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This volume discusses treatment methods. The ancients had established laws for treating Shanghan (Cold Damage), which differs from treating miscellaneous diseases. There are five distinct categories, and the Six Channels (Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, Jueyin) each have their own characteristics. The transmission of Yin and Yang, the depth and duration of the disease days, the warming or cooling nature of the prescriptions, and the timing of their use all follow a sequence. A discrepancy of even a hair's breadth can turn a mild condition into a critical one, let alone those who do not understand these laws. Among Shanghan conditions, only "Lianggan" (simultaneous involvement of exterior and interior channels) is difficult to cure. For other syndromes, although different pathogenic factors may be involved, careful assessment ensures recovery in all cases. Errors in treatment, as Zhang Zhongjing stated, result in the physician killing the patient. Those who understand these laws act like holding the headrope of a net: if sweating is indicated, sweat; if vomiting is indicated, induce vomiting; if purging is indicated, purge. Formulas such as Guizhi Tang (Cinnamon Twig Decoction), Chengqi Tang (Gastro-Regulating Decoction variants), Gualti San (Melon Seed Powder), and Sini Tang (Frigid Extremities Decoction) are used effectively without failure. However, if sweating is indicated but purging is mistakenly used, Pi syndrome (glomus) or Jie Xiong syndrome (chest binding) may result. If purging is indicated but sweating is mistakenly used, Wang Yang (loss of Yang), Zanyu (delirious speech), Xia Jue Shang Jie (cold extremities with upper depletion) may occur. Furthermore, using emesis when warming is needed, or using warm treatments for heat syndromes, leads to hundreds of variable syndromes and loss of discipline, creating chaos. Generally, injury by cold pathogens manifests as heat diseases. Sun Simiao said: After taking Chengqi Tang and achieving bowel movement with recovery, one must be cautious against tonification, as heat qi combined with tonics will re-form excess heat. Wang Shuhe said: Deficiency heat should not be aggressively attacked; once the heat is gone, cold will arise. These two theories seem contradictory, yet heat has both excess and deficiency aspects. Only by deeply understanding Zhang Zhongjing’s intent can one grasp this nuance.

(Question 31) Why is winter called Shanghan, spring called Wenbing (Warm Disease), and summer called Rebing (Heat Disease)?
The Suwen states: The three months of winter are called "closing and storing," where water freezes and earth cracks; one should not disturb Yang. It also states: The warmth of spring becomes the summer heat; the severity of autumn becomes the winter cold. Therefore, severe winter cold is a killing and harsh qi. Gentle people who know how to preserve life protect themselves meticulously whether walking, standing, sitting, or lying down during extreme cold, thus avoiding cold toxins. Those who travel hard, carry heavy loads, or engage in excessive sexual activity are laborers who disturb Yang when it should be stored. This causes Yang to stagnate and diffuse through the cou li (skin and interstices), forcing fluids to soak, leading to cold pathogens attacking dense skin and interstices, mixing with Ying and Wei qi. At this time, robust individuals recover as Qi flows freely, while weak individuals develop disease as the pathogen lingers. When illness occurs immediately in season, symptoms include headache, body ache, hot skin, and aversion to cold, named Shanghan. When illness does not occur immediately, cold toxin hides in the skin and interstices. When Yang qi arises in spring and summer, the cold toxin battles with Yang qi between Ying and Wei. The pathology is no different from immediate seasonal onset.
However, due to the influence of spring's warm qi, it changes name to Wenbing. Due to summer's hot qi, it changes name to Rebing. The terms "Wen" and "Re" define the degree of heat. When Yang heat is not yet strong and is controlled by cold, it is named Wen. When Yang heat is strong and cannot be controlled by cold, it is named Re. Thus, great physicians generally refer to them all as Shanghan.

(Question 32) Is it true that one should sweat within three days and purge after three days?
The ancients said: If less than three days have passed, sweating suffices; if three days or more have passed, purging suffices. This is a general statement. Patients vary in deficiency and excess, and the speed of pathogen transmission varies. How can one rigidly adhere to days? Zhang Zhongjing said: Even if many days have passed, if exterior signs exist and the pulse is floating, sweating is appropriate. Even if few days have passed, if interior signs exist and the pulse is deep, purging is appropriate. One must decide on sweating or purging based on the pulse. (Note: Some Shanghan cases begin with Yang excess signs requiring immediate purging; others involve cold cou li progressing to Shaoyin disease within one or two days, requiring urgent warming.) Moreover, six types of pathogenic qi enter meridians via deficiency. Invasion from the back enters Taiyang or Shaoyin (as Shaoyin has hidden pulses at the back). Invasion from the face enters Yangming, etc. It does not always start in Taiyang. Cold pathogens may stay in one channel or skip channels; one cannot apply a single rule. Treatment must rely on pulse and external signs—this is the living method. For example, if a patient has a floating pulse, stiff neck/head pain, fever, and aversion to cold daily, regardless of days, it is Taiyang channel involvement. Other channels follow this logic. Generally, treat Shanghan by sweating or purging based on pulse and signs. If many days pass but the pulse remains large, floating, and rapid, yet empty upon pressure, the issue remains in Taiyang; sweating will cure it. If the pulse is solid upon pressure, sweating will cause death; purging is required. If initially the pulse is fine, deep, and rapid, with external signs like abdominal fullness, dry throat, or dry mouth/tongue with thirst, the pathogen belongs to the interior; purging will cure it. Without these signs, if there is only fever and a deep pulse, mistaken purging will cause death; instead, use Mahuang Fuzi Gancao Tang (Mahuang, Prepared Aconite, and Licorice Decoction) or Mahuang Xixin Fuzi Tang (Mahuang, Asarum, and Prepared Aconite Decoction) for mild sweating. These are definitive conclusions of Zhang Zhongjing.

(Question 33) Regarding "Yang deficiency and Yin excess: sweating cures, purging kills; Yang excess and Yin deficiency: sweating kills, purging cures."
The Suwen states: Yang deficiency causes external cold; Yin deficiency causes internal heat; Yang excess causes internal heat; Yin excess causes external cold. Therefore, in treating Shanghan, for Yang deficiency and Yin excess, sweating cures and purging kills; for Yang excess and Yin deficiency, sweating kills and purging cures. "Yin/Yang deficiency/excess" here does not refer to specific pulse positions but to Exterior (Yang) and Interior (Yin). The Waitai Mi Yao states: Exterior disease with harmonious interior is cured by sweating; harmonious exterior with interior disease is cured by purging. This discusses treating based on Exterior/Interior Yin/Yang. (The Nan Jing discusses Yin/Yang deficiency/excess regarding pulses; the Suwen discusses it regarding Exterior/Interior. Zhang Zhongjing cites the Suwen's meaning of Exterior/Interior for Shanghan sweating/purging, aligning with the Waitai Mi Yao.) ○ Generally, Ying and Wei belong to the Exterior and are Yang; the Stomach Fu belongs to the Interior and is Yin. When cold toxin struggles within Ying and Wei, fever and aversion to cold occur. Both Cun and Chi pulses are floating and large; internally there is no restlessness. Even with slight irritability, if the patient prefers warm drinks and dislikes cold, it indicates Yang deficiency and Yin excess. Sweating cures; mistaken purging kills. ○ If cold toxin struggles within Ying and Wei, leading to Yang overcoming Yin, extreme Yin transforming into Yang, cold generating heat, and Yang heat entering the interior, heat toxin resides in the Stomach, drying fluids and forming dry feces. The patient has no external aversion to cold but experiences steaming fever and restlessness, possibly delirium. Pulses are floating, slippery, rapid, or surging and solid. This indicates Yang excess and Yin deficiency. Purging cures; mistaken sweating kills.
According to Huangdi Suwen Tiaojing Lun: Yang deficiency causes external cold, Yin deficiency causes internal heat, Yang excess causes external heat, Yin excess causes internal cold. Yang governs the exterior, Yin governs the interior. It states: Yang deficiency and Yin excess are cured by sweating and killed by purging; Yang excess and Yin deficiency are killed by sweating and cured by purging. Question 33 mistakenly writes "Yang excess causes internal heat, Yin excess causes external cold." Careful analysis shows that confusing internal/external cold/heat leads to fatal errors in sweating/purging. Wang Zongzheng’s diagram in his commentary on the Nan Jing aligns with the Suwen. Thus, Question 33 contains a transcription error and should be corrected to avoid misleading future generations.

(Question 34) Zhang Zhongjing uses sweating and harmonizing methods. What is the distinction?
Shanghan exterior signs require assessing the depth of Ying and Wei involvement. Thus, Zhang Zhongjing has specific sweating formulas like Mahuang Tang (Ephedra Decoction), Guizhi Tang (Cinnamon Twig Decoction), and Da Qinglong Tang (Major Green Dragon Decoction). He also has formulas to harmonize the exterior, such as Xiao Qinglong Tang (Minor Green Dragon Decoction), Guizhi Mahuang Ban Ge Tang (Half-and-Half Cinnamon Twig and Ephedra Decoction), Baihu Tang (White Tiger Decoction), Guizhi Er Yuebi Yi Tang (Two Parts Cinnamon Twig to One Part Yuebi Decoction), Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction), and Xiao Chaihu Tang (Minor Bupleurum Decoction). Later practitioners failed to deeply investigate the depth of cold/heat and the intensity/slowness of drug properties, applying medicines indiscriminately, causing premature death. Even survivors often suffered post-sweat deficiency, leading to relapse from exertion or generation of myriad diseases, dragging on until death. This results from excessive sweating and purging, exhausting Yin and Yang, and depleting blood and Qi. For mild illnesses, one should only harmonize, i.e., harmonize Ying and Wei to unblock Jin Ye (body fluids) so they resolve naturally.

(Question 35) Zhang Zhongjing uses purging and mild stomach-harmonizing methods. What is the distinction?
Shanghan interior signs require assessing the depth of heat. Thus, Zhang Zhongjing uses purging formulas like Dachengqi Tang (Major Gastro-Regulating Decoction), Xiaochengqi Tang (Minor Gastro-Regulating Decoction), Shizao Tang (Ten Jujube Decoction), and Daxiehu Tang (Major Bupleurum Decoction). He also uses mild stomach-harmonizing methods like Tiaowei Chengqi Tang (Stomach-Regulating Gastro-Regulating Decoction), Piyue Wan (Splee-Restriction Pill), and small doses of Xiaochengqi Tang for mild harmonization. The Jingui Yufan Jing states: For deficiency, ten times tonify, never purge; for excess/strength, purge; for equal deficiency and excess, purge moderately. Wang Shuhe warned about using Chengqi formulas in his preface. ○ Question: Which formula is most intense? Answer: Dachengqi Tang is most intense, followed by Xiaochengqi Tang, then Tiaowei Chengqi Tang, then Daxiehu Tang. Zhang Zhongjing’s method for sweeping away heat accumulation uses decoctions, not pills. (Note: Adding Rhubarb to Daxiehu Tang or adding Mirabilite to Xiao Chaihu Tang creates "transformation formulas" for milder cases.)

(Question 36) Shanghan Day 1: headache, dry mouth, irritability, fullness, thirst. Day 2: abdominal fullness, body heat, anorexia, delirium. Day 3: deafness, retraction of genitals, cold extremities, inability to swallow, unconsciousness.
This is named Lianggan Shanghan (Double-Injury Cold Damage). Lianggan means simultaneous disease of exterior and interior. Taiyang and Shaoyin are exterior-interior pairs; Yangming and Taiyin are pairs; Shaoyang and Jueyin are pairs. Dual transmission of Yin and Yang affects all Zang-Fu organs. This is difficult to treat and leads to death on the sixth day. Day 1: Taiyang and Shaoyin both diseased → headache, dry mouth, irritability, fullness, thirst. Day 2: Yangming and Taiyin both diseased → abdominal fullness, body heat, anorexia, delirium. Day 3: Shaoyang and Jueyin both diseased → deafness, genital retraction, cold extremities. Zhang Zhongjing provides no direct treatment for Lianggan but states that treatment has priorities: releasing the exterior and attacking the interior differ fundamentally. In Volume 3, it is noted that if after purging, diarrhea persists and body pain remains, one must urgently rescue the interior with Sini Tang. If body pain exists but bowels/bladder are normal, urgently rescue the exterior with Guizhi Tang. Following this logic, treating Lianggan requires prioritizing the interior first. If internal Yang is rectified, treatment can proceed. Once the interior is stabilized, urgently rescue the exterior, as the interior is more critical. Warming the interior must be followed immediately by rescuing the exterior; delay is not permitted.

(Question 37) Shanghan persists despite sweating, vomiting, or purging (called Huai Bing/Broken Disease by ancients).
Zhang Zhongjing said: If Taiyang disease for three days has been treated with sweating, vomiting, purging, or moxibustion and remains unresolved, it is called Huai Bing (Broken Disease). Guizhi Tang is no longer applicable. One must identify the deviation and treat according to the syndrome. Also: If Taiyang disease transitions to Shaoyang, presenting with hardness/fullness under the hypochondrium, dry retching, inability to eat, alternating chills and fever, and before vomiting/purging, with a deep-tight pulse, Xiao Chaihu Tang is suitable. If vomiting/purging/sweating have already occurred and Xiao Chaihu signs disappear, it is Huai Bing. Identify the deviation and treat accordingly. This occurs when a new pathogen infects the existing disease, altering it due to seasonal irregularities (cold, heat, dryness, dampness, wind), changing the pulse and syndrome from typical Shanghan. One must analyze the cause and treat legally. If Cun-Chi pulses are both strong and cold is re-contracted, it transforms into Wen Nue (Warm Malaria, hot then cold). If Yang pulse is floating-slippery and Yin pulse is soggy-weak, encountering wind transforms it into Feng Wen (Wind-Warmth, flaccid limbs, headache, fever, spontaneous sweating). If Yang pulse is floating-rapid and Yin pulse is solid-large, encountering warmth transforms it into Wen Du (Warm Toxicity, most severe, macules in spring). If Yang pulse is soggy-weak and Yin pulse is string-tight, encountering warm qi transforms it into Wen Yi (Warm Epidemic, similar symptoms across ages due to abnormal four-season qi). Pulse and syndrome variations dictate different formulas. Zhang Zhongjing states Wen Bing pulses move through various channels; treat according to the affected channel. Also, Shanghan passing its stage, re-infected with heat, lingering in Zang-Fu, causing variable syndromes and chronic non-resolution, losing Yin-Yang order, or post-Shanghan emaciation and shortness of breath, are all named Huai Shanghan. Use Zhimu Mahuang Tang, Biejia San (Turtle Shell Powder), or Heinu Wan (Black Slave Pill) based on formula-syndrome matching. For post-Shanghan emaciation, shortness of breath, and rebellious Qi with vomiting, Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) is the primary treatment.