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(From *Suwen: Re Lun Pian* [Plain Questions: Discussion on Heat], Appendix: Theory of Meridian Transmission and Treatment Methods for Cold Damage)

Huangdi asked: "Currently, febrile diseases are all of the category of Shanghan (Cold Damage). Some recover, while some die; those who die usually do so within six or seven days, while those who recover usually take ten days or more. What is the reason? I do not understand the explanation. I wish to hear the cause." (Shanghan refers to contracting Yin-cold pathogenic qi that is severe and lethal. Cold is most prevalent in winter; if one contracts it and falls ill immediately, it is called Shanghan. If one does not fall ill immediately, but develops illness in spring, it is called Wenbing (Warm Disease); if in summer, it is called Shubing (Summerheat Disease). However, there are also irregular pathogenic qi of the four seasons that cause immediate onset upon contraction, which are also termed Shanghan. When cold pathogenic qi binds the muscle surface, the acupores close, and Yang Qi cannot dissipate, thus stagnating and transforming into heat. Therefore, all external-contracted febrile diseases belong to the category of Shanghan.)

Qibo replied: "Juyang (Giant Yang, i.e., Taiyang/Sun) is the leader of all Yang meridians." (Ju means great. The Taiyang meridian is the head of the Six Meridians, commanding the Yang divisions, therefore all Yang meridians belong to it.) Its vessels connect to the Fengfu point, thus serving as the master Qi of all Yang meridians." (Fengfu is an acupoint of the Du Mai [Governing Vessel]. The Taiyang meridian channels ascend to the vertex and back surface, thus governing the Qi division of all Yang meridians.) When humans are injured by cold, they develop febrile disease; even if the fever is severe, it will not be fatal;" (When humans contract cold and transform into heat, it is because extreme cold generates heat. When cold disperses, heat recedes, so even if severe, it is not fatal.) "but those who suffer from Lianggan (Simultaneous Contraction of Exterior and Interior) due to cold will inevitably die." (Exterior and Interior meridians are simultaneously affected, this is called Lianggan; the meaning is detailed in subsequent chapters.)

The Emperor said: "I wish to hear the symptoms." Qibo said: "On the first day of Shanghan, Juyang receives the pathogen, hence headache, stiff neck, and stiffness of the lumbar spine." (Juyang refers to the Foot-Taiyang Bladder Meridian, which is the exterior of the Three Yang meridians, and its vessels connect to Fengfu; therefore, most Shanghan cases begin from the Taiyang meridian. The Taiyang meridian runs from the head and neck down to the shoulders, flanking the spine to the waist, hence its symptoms manifest thus. Zhang Zhongjing stated: 'The characteristic of Taiyang disease is floating pulse, headache, stiff neck, and aversion to cold.' Note: In the human body's meridians, the Three Yang meridians are exterior, and the Three Yin meridians are interior. The order of the Three Yang meridians is: Taiyang is the Third Yang (Yang within Yang); Yangming is the Second Yang, following Taiyang; Shaoyang is the First Yang, following Yangming. These Three Yang meridians constitute the exterior. The order of the Three Yin meridians is: Taiyin is the Third Yin, following Shaoyang; Shaoyin is the Second Yin, following Taiyin; Jueyin is the First Yin, following Shaoyin. These Three Yin meridians constitute the interior. Their numerical sequence proceeds from interior to exterior, hence the priority of First, Second, and Third as described above. Furthermore, when pathogens enter the human body, they must move from exterior to interior. As stated in chapters like *Pi Bu Lun*: 'When pathogens reside in the skin, the interstices open; when open, pathogens enter the Luo vessels; when Luo vessels are full, they inject into the Jing meridians; when Jing meridians are full, they enter and settle in the Zang-Fu organs.' This is why pathogens first invade the hair and skin, meridian pathology begins with Taiyang, and subsequently the Three Yin and Three Yang, Five Zang, and Six Fu organs all become diseased, as mentioned below.)

"On the second day, Yangming receives the pathogen. Yangming governs the flesh; its vessels flank the nose and connect to the eyes. Hence, there is body heat, eye pain, dry nose, and inability to sleep." (Shanghan often involves fever, but here specifically mentioning body heat is because Yangming governs muscles, making body heat particularly severe. Pathogenic heat in the Stomach causes irritability, hence the inability to sleep. Other symptoms are derived from this meridian's influence. Zhang Zhongjing stated: 'The characteristic of Yangming disease is excess in the Stomach-Fu.')

"On the third day, Shaoyang receives the pathogen. Shaoyang governs the Gallbladder; its vessels follow the hypochondrium and connect to the ears. Hence, there is chest and hypochondriac pain and deafness." (When pathogens are in the Shaoyang meridian, the Three Yang diseases have exhausted, and it is about to enter Taiyin; thus, it is a Half-Exterior Half-Interior meridian. Its meridian channels emerge around the ears and descend along the chest and hypochondrium, hence symptoms such as hypochondriac pain and deafness. Zhang Zhongjing stated: 'In Shanghan, if the pulse is wiry and fine, with headache and fever, it belongs to Shaoyang. The characteristic of Shaoyang disease is bitter taste, dry throat, and vertigo.' He also said: 'If Taiyang disease is not resolved and transfers to Shaoyang, there will be hardness and fullness under the ribs, dry retching, inability to eat, and alternating chills and fever.' Pathogens in Yin cause chills; in Yang cause heat; in Exterior cause no vomiting or fullness; in Interior cause chest fullness, dry retching, and inability to eat. Thus, Cheng Wuji stated: 'Shaoyang pathogens exist between Half-Exterior and Half-Interior.')

"If the meridians of the Three Yang are all affected, but the pathogens have not entered the Zang organs, they can be cured by sweating." (The Three Yang meridians belong to the Exterior and Fu organs. If pathogens are in the Exterior and have not entered the Three Yin Zang organs, they can all be dispersed by inducing sweating.)

"On the fourth day, Taiyin receives the pathogen. The Taiyin vessels distribute in the stomach and connect to the pharynx. Hence, there is abdominal fullness and dry pharynx." (If pathogens in the Three Yang fail to be resolved by sweating, they enter the Three Yin, starting with Taiyin. Zhang Zhongjing stated: 'In Shanghan, if the pulse is floating and slow, and hands and feet are naturally warm, the disease is related to Taiyin. The characteristic of Taiyin disease is abdominal fullness, vomiting, inability to eat, worsening spontaneous diarrhea, and occasional spontaneous abdominal pain.')

"On the fifth day, Shaoyin receives the pathogen. The Shaoyin vessels penetrate the Kidney, connect to the Lung, and tie to the root of the tongue. Hence, there is dry mouth, dry tongue, and thirst." (The Kidney meridian belongs to Water, which is depleted by pathogenic heat, causing dryness and thirst in the mouth and tongue. Zhang Zhongjing stated: 'The characteristic of Shaoyin disease is faint and fine pulse, and only desiring to sleep.')

"On the sixth day, Jueyin receives the pathogen. The Jueyin vessels follow the genitalia and connect to the Liver. Hence, there is irritability, fullness, and retraction of the scrotum." (After transmitting through all six meridians, reaching Jueyin, pathogenic heat is very intense in the Yin division, causing irritability and fullness. Zhang Zhongjing stated: 'The characteristic of Jueyin disease is Qi rushing up to strike the heart, pain and heat in the heart, hunger without desire to eat, vomiting roundworms after eating, and unceasing diarrhea if purged.' Note: Shanghan transmission first occurs from the Exterior of the Three Yang, then enters the Interior of the Three Yin; this is the order of Yin and Yang precedence. However, observing Li Dongyuan: Taiyang is Juyang. If the Bladder meridian is diseased and there is thirst, it has entered its own meridian, named Chuanben (Transmission to Root). Taiyang transmitting to Yangming Stomach Earth is named Xunjingchuan (Following Meridian Transmission). Taiyang transmitting to Shaoyang Gallbladder Wood is named Yuejingchuan (Crossing Meridian Transmission). Taiyang transmitting to Shaoyin Kidney Water is named Biaolichuan (Exterior-Interior Transmission). Taiyang transmitting to Taiyin Spleen Earth is named Wuxiachuan (Error-Purge Transmission). Taiyang transmitting to Jueyin Liver Wood is named Xunjingdeduchuan (Following Meridian Within Limits Transmission). Additionally, Tao Jian'an stated: Wind-cold pathogens entering humans have no constant pattern; they may enter Yin or Yang, with no fixed form, not necessarily starting at Taiyang and ending at Jueyin. Some start at Taiyang, transmitting one meridian per day, reaching Jueyin on the sixth day; if pathogenic qi declines, it stops transmitting and heals. Others may transmit again after stopping. Some transmit skipping meridians; some stop after two or three meridians; some remain in one meridian throughout; some skip meridians in transmission; some, upon initial entry into Taiyang, do not generate stagnant heat but immediately enter Shaoyin forming True Yin syndrome; some directly strike the Yin meridians forming Cold syndromes. Because the Classics lack explicit text, later practitioners made errors in reckless treatment. Regarding Yin syndromes transmitted from Three Yang to Three Yin: although there may be extremity reversal externally, internally there is pathogenic heat. If there is no fever, and extremities are reversed and cold with aversion to cold, this is a direct strike to Yin meridians forming a Cold syndrome. Since Wang Shuhe established confused theories, many later generations have suffered. There are also Hebing (Combined Disease) and Bingbing (Concurrent Disease) syndromes: Hebing refers to two or three meridians being diseased simultaneously without transmission; Bingbing refers to one meridian's disease not yet resolving before transmitting to another. Thus, there is Taiyang-Yangming Hebing, Taiyang-Shaoyang Hebing, Shaoyang-Yangming Hebing, and San Yang Hebing. If Three Yang combine with Three Yin, it is Lianggan; thus, there are no combination examples for Three Yin. These were not covered in the Classic texts but elaborated by these two scholars; their meanings largely derive from Zhang Zhongjing and are logically necessary. However, the Classic discusses the normal transmission, while these two discuss variations. Students must examine both carefully and not adhere rigidly to one view, thereby adapting to changes and avoiding the error of rigidity.)

"If the Three Yin and Three Yang, Five Zang and Six Fu organs are all diseased, and Ying and Wei circulation cease, and the Five Zang mechanisms are blocked, death ensues." (Shanghan pathogens in the meridians originally present as Exterior syndromes; after meridian transmission completes and Qi recovers, resolution should gradually occur. If pathogens persist after passing through all six meridians, they deepen into the Fu organs; if Fu organs remain affected, they deepen into the Zang organs, hence all Five Zang and Six Fu become diseased. Excess pathogens externally block Ying and Wei circulation; exhaustion of Qi internally blocks the Five Zang, leading to death within six or seven days. A skilled practitioner ensures pathogens do not enter inward and organ Qi does not exhaust. Understanding these two aspects approaches divine skill. My note: Shanghan transmission mentions only Foot meridians, not Hand meridians. This principle originates from this chapter, as seen in the previous six sections. Regrettably, Liu Congzhou failed to understand this logic, erroneously creating the theory that Shanghan transmits only to Foot meridians and not Hand meridians, claiming Foot meridians belong to Water, Wood, and Earth; Water freezes in cold, Wood withers in cold, Earth cracks in cold—all unable to withstand cold. Hand meridians belong to Metal and Fire; Metal becomes harder in cold, Fire is extremely hot and immune to cold invasion. Thus, Shanghan only transmits to Foot meridians. This is clever rhetoric for reputation, astonishing the ignorant, and grossly deceptive. Human Metal and Fire organs merely possess Five Element Qi attributes; are they true Metal and Fire that cannot be damaged? This statement caused doubt, leading to claims that Foot meridians are lower and Hand meridians upper; since cold is Yin pathogen, it transmits to Foot. Or that Foot Six Meridians correspond to Northeastern and corner Qi, while Hand Six Meridians correspond to Southwestern Qi; cold invades in Winter/Spring, seeking similar Qi, thus affecting Water/Wood/Earth first, sparing Metal/Fire. Or that without Extraordinary Vessels there is no Shanghan, and Extraordinary Vessels attach only to Foot meridians. These debates are futile and incorrect. Human Blood and Qi circulate endlessly throughout the body; how could pathogens avoid Hand meridians? Cold invading humans first affects the skin/hair, which corresponds to the Lung; thus, externally there are chills and nasal congestion, internally cough and shortness of breath—can we say it does not transmit to the Lung? Entering Hand Shaoyin/Jueyin causes coated tongue, confusion, and delirium—can we say it does not transmit to the Heart Master and Pericardium? Entering Hand Yangming causes diarrhea or constipation—can we say it does not transmit to the Large Intestine? Entering Hand Taiyang causes urinary retention—can we say it does not transmit to the Small Intestine? Entering Hand Shaoyang causes obstruction of upper/lower passages, dysfunction of five senses, and fullness/dryness/excess—can we say it does not transmit to the Sanjiao? Re-reading this section stating all Three Yin/Yang and Five Zang/Six Fu are diseased, surely Hand meridians are included? Thus, Zhang Zhongjing’s descriptions of terminal syndromes of Lung, Heart, Liver, Spleen, and Kidney make sense. Why does this Classic omit Hand meridians? Because Shanghan is an Exterior pathogen; to observe exterior signs, one examines the whole body. The meridians covering the entire body are primarily the Foot Six Meridians; Hand meridians cannot cover them all. Moreover, wherever Hand meridians reach, Foot meridians also reach. Therefore, discussing only Foot meridians allows deduction of all left/right/front/back Yin/Yang symptoms, encompassing Hand meridians implicitly. This is why the Classic mentions only Foot meridians: to observe exterior syndromes of the whole body. The principle is obvious, yet debated until now due to Liu’s false statements. Who is wrong in judging the frog in the well and the bookworm?"

"For those not suffering from Lianggan, on the seventh day, Taiyang disease declines, and headache lessens;" (Pathogenic qi gradually retreats, and healthy Qi gradually recovers, as described below.) "on the eighth day, Yangming disease declines, and body heat lessens; on the ninth day, Shaoyang disease declines, and hearing slightly returns; on the tenth day, Taiyin disease declines, abdominal fullness subsides to normal, and appetite returns; on the eleventh day, Shaoyin disease declines, thirst stops, distension resolves, tongue dryness improves, and sneezing occurs; on the twelfth day, Jueyin disease declines, scrotum relaxes, lower abdomen soothes, and major pathogenic qi departs, with the illness daily improving." (This is what is meant by recovery taking ten days or more. Sneeze pronunciation: Di.)

The Emperor asked: "How should it be treated?" Qibo said: "Treatment requires unblocking the meridians of each respective Zang; the disease will decline daily. If the duration is less than three days, it can be cured by sweating; if three days or more, it can be cured by purging." (Unblocking each Zang's meridian means treating according to specific meridians. For transmitted pathogens, if less than three days, the pathogen is in the Exterior, so sweating is appropriate. If three days or more, the pathogen has transmitted to the Interior, so purging is appropriate. However, this describes the general rule of Exterior/Interior. According to *Zhengli Shanghan Lun*: Floating, large, rapid pulses indicate Exterior disease, suitable for sweating; deep, solid, rapid pulses indicate Interior disease, suitable for purging. Thus, even if many days have passed, if Exterior signs and floating/large pulse exist, sweating is still indicated; even if few days have passed, if Interior signs and deep/solid pulse exist, purging is required. Sweating and purging methods depend on Exterior/Interior status, not rigid adherence to days. My note: Shanghan, contracted from Heaven and Earth’s Yin lethal Qi, is unpredictable and highly dangerous; a slight treatment error leads to life or death instantly. Ancients provided extensive teachings, exceeding hundreds of schools and thousands of volumes. In establishing principles, none surpass Zhang Zhongjing; in medication, Tao Jian’an excels. They detailed every nuance; what more can I add? Yet, I cannot remain silent regarding the overwhelming complexity burdening students. Tao’s *Jiami Benbo* states: Grasping the outline of Shanghan treatment makes it easy as picking mustard seeds; pursuing details fragments it like searching for a ford in the sea—it is merely Pulse-Signs and Principle. I deeply admire this. The 'outline' refers to grasping the pivot and practical application. 'Details' refer to checking formularies with no applicable prescriptions. 'Pulse-Signs' refer to distinguishing Exterior/Interior, Yin/Yang, Cold/Heat, Deficiency/Excess. 'Principle' refers to true insight and essential methods; mastering principle ensures no treatment failure. Therefore, methods must be detailed, but application concise. Detailed without conciseness is useless, like gazing at the ocean. I summarize: Shanghan treatment has six methods: Vomiting, Sweating, Purging, Warming, Clearing, and Tonifying. Vomiting contains dispersing intent, removing Upper Jiao excess, and raising sunken Qi. Without Upper excess, it is contraindicated; thus, rarely used. Excluding Vomiting, the practical methods are Sweating, Purging, Warming, Clearing, and Tonifying.

Sweating treats Exterior syndromes. Cold in the Exterior cannot resolve without sweating. Sweating has three types: Warm Dispersal, Cool Resolution, and Neutral Resolution. Warm Dispersal applies when cold weather dominates, Yin excess weakens organs, and Yang Qi is insufficient, making Exterior difficult to resolve. Even with high fever, Acrid-Warm herbs must be used without Cold-Cool auxiliaries ('Do not violate Cold with Cold'). Cool Resolution applies when heat is intense, Exterior/Interior are dried, Yin Qi fails to nourish, preventing sweating. Acrid-Cool herbs are used without Warm-Hot auxiliaries ('Do not violate Heat with Heat'). If the disease is between Yin and Yang, neither Warm nor Cool is suitable; use Neutral methods to resolve the Exterior. Contraindications for sweating: No Exterior syndrome, pseudo-Exterior syndrome, pharyngeal obstruction, Qi movement disorders, chronic strangury patients, blood-loss patients, faint pulse indicating Yang deficiency, and faint pulse with aversion to cold indicating dual Yin/Yang deficiency. Indications for sweating: As Zhang Zhongjing stated, administer warm decoctions; if severe illness persists, accelerate administration to complete three doses within half a day. Treat immediately upon detection, regardless of time, for faster recovery. Hence, sweating should not be delayed.

Purging attacks the Interior. Internal excess accumulation cannot resolve without purging. Contraindications for purging: Unresolved Exterior pathogens, all Deficiency patterns, Yang deficiency, apparent Exterior excess, pharyngeal obstruction, Qi movement disorders, weak pulse, floating-large pulse, vomiting, hard-then-loose stool, and absence of Fullness/Dryness/Excess/Hardness. Hence, purging should not be rushed.

Warming warms the Interior. Internal Cold cannot resolve without warming. External Cold enters from outside; Internal Cold arises from Qi deficiency. Qi is Yang; insufficiency generates internal Cold, classified as Yin syndrome. Warming includes Tonification.

Clearing removes Heat. Heat without accumulation is not severe excess; it must be cleared. Exterior Heat requires clearing/dispersing; Interior Heat requires clearing/descending. Heat belongs to Yang syndrome; Clearing resembles Purging. Ancients explained these thoroughly; I merely state essentials. Students should move from broad to concise.

Tonification is crucial yet misunderstood. Tonification addresses not just Middle Jiao but also Exterior/Interior. If Exterior pathogens persist despite repeated dispersal without sweating, it indicates Middle Deficiency and insufficient Yin Qi to produce sweat (Sweat is Water; insufficient Water yields no Sweat). People know Sweat relates to Yang and ascending Yang resolves Exterior, but forget Sweat is born from Yin; Tonifying Yin promotes sweating (e.g., drinking water induces sweating). If Internal Heat persists despite clearing, it indicates Yin deficiency. People know Cold removes Heat, but forget Strengthening Water extinguishes Fire. If Healthy Qi is insufficient and Pathogenic Qi excessive, illness lingers. Attack is contraindicated; instead, strengthen Middle Qi. Strong Healthy Qi expels pathogens, balancing Ying/Wei. Warming Middle disperses Cold without direct Exterior attack; this is 'treating by not treating.'

Tonification depends on Zang Yin/Yang and herb suitability. For Yang Tonification, Ginseng (*Ren Shen*) is primary, assisted by Atractylodes (*Bai Zhu*), Cimicifuga (*Sheng Ma*), Bupleurum (*Chai Hu*). For Yin Tonification, Prepared Rehmannia (*Shu Di Huang*) is primary, assisted by Cornus (*Shan Zhu Yu), Dioscorea (*Shan Yao*), Angelica (*Dang Gui*), Lycium (*Gou Qi*). Ginseng with Rehmannia enters Three Yin; Rehmannia with Atractylodes ascends to Yang divisions. Medication should be flexible, not rigid. Since Cold transforms to Heat, damaging Yin, Yin Tonification suits 70-80% of cases, Yang Tonification 20-30%. However, Yin contains Yang; assisting with Cinnamon Twig (*Gui Zhi*) and Aconite (*Fu Zi*) restores Mingmen True Yang; assisting with Ginger (*Sheng Jiang*) and Licorice (*Gan Cao*) reaches Spleen/Stomacy Yuan Qi. Insufficient dosage equals no treatment. Dosage must adjust to severity. This is my proven experience, saving many lives, not mere theory.

Some ask: Ancients prioritized Sweating/Vomiting/Purging over Tonification; you emphasize Tonification first. Why? Answer: The three methods are known; Tonification was inadequately addressed, requiring clarification. *Shanghan Lun* states: Yin syndrome with Yang pulse survives; Yang syndrome with Yin pulse dies. Most agree. I believe Yang syndrome/Yang pulse and Yin syndrome/Yang pulse are favorable. Yang syndrome/Yin pulse is adverse and difficult, often deemed fatal by ancients. My emphasis on Tonification addresses this. Based on my experience, whenever Healthy Qi is deficient..."