ancients called this "food relapse" (Shi Fu); now it is called "fa bu". Because excessive grain Qi assists Yang Qi, and "grain produces sweetness," acrid and sweet flavors disperse and belong to Yang. Therefore, for post-illness deficiency-cold syndromes, sages advised caution regarding grain consumption for recovery.

Treatment methods for Shanghan (Cold Damage): Yang syndromes have these manifestations, and Yin syndromes also have them. They appear Yang but are Yin, appear Yin but are Yang, making differentiation most difficult. The doubts mentioned earlier precisely address this, hence the item-by-item discussion. Regarding Yin Du (Yin Toxin), Yang Du (Yang Toxin), Feng Wen (Wind Warmth), Shi Wen (Damp Warmth), Wen Yi (Warm Epidemic), Wen Nüe (Warm Malaria), hematemesis, vomiting roundworms, macules, Liang Gan (Dual Infection), Baihe Disease (Lily Disease), Huhuo Disease (Fox Disease), Yin-Yang Exchange, toxin affecting Heart Qi and Pericardium/Lower Burner—all should follow the methods in *Nanyang Huoren Shu* (Mr. Living Person's Book by Zhang Zhongjing). Where are the medications detailed? The general outline of treating Shanghan does not exceed Yin and Yang. Grasping the outline, although details may not be exhaustive, reference to *Huoren Shu* is permissible.

Stomach cold必定 causes vomiting of roundworms; everyone knows vomiting roundworms indicates Yin. However, there are Yang syndrome cases vomiting roundworms. This is because the stomach is empty, lacking grain Qi, so roundworms move upward seeking food, reaching the throat and being vomited. One must observe other symptoms; one cannot solely attribute it to stomach cold. I recall a case of Yang Jaundice with vomiting roundworms, accompanied by extensive macules, belonging to Yang Du syndrome, with mouth ulcers, sore throat, and vomiting roundworms, all cured using cold agents. Does this not indicate a Yang syndrome?

Shanghan first attacks the Taiyang meridian, transmitting sequentially; this is merely a general statement. However, variations occur. Some originate from Yang and subsequently involve Shaoyin; some involve food stagnation complicating Shanghan, where food disturbs the Spleen (Taiyin meridian), presenting with abdominal fullness and pain immediately upon onset; some do not follow meridian transmission, such as directly attacking Yangming upon onset. Not all begin with Taiyang. Some remain confined to one meridian without transmitting; some transmit only one or two meridians and stop. Transmission through all meridians is not necessary. Regarding irregular transmission, one must not rigidly adhere to sequence but treat according to symptoms. Thus, Shanghan often presents with exterior signs. Zhongjing said: "Although many days have passed, if exterior signs exist, sweating is still appropriate; although few days have passed, if interior signs exist, purgation is immediate."

The preceding discussion places Shaoyang after Yangming, based on Five Elements generation and restriction. If Yang governs growth, Water generates Wood. Taiyang Bladder (Yang Water) transmits to Shaoyang Gallbladder (Wood). With Taiyang in the exterior and Shaoyang between exterior and interior, Yangming is in the interior, progressing gradually from outside to inside, which is the proper order. If it were as stated in *Shanghan Lun*: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang, how could the disease be in the interior on the second day and only half-exterior/half-interior on the third? I dare not readily refute this theory, yet my mind remains uneasy.

On the sixth or seventh day of Shanghan, if pulse is present in one hand but absent in both, this is a sign of impending complex disease (Hao Bing). Banxia Xiexin Tang (Pinellia Decoction to Drain the Epigastrium) or Shengjiang Xiexin Tang (Fresh Ginger Decoction to Drain the Epigastrium), formulas for combined diseases, are appropriate.

When Yangming purgation indications are complete, but the patient has wheezing/cough or slight aversion to cold, it is Taiyang-Yangming; if there is alternating chills and fever, it is Shaoyang-Yangming. If Yangming signs coexist with unresolved Taiyang/Shaoyang signs, it is not pure Yangming. Caution is required; do not hastily purge. Hence, ancient commentaries mention three types of Yangming; this must always be remembered.

There are complicated Shanghan diseases and typical Shanghan diseases. Complicated Shanghan is difficult to treat with standard methods. If symptoms vary, presenting both cold and heat clearly, treat the major aspects first, then slowly address remaining symptoms. Do not use purely hot or purely cold agents. For example, with vomiting, thirst, and irritability, administer Xiaochaihu Tang (Minor Bupleurum Decoction). If vomiting, thirst, and irritability cease but diarrhea persists, claiming Xiaochaihu Tang was incorrect contradicts the cessation of initial symptoms; claiming it was correct contradicts the emergence of diarrhea. With vomiting, diarrhea, and cold extremities, administer Fuzi Jiangxin Tang (Aconite and Ginger Decoction). If these cease but fever, thirst, delirium, and unconsciousness emerge, claiming Ginger/Aconite was incorrect contradicts the cessation of initial symptoms; claiming it was correct contradicts the emergence of new symptoms. This is also complicated Shanghan. Although clear concurrent cold/heat signs may not be obvious, Yin contains Yang, and Yang contains Yin, latent and not yet manifest. Bias in medication causes one aspect to weaken while the other strengthens. Physicians must carefully reconsider doubtful aspects, avoiding partiality, to achieve perfection.

Shanghan has Hao Bing (ruined/deteriorated disease), caused by failed sweating, vomiting, or purging therapies. If during illness, one contracts conflicting pathogenic factors: heavy contraction of cold leads to Wen Nüe (Warm Malaria, heat then cold); heavy contraction of wind leads to Feng Wen (Wind Warmth, flaccid limbs, headache, body heat, spontaneous sweating); heavy contraction of warm-heat leads to macules, termed Wen Du (Warm Toxin), the most severe form. At this stage, meridian transmission loses its structure, all termed Hao Shanghan. Treat according to the primary disease in *Huoren Shu*.

The critical point in Shanghan is distinguishing exterior and interior to decide on sweating or purging. Patients may have spontaneous sweating or diarrhea; doctors may induce sweating or purging. There are many nuances. Sweating agents should be used early; purging agents late. This is a general principle. For instance, patients with blood loss should not be sweated; patients with stranguria should not be sweated. Such cases require gradual resolution, not abrupt exterior-releasing agents.

If sweating is forced when inappropriate, fluids are exhausted, generating myriad diseases, leading to premature death. One cannot simply argue "sweating agents should be used early." When Yangming sweating is profuse, urgent purgation is needed; when Shaoyin diarrhea involves thirst, urgent purgation is needed; when Jueyin tongue curling and testicular retraction occur, urgent purgation is needed. Such cases require immediate purgatives. If purgation is delayed when indicated, heat-toxin deepens, becoming incurable. One cannot simply argue "purgative agents should be used late."

Regarding sweating method: aim for uniform mild sweating, not drenching sweat. Regarding purgation: after one dose, if no bowel movement after walking ten li, administer the next dose. After evacuation, do not finish the prescription. Shanghan treatment should not lightly use exterior-releasing agents. Even if Mahuang Tang (Ephedra Decoction) or Guizhi Tang are indicated, start with Xiong Zhi Pu Zhu Tang (Ligusticum, Chrysanthemum, Magnolia Bark, Atractylodes Decoction), such as Hejie San (Harmonizing Powder) or Xiong Zhi Xiang Su Yin (Ligusticum, Chrysanthemum, Perilla, Liquorice Drink) plus Cang Zhu (Atractodes Macrocephala Rhizome). For interior attack, even if Dachengqi Tang (Major Order the Yield Decoction) or Daxiehu Tang are indicated, start with Xiaochengqi Tang (Minor Order the Yield Decoction) or Xiaochaihu Tang. For Yin syndromes requiring Sini Tang (Frigid Extremities Decoction), start with Lizhong Tang (Regulate the Middle Decoction); for Zhenwu Tang (True Warrior Decoction), start with Sanbai Tang (Three Whites Decoction). This respects the ancients' caution against underestimating pathogens. If the condition is critical, do not miss the opportunity; do not rigidly adhere to this rule.

Shanghan Yin syndromes may have headaches; positive Yang syndromes invariably have headaches. Yin syndromes may have fever; positive Yang syndromes invariably have body heat. Yin syndromes may have red urine; positive Yang syndromes invariably have red urine. This is the standard method.

Ganmao (Cold Sensation) includes Wind-Cold syndromes, which are exterior signs of Shanghan. Mild initial infection is called Ganmao; severe internal invasion is Zheng Shanghan (True Shanghan). Initial treatment is similar to Taiyang syndrome. Patients often dislike the term Shanghan, not knowing light cases are Ganmao, heavy are Shanghan, and very heavy are Zhong (Strike). Denying the name despite having the disease is meaningless, likely due to colloquial fear of the term "major illness."

I once saw a patient with fever, aversion to cold, body ache, and headache. The doctor diagnosed Taiyang syndrome and used Wuji San (Five Accumulations Powder) to release the exterior. Six days later, the patient developed thirst, delirium, and constipation. Xiaochaihu Tang was given, followed by Daxiehu Tang. After evacuation, sudden cold extremities, tongue curling, testicular retraction, rapid breathing, and sleeping facing inward occurred. Zhenwu Tang was administered, but diarrhea persisted unchanged. Then Fuzi Lizhong Tang and Sini Tang were used, finally stopping diarrhea and warming hands/feet. That night, peace prevailed. The next day, fever, delirium, thirst, and painful red urination returned. After six-seven more days, constipation recurred. Run Chang Wan (Moisten Intestines Pill) restored bowel movement, but symptoms persisted. Finally, Wendan Tang (Warm Gallbladder Decoction) plus Ginseng and modified Wuling San (reduced Cinnamon) led to gradual recovery. Using cold medicines favored Yin, causing rapid changes due to overdose. If after Sini Tang Yang signs recur, and the physician fails to examine carefully, using Dachengqi/Daxiehu again will revert to Yin. Success came from Wendan Tang and Wuling San due to their stability. This serves as a warning against excessive medication.

Spring illnesses are called Wen (Warmth); summer illnesses are called Re (Heat). These do not exceed these categories, differing only by name due to season. Abnormal Qi affects people, gaining the name Shiqi (Seasonal Qi). Commonly called Shanghan today. Since weather is hot, ancients warned against using hot remedies in hot seasons. Guizhi Tang should add Huangqin (Scutellaria Root), named Yangdan Tang (Yang Dawn Decoction). Wuji San should add Shigao (Gypsum), Shengma (Cimicifuga Rhizome), and Zhimu (Anemarrhena Rhizome). Zhenwu Tang is a preliminary agent for Yin syndromes. If hesitant to use Shu Fuzi (Prepared Aconite), raw Fuzi is safer, or a mix of raw and prepared. For phlegm-heavy patients, raw Fuzi is especially suitable. For common colds, Hejie San, Xiangsu Yin, or adding Cang Zhu to Buhuan Jin Zhengqi San, Puxian Zhengqi San, Duijin Sanzi, Yangwei Tang are all exterior-releasing agents. For releasing muscle heat and Upper Jiao heat, Rensu Yin, Baidu San, Baijie San, Shishen Tang... Differences between Wind and Cold in Taiyang, and differences between typical and combined diseases in Three Yang, must be distinguished.

Northern people initially use equal parts Cang Zhu and Mahuang for sweating. Upon feeling intense heat, Fangfeng Tongsheng San (Saposhnikovia Unblocking Hero Powder) is used. North-South customs differ due to inherent constitution.

I recall an elder saying: After Ganmao sweating therapy, symptoms resolved except for residual body heat. Using warm herbs kept the heat. With no interior/exterior differences, and sweating/purging/warming/cooling all unsuitable, Yangzheng Dan (Nourishing Righteousness Pellets) 40-50 grains are appropriate.

After recovery, with no other symptoms but slight residual heat, and long-term Spleen Qi deficiency/lack of regulation: Spleen governs muscles, generating residual heat. Dry tonification is unsuitable; Lizhong Tang added with honey is appropriate.

Originally a Yang syndrome, transformed into Yin due to excessive sweating/purging. Treating it as Yin is incorrect. Claiming it follows the "Yang transmitting to Yin" theory refers to deteriorated Three Yang syndromes turning Yin. This is a reversal of Yang, not transmission.

Deficient persons with Ganmao fever: if fever lasts only one day, is not prolonged or severe, but delirium appears, it indicates deficiency cannot tolerate heat. Do not hastily use strong cold agents.

Three Yin headaches are not typical. However, Yin excess blocking Yang can cause headache. Since the root is Yin, and Yang is oppressed by Yin, Yang signs appear.

Originally Yang syndrome, suddenly treated with cold agents, leading to persistent diarrhea while Yang signs remain unchanged. Use warm medicine to secure the lower jiao, stabilize, then treat according to symptoms. Do not use hot medicine. Initial Yang meridian headache transmitting to Yin with slight absence of headache does not immediately indicate Yin syndrome. Ask if headache existed at onset.

Sweating/purging fails to reduce heat; cooling muscle agents fail; lasting half a month or more indicates Yang Qi leaving its meridian, unable to return, lodging in skin/flesh. Many suffer this. Regulate, tonify, and astringe; do not use heavy acrid-hot agents. Also, after six-seven days, when chills/fever precede sweating, if restlessness is excessive, sweating resolves it. This is because sweat formed but was incomplete. Mistakenly using cold agents during restlessness causes harm; careful examination is essential.

Slight aversion to wind, slight fever, normal daily activities/diet, but lack of refreshment. Do not overuse exterior agents. If harmonizing, stomach-nourishing, or Lung-clearing agents fail, Shenzhu San (Divine Atractylodes Powder) is appropriate. After purging Yang syndrome, heat subsides, pulse levels, but mental confusion, insensitivity to pain/itch, unconsciousness, resembling dementia/muteness occurs. Do not assume deficiency and blindly tonify. Single herb Ginseng Decoction or no medicine may lead to self-healing.

Yang syndrome with body heat and chest/diaphragm stuffiness: reduce Jiegeng (Platycodon Root) and Zhike (Aurantii Fructus) by half; increase Qianhu (Peucedani Radix) and Chaihu (Bupleuri Radix) to compensate.