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Dai Shi stated: In general, when treating Shanghan (Cold Damage), one must distinguish between Yin and Yang syndromes to avoid misdiagnosis. There are three Yang meridians: Taiyang (Greater Yang), Yangming (Yang Brightness), and Shaoyang (Lesser Yang). There are also three Yin meridians: Taiyin (Greater Yin), Shaoyin (Lesser Yin), and Jueyin (Terminal Yin). The Yin-Yang of the meridians is discussed in terms of Zang-Fu organs: Fu organs are Yang, including the Bladder, Stomach, and Gallbladder; Zang organs are Yin, including the Spleen, Kidney, and Liver. The Yin-Yang of diseases refers to the Yin-Yang nature of external pathogens, namely Yin Qi and Yang Qi.

When the disease is in the Taiyang meridian, the heat is at the skin level, manifesting as "Xi Xi" fever (a warm sensation like feathers covering) or "Fu Fu" fever (fever due to stagnation), accompanied by headache, aversion to cold, and body ache. The pulse will necessarily be floating and tight. When the disease is in the Yangming meridian, the heat is at the muscle level, manifesting as high fever ("Zhuang Re"), steaming fever ("Zheng Zheng Re"), or tidal fever ("Chao Re") with spontaneous sweating, accompanied by forehead pain. The pulse will necessarily be long and rapid. When the disease is in the Shaoyang meridian, it is a half-exterior, half-interior heat syndrome, manifesting as alternating chills and fever ("Wang Lai Han Re"), accompanied by pain at the temples, bitter taste in the mouth, vomiting, chest fullness, and hypochondriac pain. The pulse will necessarily be wiry and rapid. When the disease is in the Taiyin meridian, the hands and feet gradually become cold, the pulse becomes sinking, or there is spontaneous diarrhea, abdominal fullness, and vomiting without thirst. When the disease is in the Shaoyin meridian, although there may be fever, the hands and feet are naturally cold, and the pulse is necessarily deep and fine. When the disease is in the Jueyin meridian, the hands and feet are cold, the pulse is faint and slow, and in severe cases, cyanosis of the lips, curling of the tongue, and retraction of the testicles occur.

Yang syndrome manifestations include: a red and lustrous face, red lips, dry mouth and tongue, ability to drink fluids. The patient's body is light and easy to move, often wanting to open eyes and see people, with bright eyes, preferring to speak with a loud voice. Breathing through the nose and mouth is smooth. Urine may be red or yellow, stool may be constipated or hard, hands and feet are naturally warm, and nails are ruddy and vibrant.

Yin syndrome manifestations include: a blue-black face, or false Yang floating upward (red but not vibrant/lustrous). The patient's body is heavy and difficult to turn, preferring to lie facing the wall or curled up, drowsy, closing eyes and avoiding people, with dull eyes, reluctance to speak, and low voice. Breath is short, unable to inhale/exhale effectively, breath from mouth and nose is cold, no desire to drink. Face is sensitive to cold as if scraped by a knife, lips or mouth may be blue or purple, tongue color may be blue, purple, or white with a slippery coating covering the surface, lacking redness. Hands and feet are naturally cold, nails may be blue or purple, blood is not vibrant. Urine is clear and white or pale yellow, stool is loose or diarrheal. Even if the skin feels hot, pressing reveals little heat; in severe Yin cold, the cold penetrates the hand.

Both Yin and Yang Qi can invade Zang-Fu organs. Thus, if Yang Qi invades the Taiyang meridian, it is Wind Strike (Shang Feng), characterized by aversion to wind and sweating. If Yin Qi invades the Taiyang meridian, it is Cold Damage (Shang Han), characterized by aversion to cold and no sweating. If unresolved in Taiyang and transferring to Yangming and Shaoyang, it becomes purely Yang syndrome, which is harder to treat than Taiyang. If Yang Qi continues to transmit into Yin meridians, it becomes "Yang within Yin." Although symptoms like diarrhea, drowsiness, cyanotic lips, cold limbs, curled tongue, and retracted testicles appear, one must not recklessly administer warming herbs; instead, one should purge the Yang heat residing in the Yin meridians. If Yang disease is treated with purgatives excessively, causing Yang Qi depletion, it transforms into Yin syndrome, described as "the harm of heat has not ceased, yet cold disease arises," or initial Yin syndrome, known as "Yin within Yin." This occurs because Yin Qi attacks Yin meridians directly, not from Yang meridians. One should only use warming herbs to restore Yang. Therefore, when Yang enters Yin, transform Yang to save Yin; when Yin enters Yang, use Yang to save Yang. These two must be distinguished.

Huorenshu (The Living Manual) states: Taiyang, Yangming, and Shaoyang all belong to Yang syndromes. Taiyang belongs to the Bladder, with symptoms of fever, aversion to cold, headache, lower back pain, and floating pulse. Yangming belongs to the Stomach, with symptoms of no aversion to cold but aversion to heat, sweating, constipation, tidal fever, and long pulse. Shaoyang belongs to the Gallbladder, with symptoms of bitter taste, dry throat, hypochondriac fullness, fever with vomiting, or alternating chills and fever, and wiry pulse. Mahuang Tang (Ephedra Decoction), Da Qing Long Tang (Great Blue Dragon Decoction), and Guizhi Tang (Cinnamon Twig Decoction) treat Taiyang Wind Strike and Cold Damage. Da Chai Hu Tang (Major Bupleurum Decoction), Tiao Wei Cheng Qi Tang (Regulate the Stomach and Restore the Qi Decoction), Xiao Cheng Qi Tang (Minor Restoring the Qi Decoction), and Da Cheng Qi Tang (Major Restoring the Qi Decoction) treat Yangming Cold Damage. Xiao Chai Hu Tang (Minor Bupleurum Decoction) treats Shaoyin Cold Damage (Note: Textual error in original, typically for Shaoyang). Other formulas treat post-sweating, post-emetic, or post-purgative conditions.

If Yang Qi is exclusively abundant and Yin Qi abruptly ceases, it is called Yang Du (Yang Toxin), manifesting as restlessness, madness, running about, delirious speech, red face, sore throat, rash like brocade, or bloody diarrhea with crimson stool, and surging or slippery-rapid pulse. Acid-bitter herbs should be administered to restore Yin Qi, leading to resolution via profuse sweating. Ancients said: "Acid and bitter induce vomiting and purging, belonging to Yin," referring to herbs like Kushen (Sophora Root), Daqing (Arctium Leaf), Tinglizi (Lepidium Seed), and vinegar, which restore Yin. Mildly use bitter, heavily use acid to reduce heat and restore Yin. If extreme heat causes jue (cold extremities), and Yang syndrome resembles Yin, learners must distinguish by pulse.

Taiyin, Shaoyin, and Jueyin all belong to Yin syndromes. What is Taiyin syndrome? Taiyin is the Spleen meridian, mainly presenting with chest and diaphragm distension. What is Shaoyin syndrome? Shaoyin is the Kidney meridian, mainly presenting with fine pulse, vexation, desire to sleep, or spontaneous diarrhea with thirst. What is Jueyin syndrome? Jueyin is the Liver meridian, mainly presenting with excessive thirst, Qi rushing to the heart, heart pain, muscle heat, anorexia, vomiting worms after eating, and worsening diarrhea if purged. For mild cold in the Three Yin meridians, Lizhong Tang (Regulate the Middle Decoction) is used. For slight cold extremities or cold-induced diarrhea, Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction) is used. For severe cases, Sini Tang (Frigid Extremities Decoction) is used. For absent pulse, Tongmai Sini Tang (Pulse-Restoring Frigid Extremities Decoction) is used. If Yin Qi is exclusively abundant and Yang Qi abruptly ceases, it is called Yin Du (Yin Toxin), manifesting as cold extremities, severe umbilical/abdominal pain, body feeling beaten, and sinking pulse. With vomiting or diarrhea, urgently moxa below the navel and administer acrid-hot herbs to restore Yang, resolving via profuse sweating. Ancients said: "Acrid and sweet disperse and ascend, belonging to Yang," referring to Guizhi (Cinnamon Twig), Gancao (Licorice), Ganjiang (Dried Ginger), and Fuzi (Aconite Root), which restore Yang. Mildly use acrid-sweet, heavily use acrid-bitter. If extreme Yin causes restlessness, and Yin syndrome resembles Yang, learners must distinguish by pulse.

Luo Shi stated: Distinguishing Yin and Yang syndromes. The eldest son of Li Jun, Procurator of Jingjiang Prefecture, aged 19, contracted Shanghan in April. After nine days, a physician treated him as Yin syndrome with Fuzi Lizhong Wan (Aconite Regulate the Middle Pills) several times, worsening the condition. Another physician argued it was Yang syndrome, causing confusion and hesitation to take medicine. Li Jun invited me to examine. I did not state the diagnosis directly but explained the distinctions for self-reflection. Yang syndrome: High body heat, cold-free extremities, restless lying but strong rising, no aversion to cold but aversion to heat, no vomiting/diarrhea, thirsty for water, vexed insomnia, able to eat and talk much, floating-large-rapid pulse. Yin syndrome: No body heat, cold extremities, aversion to cold, curled posture, aversion to sound, pulling covers, no vexation/thirst, anorexia, free urination, loose stool, deep-fine-micro-slow pulse. His pulse was 6-7 beats per breath. His mother reported night-long screaming, insomnia, and thirst. Knowing all Yang symptoms were present and no bowel movement for three days, I urgently purged. I prescribed Jiuhuang (Wine-processed Rhubarb) 6 qian, Zhigancao (Honey-fried Licorice) 2 qian, Mangxiao (Mirabilite) 5 qian. By evening, several movements of dry feces (over 20 pieces) passed. That night, profuse sweating occurred. Next day, body cool, pulse calm. Reflecting on Suwen's "Treat by unblocking Zang-Fu," Zhang Zhongjing's "Six Meridians differ in transmission," and Huorenshu's "Must understand meridians first," the principle is one. Ignorant physicians who ignore meridians and source, guessing blindly, cause disaster. As Han Yu said, physicians err by lacking deep thought. Learners must be prudent.

Wu Shi stated: Yin syndrome resembling Yang is like water extreme resembling fire. Due to rapid cooling herb misuse in Shanghan transmission, in patients with inherent Kidney Qi deficiency and cold, Yin syndrome develops. Internal cold forces floating Yang fire outward. Symptoms: red face, vexation, slight fever, thirst but inability to drink much, constipation, pale yellow urine, vomiting, shortness of breath, dysphonia, or sore throat, mimicking Yang syndrome. Misdiagnosing as Yang and administering cold herbs leads to death. Be cautious! Deep-fine-slow-micro pulse indicates urgent need for Tongmai Sini Tang with extra Renshen (Ginseng Root) and Fuzi (Aconite Root) to connect True Yang. Delay leads to Yin excess/Yang decline, where Ginseng and Aconite cannot save. This is Yin Excess Blocking Yang. Wang Bing stated: "Body heat, rapid pulse, non-beating upon pressure" is Yin Excess Blocking Yang, not heat.

Lou Shi stated: Suwen says: "Pulse follows but disease reverses." Syndrome resembles Yang, pulse resembles Yang, but disease is Cold. Syndrome resembles Yin, pulse resembles Yin, but disease is Heat. Thus, treat opposite to apparent syndrome/pulse. E.g., fever, slight heat, vexation, red face, but deep-micro pulse indicates Yin syndrome resembling Yang. Fever due to interior cold, vexation due to Yin excess, facial flushing (Dai Yang) due to lower deficiency. Misdiagnosing as excess heat and giving cold herbs destroys Qi. Waitai Miyao states: "Yin excess causes restlessness, named Yin Zaosao," desiring to sit in a well, treat with hot herbs. Thus, Zhang Zhongjing treats Shaoyang red face with Sini Tang plus Congbai (Scallion White). (Yuan Zhi Zhu note: Cold herbs enter stomach, fire rises with water, reaching extreme Yin Zaosao, desiring well. Yang is already lost. Physician unaware, treats as heat with cold herbs, death is certain.)

Yuan Zhi stated: Restlessness after vomiting/coughing, steaming fever like sitting in a steamer, wanting to remove clothes/cold places/hot water, then returning chills, shortness of breath, chest oppression, severe open-mouth/stare/extreme phlegm/saliva. Restlessness is brief. Six pulses are fine-wiry-choppy, empty upon pressure, indicating severe cold. Use acrid-cold and sweet-warm herbs to strongly drain South (Fire) and North (Water) to cure. Feng Neihan's nephew had Shanghan with red eyes, vexation, thirst, 7-beat pulse, non-beating upon pressure. Classic: "Pulse follows, non-beating upon pressure" applies to all Yang, indicating Yin Excess Blocking Yang externally, not heat. Given Jiangfu (Ginger and Aconite) decoction, resolved with sweating.

Xu Shi stated: Shanghan 6-7 days, no fever, deep-tight-fine pulse, vexation, no thirst, indicates Yin Excess Blocking Yang. Use Fuzi Pili San (Aconite Thunderbolt Powder). Do not use if drinking water.

Wu Shi stated: Yang syndrome resembling Yin is like fire extreme resembling water. Severe Shanghan heat, missed sweating/purging, Yang Qi hyperactive and depressed internally, manifests as cold externally (victor's transformation). Symptoms: cold extremities, dull spirit, resembling Yin. But dry lips/tongue, ability to drink, constipation, dark scanty urine indicate internal dryness. Loose stool is "side-flow" from dry feces accumulation, not cold diarrhea. Foul gas confirms this. Pulse deep but slippery-strong upon pressure, or periodic heat/restlessness, kicking, forceful delirium, indicates Yang syndrome. Mild cases: Renshen Baihu Tang (Ginseng White Tiger Decoction) or Xiao Chai Hu Tang combined with Jiedu Tang. Internal excess requires purging: Tiao Wei Cheng Qi Tang. Tidal fever: Da Chai Hu Tang plus Mangxiao. Severe excess/blockage: Da Cheng Qi Tang. Judge severity carefully. Similar to Yang Excess Rejecting Yin. Wang Bing stated: "Body cold/cold extremities, slippery-rapid pulse, beating upon pressure" is Yang Excess Rejecting Yin, not cold.

Huorenshu stated: Cold extremities, constipation, dark urine, or black stool, deep-slippery pulse, indicates Yang syndrome resembling Yin. Mild: Baihu Tang. Severe: Cheng Qi Tang. Missed purging in Shanghan causes Qi/Blood blockage, cold extremities due to deep latent heat ("Jue deep, heat deep"). Urgently purge with Da Cheng Qi Tang plus Nifen (Calomel). Sweating resolves immediately. Heat Jue differs from Yin Jue. Heat Jue: slight cold extremities with fever. Yin Jue: no fever, cold extremities, aversion to cold, deep-fine pulse, loose stool. Previous sections: Syndrome resembles Yang but pulse/disease is Yin; Syndrome resembles Yin but pulse/disease is Yang. Treat oppositely. People can distinguish syndrome-resembling-Yang/pulse-Yin. But pulse-syndrome-both-Yin/disease-Yang is universally unrecognized, causing many deaths. Xu Xueshi noted: Song Di's nephew had Shanghan with vexation/thirst/sweating, treated with cold herbs, became Yin Toxin, died. Song Di wrote "Yin Toxin Syndrome Resolution" out of grief.

Discussion: Yin excess causes exterior cold, Yang deficiency causes exterior cold. Exterior syndrome: sweat to cure. Yang excess causes interior heat, Yin deficiency causes interior heat. Interior syndrome: purge to cure.

Zhao Shi stated: Huorenshu Q33 cites Suwen: "Yang deficiency exterior cold, Yin deficiency interior heat, Yang excess interior heat, Yin excess exterior cold." Thus, Yang deficiency/Yin excess: sweat to cure, purge kills. Yin deficiency/Yang excess: purge to cure, sweat kills. Yin-Yang deficiency/excess refers to pulse in Nanjing, but exterior/interior in Suwen. Zhang Zhongjing cites Suwen's exterior/interior for Shanghan, matching Waitai Miyao: "Exterior disease interior harmony: sweat to cure; Interior disease exterior harmony: purge to cure." I analyze: Suwen's four Yin-Yang deficiency/excess syndromes refer to miscellaneous diseases. Nanjing Ch. 6 refers to pulse. Waitai refers to Shanghan exterior/interior. Zhang Zhongjing's meaning is profound. Classic: "Pathogen excess is excess, Essence depletion is deficiency." Primary Qi deficiency allows Pathogen invasion, creating Yin deficiency/Yang excess and Yang deficiency/Yin excess. Huorenshu conflates Suwen's miscellaneous disease theory with Zhang's Shanghan theory, changing "Yang excess interior heat" to "exterior heat" and "Yin sensation interior cold" to "exterior cold," which does not align. I expand on Zhang's theory: "Excess" refers to Pathogen, "Deficiency" refers to Primary Qi. It is the mechanism of Pathogen/Primary Qi fluctuation. Primary Qi: Yang governs exterior, Yin governs interior. Pathogen: Exterior is Yin, Interior is Yang. If True Yang of exterior is deficient, Yin Pathogen overcomes and becomes excess. Exterior disease is Yang deficiency. Floating-tight pulse indicates Yin Pathogen excess externally. This is Yang deficiency/Yin excess. Treat with Guizhi Tang (acrid-sweet-warm) to sweat, eliminating Yin Pathogen and growing True Yang. If True Yin of interior is deficient, Yang Pathogen enters and becomes excess. Interior disease is Yin deficiency. Deep-solid pulse indicates Yang Pathogen excess internally. This is Yin deficiency/Yang excess. Treat with Cheng Qi Tang (acid-bitter-cold) to purge, eliminating Yang Pathogen and growing True Yin. Otherwise, using Guizhi for Yang excess kills; using Cheng Qi for Yin excess kills. This is exacerbating excess and depleting deficiency. Zhang's intent is profound: one refers to exterior syndrome, one to interior syndrome, regarding Pathogen/Primary Qi balance, not mixing exterior-harmony/interior-disease concepts. "Harmony" means no disease. Using "harmony" to explain "deficiency" is logically flawed.

Wang Shi stated: Nanjing says: "Shanghan Yang deficiency Yin excess: sweat cures, purge kills. Yang excess Yin deficiency: sweat kills, purge cures." Alas, this is the pivot of Shanghan sweating/purging. Pathogen depth varies: shallow in exterior, deep in interior. Exterior: closes pores, causes Fu Re (stagnant heat), aversion to cold/wind, headache. Treat with acrid-warm dispersal. Interior: dry feces, tidal fever, madness, delirium, great thirst. Treat with salty-cold purgation. External cold pathogen is Yin excess/Yang deficiency? Internal hot pathogen is Yang excess/Yin deficiency? One mistake in sweating/purging determines life/death. This is indeed the pivot. Critics interpret vaguely. Waitai Miyao says: Yin-Yang refers to body exterior/interior. Diseased part is deficiency, healthy part is excess. Exterior disease/Interior harmony = Yang deficiency/Yin excess. Interior disease/Exterior harmony = Yang excess/Yin deficiency. I argue: Yin-Yang in humans, balanced is peace, biased is disease. No excess or deficiency is balance. Excess is over, deficiency is under. Can excess be called harmony? Neijing says: "Pathogen excess is excess, Essence depletion is deficiency." Saying Yang deficiency needs sweating and Yin deficiency needs purging, while ignoring Pathogen and focusing on Primary Qi, is obscure. Shanghan Weizhi says: Yin-Yang refers to Cun-Chi pulse positions. Chi solid-large, Cun short-small = Yin excess/Yang deficiency, can sweat. Cun solid-large, Chi short-small = Yang excess/Yin deficiency, can purge. If sweating signs exist but pulse doesn't match, wait for Chi > Cun? If purging signs exist but pulse doesn't match, wait for Cun > Chi? Yue Ren set difficulties based on disease, not pulse. Why reverse to pulse? Pulse diagnoses disease. If sweating/purging signs are urgent, waiting for pulse match causes dilemma: follow disease or pulse? Doubt remains. Objection: Zhang Zhongjing cites this, then says "Guizhi down, Yang excess dies; Cheng Qi in, Yin excess dies." Guizhi is exterior, Cheng Qi is interior. Reversal is harmful. But Mahuang Tang is also exterior, why omitted? You say Yin excess is cold pathogen, suitable for Mahuang, why cite Guizhi? Answer: Consider Zhang's words: "Shanghan mostly from Wind-Cold." "Floating is Wind, Tight is Cold." Guizhi Tang: "Chilly aversion to cold, shivering aversion to wind." Mahuang Tang: "Aversion to wind." Wind and Cold are often linked. Wind in freezing weather, can it be called Yang? Wind and Cold are both Yin pathogens. Guizhi and Mahuang are both warm agents. Treating with warm agents shows both are Yin pathogens. Guizhi treats Wei (Defensive) injury, Mahuang treats Ying (Nutritive) injury. Both are exterior. Zhang's warning against sweating/purging errors includes Mahuang under Guizhi. "Yang excess dies" means exterior signs resolved, interior signs full, purge not sweat. "Yin excess dies" means interior signs not formed, exterior signs unique, sweat not purge. Thus, Yue Ren and Zhang Zhongjing's intent is clear.