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Spontaneous recovery. This clearly uses the number of days with fever to determine the period for the resolution of Jue (cold limbs). It also states: If Jue is frequent and fever is rare, the disease progresses; if fever is frequent and Jue is rare, the disease recedes. If Jue has resolved but fever persists for too long, pus and blood in the stool or carbuncles will inevitably occur. If Jue should be treated with purgation but sweating is used instead, oral injury and redness will inevitably result. If Jue appears first followed by fever, diarrhea will stop spontaneously. If Jue reappears, diarrhea returns; if diarrhea stops but sweating and sore throat appear, Bi syndrome of the throat (throat obstruction) will occur. If one can eat during Jue, one must fear Chu Zhong (a false sign of stomach Qi exhaustion); if Jue stops and appetite returns, it indicates that pathogenic factors are retreating and recovery is imminent. All these cases fall under the principle of "deep heat causing deep Jue," and originally did not discuss Yin Jue (cold-type cold limbs). As for diseases of the Yang aspect, if mistaken sweating, vomiting, or purging leads to extreme conditions—such as excessive sweating causing Yang collapse, vomiting and diarrhea accompanied by irritability and cold limbs—the cause is medication error. Without using formulas like Sini Tang (Four Reversal Decoction) or Zhenwu Tang (True Warrior Decoction) to rescue Yang, Yang cannot return. These were originally not prescribed for Yin syndromes. Generally, once Shanghan (Cold Damage) presents with fever and thirst, Yin deficiency must have existed initially. Due to mistreatment, Yang deficiency becomes worse than Yin deficiency. Reluctantly, acrid-hot medicines are used temporarily to rescue Yang first. This differs vastly from pure Yin without Yang, or Yin excess repelling Yang syndromes. Later generations, unaware of the intent behind formula creation, blindly follow established methods, failing to realize that treating Yin syndromes prioritizes rescuing Yang, while treating Shanghan prioritizes rescuing Yin. (This statement is the secret key to treating transmitted syndromes.) Even if Shanghan involves Yang deficiency requiring treatment, one must assess whether the patient's flesh and blood are robust enough to tolerate Yang-tonifying medicines before attempting to restore Yang. If the face is dark, tongue black, body emaciated like dry firewood, and internal pathogenic heat blazes, Yin fluids are exhausted, leaving no Yang to restore. Thus, preserving even a fraction of body fluids and Yuan Qi when addressing Jue and heat is already late; how could one dare to assist Yang by劫 (plundering) Yin? *Zhengzhi Fang* states: If Yin and Yang syndromes are undifferentiated, try Sixun Wan (Six Smooth Pill) first. *Zhizhi Fang* states: If doubt remains, try Lizhong Wan (Regulate the Middle Pill) first. This shows that previously, this critical point was not fully understood; despite deep study, there was no way forward. Therefore, I clarify this for my descendants and inform future practitioners.

Cheng Wuji said: Regarding all Jue, if at onset hands and feet are immediately cold and unwarmed, it is pathogen invading the Yin meridians with insufficient Yang Qi; Sini Tang can be used to warm it. If hands and feet go from hot to warm, or from reversed cold to Jue, it is a transmitted pathogen; Sini San (Four Reversal Powder) is the primary formula. One must recognize this to avoid errors, and differentiate based on external symptoms. I once treated a middle-aged woman with aversion to wind, body heat, and thirst, with a rapid, thin, and weak pulse. She presented with initial Jue followed by fever; warming medicines worsened her condition. Later, Sini San combined with Ginseng and Atractylodes Macrocephala (each 1.5g) cured her Jue immediately, and her pulse became surging and large, leading to recovery.

Commentary: Cheng’s discussion of two types of Jue—Yin meridian invasion and transmitted pathogen—one treated with warming Sini Tang and the other with cooling Sini San—is clear. Yu Chang may not have seen this, hence listing this case here.

Lu Pingshu, a scholar, had a constitution of deficiency and timidity, with sallow complexion. Medicines suitable for him should be warming and tonifying, not cold and clearing, which is standard. In autumn, he contracted San Nüe (tertian malaria), and in early winter, caught an external cold. Although he had chills and fever, they were not severe. Physicians thought it was post-malaria deficiency pathogen, not realizing it was a new excess pathogen. (Old illness compounded by new pathogen easily misleads.) They administered tonics of Ginseng and Atractylodes Macrocephala, causing his breath to become faint. After twenty days, occasionally considered as external contraction, Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction) was used with no effect. He was dazed and confused, with no clear direction, deemed incurable. Yu Chang examined him, finding the pulse not severely damaged, abdomen not distended, and urination still free, concluding it was treatable. However, continuous muscle twitching raised fear of limb flaccidity. Zhang Zhongjing stated: Twitching muscles eventually lead to flaccidity. Now, after twenty days, blood depletion and tendon dryness are evident. Treatment must address both; outside Zhang’s methods, new approaches are needed. Although Zhang had Da Chai Hu Tang (Major Bupleurum Decoction) for simultaneous exterior-interior resolution, there was no method for flaccidity. (Treating flaccidity focuses on the Yangming channel; clearing Yangming heat cures flaccidity. Moreover, this is acute injury, not chronic depletion.) Modified Fangfeng Tongsheng San (Wind-Protecting Universal Relief Powder) was used, removing Baizhu (Atractylodes Macrocephala). Fangfeng, Jingjie, Bohe, Mahuang, Jiegeng served as exterior herbs; Dahuang, Mangxiao, Huangqin, Lianqiao, Zhizi, Shigao, Huashi served as interior herbs. This resembles Da Chai Hu Tang’s structure, and includes Danggui, Chuanxiong, Baishao to guide herbs into the blood level and unblock meridians. Baizhu was removed because previous use caused error. Two doses were taken that night; the first was tolerated, the second resulted in bowel movement, followed by sleep and slight sweating. Next morning, twitching ceased, but Yangming stomach pulse became more surging. Baihu Tang was used with Shigao and Zhimu (approx. 30g each), followed by Chaihu, Huafen, Huangqin, Huangbai, Lianqiao, Zhizi—a batch of bitter-cold herbs. Over ten doses later, consciousness cleared, diet improved, bedridden status lifted in half a month, walking resumed in one month. Ignoring dietary restrictions caused abdominal pain and diarrhea, resembling deficiency. Yu Chang ignored this, adding Chaihu and Guizhi to moving stagnation herbs to disperse residual pathogen upward, preventing downward flow into dysentery. Then Weirui, Dongtianma, and Maidong were used to harmonize Stomach Qi, with occasional Ginseng (approx. 1.5g). Adhering strictly to principles allowed recovery from near-death.

Xu Guozhen had Shanghan for six to seven days, with body heat, red eyes, seeking water but refusing to drink, extreme restlessness, opening doors/windows wide, lying on the ground, restless, even wishing to enter a well. A panicked physician urgently administered Dachengqi Tang (Major Order the Qi Decoction). Yu Chang found the pulse extremely surging but empty upon heavy pressure. He said: This requires Renshen, Fuzi, and Ganjiang (Ginger). Why treat it as a purgation case? The doctor argued: Body heat and red eyes indicate excess pathogen; such restlessness would cause climbing walls if given Ginger and Aconite. Yu Chang replied: Yang is about to violently collapse, showing false heat externally and true cold internally. Using Ginger and Aconite might barely suffice to restore Yang; how dare we use purely Yin drugs to further deplete Yang? His refusal to swallow water reveals the truth. (Heat in Yangming channel also presents as rinsing mouth without swallowing.) Can one swallow Rhubarb and Mirabilite if one won't even swallow water? Muggy weather brings rain; this patient will sweat profusely and die instantly. If treated as Yang excess with purgation, Jie Xiong (Chest Binding) will form, which is more worrying. Only Ginger and Aconite work, offering both tonification and dispersal, resolving heat and pathogen simultaneously. Fuzi and Ganjiang (15g each), Renshen (9g), Gancao (6g) were decocted and taken cold. Post-ingestion, shivering and teeth chattering occurred; covered with thick cotton, pulling hand away, Yang deficiency signs became apparent. Another dose led to slight sweating, heat reduction, and calm. (This is a Dai Yang syndrome. Unusual but real.)

Zhang Qingzi treated a woman from Tangxi with Shanghan for ten days, fever without sweat. Someone suggested using Jinhuang (Rhubarb) for purgation; the family feared it. Zhang diagnosed: Strong pulse, black tongue with prickles suggests Rhubarb is appropriate. But now the tongue is black, moist, and non-thirsty, indicating Fuzi syndrome. Lack of sweat is due to Qi weakness; Renshen and Huangqi are essential. One dose produced sweat. (*Renhe County Gazetteer*).

Zhang Luyu treated Fan Zhu Shi Qiu, who suffered Shanghan Ying syndrome with three days of unceasing aversion to cold. Two doses of diaphoretics were used. On the seventh day, irritability increased, pulse disappeared, and limbs turned cold. Diagnosis revealed only the left Cun pulse trembling vigorously (Heart governs sweat). Zhang knew this indicated impending Zhan Han (battle sweat). He ordered no medicine, only hot ginger soup to assist sweating. Mistaken medicine would prolong heat. Days later, he thanked Zhang, confirming recovery without medicine. (Treatment of Battle Sweat).

Wu’s son, over twenty, prone to nocturnal emissions, contracted Shanghan in October with headache and cold feet. Diaphoretic and digestive aids failed to resolve confusion and heat despite multiple sweats; wheezing worsened. Another doctor used Mahuang, causing profuse head/face sweating and worsening wheezing. Some attributed it to internal heat, suggesting Huangqin and Huanglian; others to severe Qi deficiency, suggesting Dongchong Xiacao and Dihuang. Dispute ensued. Zhang found six pulses fleeting, nearly imperceptible upon pressure, signaling Yang collapse. Urgent Renshen and Fuzi were needed to restore Yang (Yu Jiayan’s warning against mistreatment causing Yang deficiency). Huayang Fanben Tang (Return Yang Restore Foundation Decoction) was prescribed with Tongbian (Child’s Urine) to consolidate Yang. Three doses brought peace; then large-dose Dushen Tang (Single Ginseng Decoction) with Tongbian restored health over several days with frequent gruel.

A man contracted Shanghan en route, stopping at Suzhou for treatment. He reported exposure to cold while sleeping outdoors after crossing the Huai River, followed by binge drinking liquor. Fever persisted despite two bowel movements and prior medication in Beijing. He was comatose, silent, yet intermittently irritable. Lips and tongue were red, swollen, dry, and cracked; he drank water if offered but refused otherwise. Cun pulses were fleeting and large; Guan pulses small and weak; all pulses empty upon prolonged pressure. Zhang diagnosed: Heat transmitted to Hand Shaoyin channel. Daochi Xiexin Tang was given; one dose calmed consciousness slightly. After two days and two doses, bladder/bowel control returned. Next morning, pulse quiet, spirit calm. Small Wuling San (Five Ling Powder) minus Guizhi plus Maidong was given for two doses, with instructions for frequent gruel. Recovery achieved.

Wu Jiechen had Shanghan with lingering heat, swelling at Quchi point, neither suppurating nor resolving, with daily chills and fever. Surgeons forbade food, prescribing daily detoxifying/clearing herbs. Upper Qi deficiency, emaciation, orthopnea, thirst for small sips of water, abdominal distension, and obstipation developed. Over two months, four honey suppositories yielded little relief; condition critical. Pulse was tense initially but vanished upon pressure, signaling Spleen/Stomach Qi exhaustion. Further medication was impossible. Continued gruel feeding, cooked with duck for aroma, was slowly sipped. That night, significant hard stool passed, wheezing/distension stopped, diet improved. Swelling subsided over days. Although Baoyuan Tang or Dushen Tang were indicated, strength was insufficient; dietary management sufficed. Recently, another patient overusing digestive aids lost Stomach Qi, vomited at smell of food, and recovered similarly without medicine.

Gao Gufeng treated Xu Wuyi’s eldest son, critically ill with Shanghan. Upon arrival, news came: Patient screamed wildly, fainted five-six times, died upon waking. Do not come. Questioned: How many days? Nine. Chest hot? Just not cold. Treatable. Rushed to see corpse-like figure on bed, no breath, blue-black face, clenched jaw, closed eyes, limp hands, purple-black lips. Gao laughed: Not dead. Yin deficiency syndrome, caused by mistaken Baihu Tang. Pulses at Chi positions remained. (Pulse presence indicates Jue.) Renshen (30g), Shudi (60g), Paojiang (15g) were decocted strongly and forced down. Mouth opened, color reddened. Within an hour, complained of intense cold, drank hot soup, developed high fever, profuse sweating, and woke up. That night, abdominal distension and constipation. Don’t worry, post-sweat deficiency prevents evacuation. One more cup of medicine solved it. Next day, all symptoms gone except delirious cursing (spirit unsettled). Several days of regulation, midnight pulse check: Extremely deficient. Large doses of Fuzi Lizhong Tang and Jianzhong Tang cured him.

Hangzhou friend Shen Qiaoru’s nephew had Shanghan. Pulse floating, rapid, forceful; black tongue; chest/hypochondriac pain/distension. Caused by fatigue and dietary injury. (Battle sweat resolution isn't solely due to diet/fatigue.) Doctors used cold/clearing/digestive attacks, suppressing fire, leaving it无处归依 (nowhere to go). Urgent large doses of Renshen, Baizhu, Danggui, Huangqi, Paojiang rescued him. Warned family: Battle sweat will occur at midnight; feed gruel frequently during battle. At Tianchang Temple, 4th watch, family knocked urgently: Severe cold after medicine, then high fever, coma, death. Any hope? No need to worry, sweat is coming. Did you give gruel during battle? No. I told you, gruel aids Stomach Qi for swift sweat without exhaustion. Go home; sweat will come. Indeed, slept peacefully. (Feeding gruel assists sweat, imitating Zhang Zhongjing’s Guizhi Tang method.)

Zhang Yinan treated a youth with Shanghan for 3-4 days, headache, fever, unbearable chest pain. Family blamed noodles eaten three days prior. Zhang disagreed: Noodles are common; this was external cold causing internal food stagnation, not noodle-induced. For food stagnation with cold, release exterior only; do not blame food. If interior Qi loosens, exterior pathogen sinks in. (Critique of mediocre doctors.) Food stagnation causes pain below chest/stomach upon pressure. Current upper chest pain is unpressable, indicating Jie Xiong from mistaken purgation. Family confirmed previous doctor used digestive meds due to noodle story, worsening pain. Exterior signs remained; Guizhi Tang modified cured him in one dose.

Zhanglingshao treated a woman with Shanghan for 10+ days, restlessness, eye/mouth twitching, pale face, cold body, delirium, madness, unconsciousness. Critical. Family bound limbs thinking it was wind. Others suspected phlegm confusing heart, deficiency, or cold. Refused treatment. Zhang found no pulse, no response to questions, no body heat. Said: Either Renshen/Fuzi case or Dahuang/Mangxiao case. Life/death depends on choice. Observed for a while, heard loud, long voice. (Some mid-jiao food stagnation mimics death but responds to purgation, e.g., Miao Zhongchun’s case). If deficiency-cold, Qi would fade silently; why shout loudly and continuously? Prepared Dachengqi Tang. Forced down through clenched teeth. By dusk, half a bed of black stool passed. Next morning, pulse returned, heat appeared, consciousness returned, black tongue extended. Xiao Xianxiong Tang (Small Trap Chest Decoction) for two doses cured her.

A woman with chronic weakness contracted Shanghan. Doctor diagnosed Yin deficiency heat, prescribed Yin-nourishing meds, eggs, fatty meat. Condition worsened. Used Yuzhu, Gubpi, Danpi, Danggui, Baishao for 10+ days; death signs appeared. Zhang arrived after death. Requested examination: Breath stopped, but pulse present and slippery. Said: Not fatal. Mistaken tonics trapped pathogen, blocked Stomach collaterals, causing Stomach excess. Righteous Qi intact, treatable. Soon revived (due to Jue). Tiaowei Chengqi Tang cured hardness and symptoms next dose. Next day, profuse sweat (deficiency sign). Renshen (9g), Huangqi, Baizhu, Suanzaoren (each 15g) cured her.

A newlywed man vomited roundworms with fever. Doctor diagnosed Yin syndrome, gave Lizhong Tang, worsening vomiting. Zhang found slow, long pulse. Vomited 10+ worms overnight. Diagnosed Wind-Wood generating worms, damp-heat steaming them. Proposed Huanglian to clear damp-heat. Disbelieved. Changed doctor. Used Danggui, Baishao, Yuzhu, worsening vomiting and worm count. Zhang insisted on Huanglian. Huanglian, Houpo, Zhishi, Guangpi, Banxia (equal parts) stopped vomiting. Second dose: no vomiting, clear spirit, worms passed in stool (dozens, varying sizes). Added Baizhu etc. for tonification, causing bloating. Total 20 doses of Huanglian/Zhishi cured him. Rare case, not common.

Commentary: Fever with slow-long pulse indicates Yangming channel syndrome. Case focuses on worm treatment, seemingly incomplete; await further verification.

Lu Yangyu treated Zhou Liangfeng with headache, fever, capsizing incident. Arrived home with severe hypochondriac pain, deafness, irritability, thirst, delirium. Doctor diagnosed sudden massive hematemesis. Pulse: Chi absent, Cun/Guan wiry-tight. Irritability/thirst/delirium = Yang syndrome. Wiry = Yin pulse. Zhang Zhongjing: Yang disease with Yin pulse dies. Chi is root; absent root means isolated Yang floating up, forcing blood out. Incurable. Left. Lu arrived, bleeding stopped, breathing stabilized. Pulse: Cun/Guan wiry-slight rapid; Chi sunken-absent. Syndrome belongs to Shaoyang; wiry-rapid fits. Hypochondriac pain/deafness are Shaoyang basics. Chi absence due to year factors: Yangming Dry Metal ruling Heaven, Shaoyin Minister Fire ruling Earth, hence absent. Hematemesis from fright/shock in boat, blood pooling, spirit grasped, heat forcing it. Delirium: Three Yang exterior signs exhausted, transmitting to Three Yin. Started with Xiaochaihu Tang to harmonize, wait for solidity then purge. Expected cure in 10 days. Two doses given. Next day, pain reduced, hearing improved, but delirium persisted, chest fullness, thin yellow coating. Xiaochaihu Tang + Jiegeng, Huanglian daily. Two days later, chest relieved, coating black-prickly, no stool for 7 days. Runzi Wan (3g) with decoction given. Night: Bowel movement, clean body, symptoms vanished. Removed Zhiji/Jiejeng, added Danggui/Baishao, regulated 10 days to rise.

Wang Yexi had Shanghan 6-7 days, released exterior. Suddenly fever, irritability, thirst, dry throat, loose stools, intolerance to wind/cold. Used Liangge San, developed few red spots on chest. Given Xiaoban Qingdai Yin, developed delirium, cold limbs. Attributed to deep heat, planned Chengqi purgation. Lu found pulse floating-rapid (6-7 beats), empty upon pressure. Said: Yin excess repelling Yang. Purgation leads to instant death. *Neijing* says: Pulse follows but disease reverses? Qibo: Pulse follows, pressure doesn't scatter, all Yang similar. Now floating-rapid, empty-pressure, Yang deficiency rejected by Yin, unable to enter/yin-yang interaction. Fever/irritability/thirst/dry throat = floating Yang escaping. Aversion to wind/cold = Yang insufficiency. Spots = cold herbs stimulating rootless fire gathering in chest, steaming lungs/skin. Delirium = spirit not dwelling. Cold limbs = Yang exhausting. If cold reaches elbows/knees, too late. This matches Dongyuan’s treatment of Hanlin Feng...