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Background Information:
Book Title: Dingzheng Zhongjing Quanshanghan Lun Zhu (Corrected Annotations on the Complete Works of Zhang Zhongjing: Treatise on Cold Damage)
Author: Wu Qian
Dynasty: Qing
Chapter: Differentiating Pulse, Syndrome and Treatment of Taiyang Disease (Part 1/6)
Category: Shanghan (Cold Damage)

The Ying (Nutritive Qi) and Wei (Defensive Qi) governed by the Taiyang (Greater Yang) meridian are the two pathways through which Wind-Cold pathogens first enter the body. Wind pathogen injures the Wei Qi, while Cold pathogen injures the Ying Qi. The Wei Qi is swift and vigorous, governing Qi and circulating outside the vessels; its function is dispersion and excretion, belonging to Yang. Therefore, it is easily invaded by pathogens, resulting in sweating upon invasion, which constitutes a Deficient Pathogen (Xu Xie). The Ying Qi is pure and concentrated, governing Blood and circulating inside the vessels; its structure is solid and dense, belonging to Yin. Therefore, it is difficult for pathogens to invade, resulting in an absence of sweating upon invasion, which constitutes an Excess Pathogen (Shi Xie). Although Winter is the season of Cold, residual Cold in Spring and early Cold in late Autumn can also cause disease. As long as the symptom of anhidrosis (absence of sweating) appears, indicating an Excess Pathogen syndrome, it can be called Shanghan (Cold Damage), not necessarily limited to the depth of Winter. However, the Taiyang Meridian corresponds to the Bladder Organ. Viewing from the meridian to the organ, the meridian is Exterior and the organ is Interior. In the previous section, Guizhi Tang (Cinnamon Twig Decoction) was used to resolve the muscle layer, treating the Exterior syndrome of Wind injuring the Wei Qi, but it did not address the Interior of the Wei division. Therefore, Wuling San (Five-Ingredient Powder with Poria) was established to assist Guizhi Tang in harmonizing the Interior of the Wei division. In this section, Mahuang Tang (Ephedra Decoction) is used to induce sweating, treating the Exterior syndrome of Cold injuring the Ying Qi, but it does not address the Interior of the Ying division. Therefore, the Peach Kernel and Earth-Shield Decoction (Taohé Dǐdāng Fāng, referring to blood-invigorating formulas like Taohong Siwu or Didang Tang contextually) is established to assist Mahuang Tang in attacking the stasis in the Interior of the Ying division. Regarding improper sweating and purging methods: excessive sweating damages Zheng Qi (Upright Qi) and depletes Yang, while insufficient sweating allows Heat to blaze and damage Yin. Depletion of Yang leads to many Yin-transformation syndromes of Shaoyin (Lesser Yin), because Taiyang and Shaoyin are exterior-interior pairs. Damage to Yin leads to many Yang-transformation syndromes of Yangming (Bright Yang), because Taiyang and Yangming transmit sequentially. This explains why Sinixi Tang (Four-Reverse Decoction) and Chengqi Tang (Purge the Ganglion Decoctions) treatments appear in this section. All deficient pathogenic conditions of Wind injuring the Wei have been listed in the previous section; here, the excess pathogenic conditions of Cold injuring the Ying are organized as the middle section, enabling readers to grasp the general principles beforehand, so that clinical prescription will naturally avoid errors.

In Taiyang Bing (Taiyang Disease), whether fever has already appeared or has not yet appeared, there must be aversion to cold, body pain, vomiting and reflux of Qi, and pulse tightness at both cun and chi positions. This is named Shanghan (Cold Damage).
[Annotation] Taiyang Bing refers to the pulse floating, stiffness and pain in the head and neck, and aversion to cold mentioned in the first article of the previous section. Ying Qi belongs to the Yin aspect of the Exterior. Cold is a Yin pathogen. When Cold pathogen injures the person, the Ying Qi receives the injury due to similarity. "Already feverish" means Cold pathogen binds the skin and hair, closing the Yuanfu (pores), causing Yang Qi to stagnate and transform into heat. "Not yet feverish" means Cold pathogen has just entered and has not yet stagnated to form heat; soon after, fever will appear. Aversion to cold occurs because one is injured by Cold, hence the aversion. "Must be aversive to cold" means regardless of whether fever has appeared or not, aversion to cold is inevitable. Cold entering the meridian causes body pain. The Qi in the stomach is bound externally by Cold and cannot disperse, causing vomiting and reflux. Cold nature is forceful and urgent, hence the pulse is tight at both Yin (chi) and Yang (cun) positions. This follows the first article of the previous section regarding Taiyang Bing, adding these specific pulses and syndromes, naming it Shanghan. It serves as the outline for Shanghan diseases. Henceforth, whenever Shanghan is mentioned, it refers to these pulses and syndromes.
[Collected Annotations] Fang Youzhi said: "Or" indicates uncertainty; "must" indicates certainty. Saying "or" and "must" implies that the timing of fever varies, but aversion to cold is invariably present immediately.
Yu Chang said: Zhang Zhongjing feared that aversion to cold, body pain, vomiting, and the absence of fever might be mistaken for a disease of the Yin meridians. Thus, he clarified this statement at the beginning of the chapter to differentiate it.
Cheng Yingmao said: The pulse of Shanghan being tight at both Yin and Yang positions is vastly different from the moderate pulse of wind-stroke where Yang floats and Yin is weak. Only when both syndrome and pulse match reality can it be correctly named Taiyang Shanghan, distinct from wind-stroke.
Wei Litong said: Both Shanghan and wind-stroke present with a floating pulse, but wind-stroke is floating-moderate, while Shanghan is floating-tight. Yang pathogen is dispersive, hence moderate; Yin pathogen is forceful and urgent, hence tight. Both are floating in the exterior, but one is moderate and the other tight, showing the distinct difference between Wind and Cold.

In Taiyang Bing, with headache, fever, body pain, lower back pain, joint pain, aversion to wind, anhidrosis, and wheezing, Mahuang Tang (Ephedra Decoction) is the primary treatment.
[Annotation] This elaborates on the syndrome following the previous article to propose the treatment. The Taiyang meridian originates from the inner canthus, ascends to the forehead, intersects at the vertex, enters to connect with the brain, emerges again, descends separately behind the neck, follows the shoulder blades internally, flanks the spine to reach the waist, and ends at the little toe. When Cold pathogen lodges in this meridian, Ying Blood becomes stagnant and sluggish, causing pain everywhere it injures. Ying pathology causes aversion to cold; Wei pathology causes aversion to wind. Now, Ying pathology presents with aversion to wind, likely because wind movement generates cold; aversion to cold and wind often coexist. There is no case of aversion to cold without aversion to wind, nor aversion to wind without aversion to cold. Therefore, Zhang Zhongjing often mentions them interchangeably in wind-stroke and Shanghan syndromes. This shows that distinguishing wind-stroke from Shanghan lies not in aversion to cold versus wind, but in their severity. Anhidrosis occurs because Shanghan is an excess pathogen, closing the couli (pores); although feverish, sweat does not come out, unlike wind-stroke's deficient pathogen where fever comes with spontaneous sweating. Yang Qi is suppressed by Cold pathogen, reversing upward to cause wheezing. Mahuang Tang is used to release the exterior, induce sweating, expel pathogens, and protect Zheng Qi.
[Collected Annotations] Cheng Wuji said: Cold injuring the Ying causes headache, body pain, lower back pain, extending to joint pain, due to impaired circulation of Ying Blood in the Taiyang meridian.
Cheng Yingmao said: Headache and fever are common to all Taiyang diseases, but body pain, lower back pain, and joint pain indicate Cold injuring the Ying chamber; if Wind injured the Wei, these would not occur. Aversion to wind is common to Taiyang diseases, but anhidrosis and wheezing indicate Yang obstruction; if Wind injured the Wei, these would not occur. By identifying similarities, one distinguishes differences.
Shen Mingzong said: Taiyang pathogens enter via the skin and hair, stagnating and reversing Lung Qi, thus causing wheezing. Moreover, Cold governs contraction; injuring Ying closes the couli, so Mahuang Tang is used to disperse.

Mahuang Tang Formula
Ephedrae Herba (Mahuang, 麻黄) - removed nodes, 3 liang
Cinnamomi Ramulus (Guizhi, 桂枝) - 2 liang
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - roasted, 1 liang
Pruni Semen Armeniacae Amarum (Xingren, 杏仁) - soaked in hot water, skin and tips removed, 70 seeds
These four ingredients are boiled in 9 sheng of water. First, boil Ephedra, reducing by 2 sheng, remove the foam on top. Add the remaining herbs, boil to obtain 2.5 sheng. Strain and take 0.8 sheng warm. Cover with blankets to induce slight sweating. No need to drink porridge. Rest and care follow the method of Guizhi Tang.
[Formula Analysis] Named Mahuang Tang because Ephedra is the Sovereign herb. Ephedra is warm in nature, pungent and bitter in taste, acting with rapid ascent. Cinnamon Twig is warm in nature, pungent and sweet in taste, capable of securing the exterior. Since the syndrome is Excess, Ephedra is the decisive strategy; Cinnamon Twig acts as the supervisor to regulate. Bitter-warm Apricot Seed assists Ephedra in expelling pathogens and descending rebellious Qi. Sweet-pacifying Licorice assists Cinnamon Twig in harmonizing the interior and resisting the exterior. Upon ingestion, Qi moves in the Yuanfu, essence is transported to the skin and hair. When Hair and Vessel essence combine, profuse sweating occurs. Exterior pathogens are completely expelled without retention; pain stops, wheezing subsides, cold and heat resolve instantly. No porridge is needed to borrow grain energy for sweating. The foam must be boiled off to prevent irritability, as its light and floating nature excessively guides Qi upward. Ginger and Jujube are omitted because Ginger's nature disperses horizontally in the muscles, hindering Ephedra's rapid ascent; Jujube's nature is sticky and obstructs the diaphragm, hindering Apricot Seed's rapid descent. This formula aims for rapid direct action; delay reduces speed, horizontal dispersion prevents ascent. However, this is a Pure Yang agent with excessive sweating power, like a general charging straight ahead. Used correctly, it wins in one battle; incorrectly, it invites disaster. Thus, it should be used once, not twice. If the condition persists after sweating, substitute with Guizhi Tang. This is Zhang Zhongjing's most potent first-line formula for releasing the exterior and expelling pathogens via sweating. Unskilled practitioners do not know its potency depends on covering with blankets to induce sweating. Without covering, it is not potent, leading them to believe Ephedra only releases the exterior and treats nothing else. They fail to realize that combining this decoction with Guizhi Tang creates Mahgui Banban Tang (Half-Mahuang Half-Guizhi Decoction) to harmonize lingering cold-heat in Taiyang. Removing Apricot Seed and adding Gypsum, combined with Guizhi Tang, creates Guizhi Er Yuebi Yi Tang (Guizhi Two-Yuebi One Decoction) to resolve heat-dominant cold-heat in Taiyang. If Yang is excessive internally with anhidrosis and wheezing, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Seed, Licorice, and Gypsum Decoction) is used to dissipate pathogens in the Taiyin Lung. If Yin is excessive internally with anhidrosis, Mahuang Fuzi Xixin Gancao Tang (Ephedra, Aconite, Asarum, and Licorice Decoction) is used to warm and dissipate Cold in the Shaoyin Kidney. The Jingui Yaolue removes Cinnamon Twig from this formula, and the Qianjin Fang replaces Cinnamon Twig with Cassia Bark, both named Huanhun Tang (Soul-Returning Decoction) to treat sudden syncope with locked jaw and absent breath due to pathogens in Taiyin, effective upon swallowing, without requiring blanket coverage. Thus, the potency of Mahuang Tang depends on blanket coverage. This is Zhang Zhongjing's secret method of using formulas, inaccessible to ordinary people!
[Collected Solutions] Wang Kentang said: This formula is designed for those with robust Zheng Qi. If complicated by seasonal pathogens, use Shishen Tang; by summer-dampness, use Zhengqi Tang; by Cold, use Wuji San; by Heat, use Tongsheng San; by food stagnation, use Yangwei Tang; by phlegm, use Xongsu San. Note: Kentang's discussion is indeed appropriate. However, it applies only when syndromes involve both exterior and interior, with mixed pathogens, resembling but not being Shanghan. If pulses and syndromes match Mahuang or Guizhi indications, one must follow Zhang Zhongjing's methods. Even if Zheng Qi is inherently weak or there is pre-existing heat, making Mahuang/Guizhi unsuitable, one must slowly adjust treatment following Liu Wansu and Zhang Jiegu's methods to avoid harming patients. Clinicians should examine carefully.
Wu Shou said: In all Shanghan, when Cold pathogen is in the exterior, closing the couli, causing body pain, stiffness, aversion to cold, and anhidrosis, one must use the pungent and bitter properties of Ephedra to open the couli, expel Cold, and resolve via sweating. Only in midsummer heat, even with these symptoms, cool herbs should be added before use, such as Fangfeng Tongsheng San or Sanhuang Shigao Tang.

On the first day of Shanghan, the Taiyang meridian is affected. If the pulse is calm, the disease does not transmit; if there is a strong desire to vomit, or restlessness, and the pulse is rapid and urgent, the disease is transmitting.
[Annotation] On the first day of Shanghan, affecting Taiyang, the pulse should be floating and tight. Whether sweating has occurred or not, if the pulse remains calm as usual, the patient's disease pulse does not match the disease state, indicating no transmission. Initial vomiting or a strong desire to vomit, along with restlessness and a rapid, urgent pulse, indicates external pathogens are unresolved and internal heat has formed, signaling impending transmission. Daqinglong Tang (Major Green Dragon Decoction) should be used to release the exterior and resolve heat to curb the momentum; or if there are exterior and interior heat syndromes, Shuangjie Tang (Double-Resolution Decoction) should be used for simultaneous resolution.
[Collected Annotations] Shen Mingzong said: This uses pulse differentiation to judge transmission. Floating and tight pulse is the correct Taiyang pulse; if calm, it does not transmit to other meridians. If there is a desire to vomit or restlessness with a rapid, urgent pulse, the pathogen is moving inward significantly, inevitably transmitting to cause disease.

On the second or third day of Shanghan, if Yangming and Shaoyang syndromes are not seen, the disease is not transmitting.
[Annotation] On the second day, Yangming is affected; on the third day, Shaoyang is affected; this is the normal sequence. If on the second or third day, Yangming syndromes (aversion to cold replaced by aversion to heat, feverish body, restlessness, thirst, insomnia) and Shaoyang syndromes (alternating chills and fever, fullness in chest and hypochondrium, frequent vomiting, bitter taste, deafness) are absent, it is because the Taiyang pathogen is mild and heat is slight, not transmitting to Yangming or Shaoyang.
[Collected Annotations] Cheng Zhi said: Day 1-2 Taiyang, Day 2-3 Yangming, Day 3-4 Shaoyang, Day 4-5 Taiyin, Day 5-6 Shaoyin, Day 6-7 Jueyin. This merely states the norm! Variations include: staying in one meridian without transmitting, skipping meridians, stopping after transmitting one or two meridians, entering Shaoyin directly from Yang, direct attack on the Three Yin meridians, hand meridian transmission from foot meridian heat, transmission due to medication error. Generally, Heat transmits when exploiting meridian deficiency; if the meridian is solid, it resists pathogens and does not transmit. Yang pathogen dominance leads to transmission; Yin pathogen dominance rarely transmits. Hence, calm pulse means no transmission, rapid/urgent pulse means impending transmission. Also, foot meridians ascend from feet to chest, abdomen, head, and back, governing the body's main framework. Thus, Cold entering manifests in foot meridians. Hand meridians only traverse chest and hands, not governing the main framework. Once pathogens enter foot meridians, they must transmit to hand meridians. Hence, severe Wind-Cold causes pain in head/neck, shoulders, back, and elbows. The Sages spoke of foot meridians but not hand meridians because foot meridians encompass hand meridians, but not vice versa; it is not that hand meridians do not transmit. The Five Zang and Six Fu organs and twelve meridians exchange Qi and connect via collaterals; how could transmission occur in foot meridians but not hand meridians? Or injury to foot meridians but not hand meridians? Yu Tianmin said: Heat affects hands first, Cold affects feet first. These ideas can be interrelated.
Cheng Yingmao said: The six meridians of Shanghan are arranged based on depth. Skin is governed by Taiyang, hence named Taiyang; Muscle is governed by Yangming, hence named Yangming; Fascia is governed by Shaoyang, hence named Shaoyang. Hua Tuo said: Day 1 in skin, Day 2 in flesh, Day 3 in muscle, Day 4 in chest, Day 5 in abdomen, Day 6 in stomach. This roughly delineates depth within the body shell without naming Taiyang or Yangming. Thus, Zhang Zhongjing's division into Taiyang, Yangming, etc., is also about setting boundaries to manage disease locations.

If the pulse is floating, the disease is in the exterior; sweating may be induced, preferably with Mahuang Tang. If the pulse is floating and rapid, sweating may be induced, preferably with Mahuang Tang.
[Annotation] For Shanghan with floating-tight pulse, Mahuang Tang is indeed the primary agent. Now, with floating or floating-rapid pulses, which seem outside the scope of sweating, observing that the syndrome is still exterior-excess Shanghan without sweating, one may overlook the pulse and focus on the syndrome, using Mahuang Tang to induce sweating. The text says "may induce sweating" rather than "governed by" or "released by" Mahuang Tang, implying discretion.
[Collected Annotations] Fang Youzhi said: Shanghan pulse is typically tight; if floating instead, it indicates the pathogen is returning to the exterior and wanting to disperse. "Release" means pushing it out. Mahuang Tang takes advantage of this desire to disperse to push it out. If floating and rapid, indicating impending transmission, Mahuang Tang is still suitable to induce sweating, taking advantage of the floating pulse indicating outward movement to dissipate the rapidity and prevent transmission.
Cheng Yingmao said: Mahuang Tang is the primary agent for Cold injuring Ying, but one must consider pulse and syndrome together, not rigidly adhering to "tight". Floating without tightness seems unsuitable for sweating, but if the syndrome matches Cold injuring Ying's exterior disease, one may overlook the pulse and detail the syndrome: anhidrosis allows sweating, definitively using Mahuang Tang. If floating and rapid, indicating pathogen moving inward, one may overlook the syndrome and detail the pulse: anhidrosis allows sweating, also suitable for Mahuang Tang. Comparing these two aspects of pulse and syndrome, if both floating-tight pulse and Shanghan syndrome match, what prohibition exists against Mahuang Tang!
Liu Hongbi said: How do we know it is exterior Cold-excess if the pulse is floating but not tight? Only if there is anhidrosis can sweating be induced. How do we know it hasn't entered the interior if the pulse is rapid? Because the pulse is also floating, sweating is permissible.

In Taiyang Bing, if exterior syndromes are unresolved and the pulse is floating and weak, sweating should be induced, preferably with Guizhi Tang (Cinnamon Twig Decoction).
[Annotation] "Exterior syndromes unresolved" means Taiyang exterior syndromes are unresolved. If the pulse is floating and tight, it is unresolved Shanghan exterior syndrome. Now, with floating and weak pulse, it is unresolved wind-stroke exterior syndrome, so Guizhi Tang should be used to induce sweating.
[Collected Annotations] Fang Youzhi said: "Exterior syndromes unresolved" means headache, neck stiffness, aversion to cold, etc., persist. Floating and weak corresponds to Yang floating and Yin weak. This states that for any Taiyang syndrome not yet transmitted, one should still resolve the exterior, strictly warning against premature purging.
Cheng Zhi said: Exterior syndromes unresolved with floating-weak pulse requires sweating even after a long time. However, only Guizhi Tang's muscle-resolving method is suitable; erroneous use of heavy sweating agents must be avoided. Prohibition against purging goes without saying.

After inducing sweating in Shanghan, if the condition resolves but restlessness returns after half a day, and the pulse is floating and rapid, sweating may be induced again, preferably with Guizhi Tang.
[Annotation] After taking Mahuang Tang for Shanghan, sweating occurs, heat recedes, body cools, and condition resolves. If restlessness and floating-rapid pulse return after half a day, it means exterior pathogens have not fully cleared and have re-aggregated. Sweating may be induced again. Mahuang Tang is not used because fluids were previously damaged by sweating and cannot withstand Mahuang again; thus, Guizhi Tang is preferred for subsequent sweating.
[Collected Annotations] Fang Youzhi said: "Inducing sweating in Shanghan" refers to taking Mahuang Tang to induce it. "Resolve" means disperse; "return" means repeat. Why repeat after resolving for half a day? It means improper sweating technique or failure to avoid wind-cold after sweating led to recurrent restlessness and heat, with pulse turning floating and rapid. Hence, "may induce sweating again." "Geng" means change. It means changing the previous method, hence Guizhi Tang is suitable.
Yu Chang said: Guizhi Tang is used because the pathogen is heavy and invades the Wei, and Ying is deficient, unable to withstand Mahuang again.
Cheng Yingmao said: Changing the previous sweating method to muscle-resolution means using Guizhi does not violate Shanghan prohibitions.
Wang Hu said: Zhang Zhongjing's rule states that floating and rapid pulse allows sweating, preferring Mahuang Tang. But this clause already used Mahuang Tang, so a new formula is needed to induce sweating, hence Guizhi Tang.

After inducing sweating, if the disease does not resolve but aversion to cold worsens, it is a deficiency syndrome; Shaoyao Gancao Fuzi Tang (Peony, Licorice, and Aconite Decoction) is the primary treatment.
[Note] The character "not" in "disease does not resolve" is likely a textual error. If the disease did not resolve after sweating, aversion to cold would be expected. Saying "worsens aversion to cold" implies the disease has resolved, leaving only deficiency. Disease resolution with aversion to cold defines deficiency.
[Annotation] In Shanghan, if the disease does not resolve after sweating, aversion to cold is expected, indicating exterior pathogen remains unresolved, requiring further sweating. Now, after sweating, the disease has resolved, and aversion to cold should cease. If aversion to cold persists/worsens, it is not due to exterior pathogen, but Yang deficiency failing to guard the exterior. Thus, Shaoyao Gancao Fuzi Tang is used. Aconite supports Yang; Peony nourishes Yin; Licorice assists Aconite and Peony to tonify Yin and Yang and harmonize Ying and Wei.
[Collected Annotations] Fang Youzhi said: Before sweating, aversion to cold indicates pathogen excess and exterior excess. After sweating, aversion to cold indicates pathogen retreat and exterior deficiency. After sweating, major pathogens disperse, Ying Qi declines, Wei Qi becomes lax, leading to mere aversion to cold, hence called deficiency.

Shaoyao Gancao Fuzi Tang Formula
Peoniae Radix Alba (Shaoyao, 芍药) - 3 liang
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - roasted, 2 liang
Aconiti Lateralis Radix Praeparata (Fuzi, 附子) - processed, skin removed, broken into eight pieces, 1 piece
These three ingredients are boiled in 5 sheng of water to obtain 1.5 sheng. Strain and take warm in divided doses.
[Collected Solutions] Cheng Yingmao said: The sweating method in Shanghan was originally set to remove Cold. If the exterior is resolved and aversion to cold is worse than before, it is clearly no longer an exterior pathogen. Sweat leakage causes exterior deficiency, so Shaoyao Gancao Fuzi Tang is used. Peony with Cinnamon Twig releases the exterior; Peony with Aconite tonifies the exterior. Licorice harmonizes the middle and draws from the Yin aspect, restraining Yang. When Yang returns, the deficiency is no longer deficient.

After inducing sweating, if aversion to cold occurs, it is deficiency; if there is no aversion to cold but only heat, it is excess. One should harmonize Stomach Qi, administering Tiaowei Chengqi Tang (Harmonizing the Stomach and Purging the Ganglion Decoction).
[Annotation] After Shanghan sweating, if the condition resolves, there should be neither aversion to cold nor aversion to heat, indicating cure. If aversion to cold occurs after sweating, it is Yang deficiency, treated with Shaoyao Gancao Fuzi Tang. Now, if there is no aversion to cold but only aversion to heat after sweating, it is Stomach excess, so Tiaowei Chengqi Tang is given to purge heat and harmonize the Stomach.