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(The *Neijing* refers to this as Zhonghan (Middle Cold), which is the True Cold Syndrome where pathogenic cold directly invades the Yin meridians.)

[Etiology] The patient suffers from deficiency of Yang Qi in the Stomach and Kidneys, causing internal cold to arise first, followed by external cold invading. As stated in the *Neijing*: "Excess of Yin generates internal cold." Due to the counterflow of Jue Qi (Rebellious Qi) moving upward, cold qi accumulates in the chest without being discharged. If not discharged, the overflowing vital energy departs, leaving only cold behind. When cold remains, blood coagulates; when blood coagulates, the vessels become obstructed, thus resulting in Zhonghan (Middle Cold). Zhonghan refers to pathogenic cold suddenly and directly invading the Yin meridians, with Yin pathogens erupting violently. This condition is more severe than Shanghan (Cold Damage) and requires prioritizing the differentiation of syndromes of the Three Yin meridians.

[Symptoms] In cases where cold invades the Taiyin Meridian, initial symptoms include aversion to cold and shivering, absence of headache, absence of fever, absence of thirst, cold limbs, vomiting and diarrhea, fullness and pain in the epigastrium and abdomen, and difficult urination. The tongue coating is white, slippery, and grayish; in severe cases, it may be gray, slippery, and greasy, or grayish and pale white. In cases where cold invades the Shaoyin Meridian, initial symptoms include aversion to cold and cold limbs, curling up in sleep without thirst, fullness below the heart, cramping pain in the lower abdomen, clear and cold watery diarrhea with more water than feces, and white or pale yellow urine. In severe cases, there is redness of the face, irritability, a desire to sit in a well, slight body heat, thirst for water but immediate vomiting upon drinking, abdominal distension after even small sips preventing further drinking, sore throat, shortness of breath, muttering delirium, hiccups, a pale white and swollen tender tongue coating, or a gray-black coating with a tender, slippery, and moist tongue body. The color may turn from pale white to black, appearing cracked and thorn-like visually, but feeling wet and slippery to the touch. In cases where cold invades the Jueyin Meridian, initial symptoms include cold limbs, vomiting of saliva/phlegm, passage of clear watery stool with a raw fishy odor, epigastric fullness, immediate vomiting of any liquid ingested, cyanosis of fingernails and toenails, aversion to cold and shivering, profuse spontaneous sweating, muscle twitching, floating false Yang manifesting as redness of the face (Daiyang), mental depression and drowsiness, curled tongue, and retracted testicles. The tongue coating is green and slippery, or purple-green and slippery, or pale purple with a green tint, dark in color and smooth in texture.

[Pulse] In cold invading the Taiyin Meridian, the pulse is deep, soggy, and slow; in severe cases, it is deep, soggy, and faint. In cold invading the Shaoyin Meridian, the pulse is deep and faint; in severe cases, it is deep, faint, and nearly imperceptible. In cold invading the Jueyin Meridian, the pulse is thin and nearly imperceptible; in severe cases, the pulse ceases. A gradual return of the pulse indicates survival; its absence indicates death. A gradually slowing pulse returning indicates survival; a sudden emergence indicates death. These are all critical signs of Yin excess extinguishing Yang. As Mr. Tao stated: "Regardless of whether the pulse is floating, sunken, large, or small, if it feels powerless under the fingers and completely absent upon heavy pressure, it is a Yin syndrome." Prescribing medication based on the pulse is most appropriate.

[Treatment] For Taiyin syndrome, mild cases are treated primarily with Weiling Tang (Poria Decoction), severe cases with Shenxiang Shengzhu Jian (Aromatic Sage-Invigorating Decoction), and extreme cases with Fuzi Lizhong Tang (Aconite Regulate-the-Middle Decoction). For severe vomiting with hiccups, add Jiang Banxia (Pinelliae Rhizoma Preparatum, 4 qian), Shang Chenxiang (Aquilaria Lignum, 8 fen), and Zhen Shidi (Diospyri Fructus, 30 pieces). For severe abdominal distension and pain, add Zhen Houpo (Magnoliae Officinalis Cortex, 1.5 qian) and Ming Ruxiang (Boswelliae Resina, 8 fen); for persistent diarrhea, add Wei Rougu (Myristicae Semen, 1 qian) and Zaoxin Tu (Caulis Trichosanthis preparatus/Fired Hearth Earth, wrapped and decocted, 5 fang). For Shaoyin syndrome, mild cases are treated primarily with Zhenwu Tang (True Warrior Decoction), severe cases with Fuzi Bai Tong Tang (Aconite White Passage Decoction), slightly milder cases with Fuzi Gui Gu Tang (Aconite Cinnamon Return-Glucose Decoction), and even milder cases with Fuzi Gui Gu Shen Gan Tang (Aconite Cinnamon Return-Ginseng Licorice Decoction). If Yang returns, the body warms, and vomiting/diarrhea cease, add Zhi Huangqi (Prepared Astragali Radix, 1 qian each), Chao Baizhu (Stir-fried Atractylodis Macrocephalae Rhizoma, 1 qian each), Jiu Chao Baishao (Wine-stir-fried Paeoniae Radix Alba, 1.5 qian), and Bei Wuweizi (Schisandrae Chinensis Fructus, 12 grains) to gently warm and tonify to conclude treatment. For Jueyin syndrome, mild cases are treated with Danggui Sini Tang (Angelica Sinensis Replenish-Cold Decoction) plus Wuzhuyu (Evodiae Fructus, 8 fen) and Shengjiang Zhi (Zingiberis Recens Juice, 1 spoon taken separately); severe cases with Tongmai Sini Tang (Unblock-Vessels Replenish-Cold Decoction) plus Wuzhuyu (Salt-water stir-fried Evodiae Fructus, 1 qian) and Zi Gui (Purple Cinnamomi Ramulus, 1 qian ground and taken separately); extreme cases with Huiyang Jijiu Tang (Restore-Yang Emergency Rescue Decoction). External therapy involves moxibustion on Qihai (CV6, 1.5 cun below umbilicus), Dantian (CV4, 2 cun below umbilicus), and Guanyuan (CV4, 3 cun below umbilicus). Use six or seven large moxa cones until limbs warm and pulse returns.

[Xiu's Commentary] Direct invasion of Taiyin presents with slightly cold hands/feet, vomiting without thirst, spontaneous diarrhea, abdominal fullness, and a deep-slow pulse. Shaoyin presents with cold limbs and a deep-faint pulse. Jueyin presents with cold limbs and a thin pulse, potentially ceasing entirely, with blue lips, curled tongue, tendon contraction, and retracted testicles. However, the facial color is always blue-dark. Even if deficient Yang floats upward causing facial redness, it lacks vitality and brightness, appearing delicate and white. The tongue is blue, purple, or covered with a slippery white coating. Hands and feet are naturally cold; nails are blue or purple with dull blood color. Skin has no significant heat, often ice-cold to the touch. These are definitive evidence of Yin syndromes. Although treatment necessitates using Fuzi (Aconiti Lateralis Radix Praeparata) and Ganjiang (Zingiberis Rhizoma) to break Yin and restore Yang, Fuzi is highly toxic. While necessary for emergency rescue, overdose leaves residual toxin, often causing red face, red eyes, restlessness, and unquenchable thirst. Delayed antidote administration leading to bleeding from ears, eyes, mouth, or nose results in death. The best antidote is Xijiao Wuhuang Tang (Rhinoceros Horn Five-Yellow Decoction): Xijiao (Rhinocerotis Cornu, 1 qian), Chuanlian (Coptidis Rhizoma, 3 qian), Qin (Scutellariae Radix, 2 qian), Bo (Phellodendri Cortex, 2 qian), Shanzhi (Gardeniae Fructus, 2 qian), Xian Shengdi (Rehmanniae Radix Recens, 3 qian), Maidong (Ophiopogonis Radix, 3 qian), Sheng Gancao (Glycyrrhizae Radix et Rhizoma, 2 qian). First decoct 1 liang of fresh Moutan (Moutan Cortex? Note: Text says Sheng Lv Dou - Green Bean) in 3 bowls of water until skins split, take clear soup to decoct herbs to 8 fen (approx 2 bowls), mix with half a cup of fresh Raphani juice, and drink cold frequently.

[Lian's Verification] Yin syndrome Shanghan refers to cold directly invading Taiyin, Shaoyin, and Jueyin meridians, also called Direct Invasion of Three Yin True Cold Syndrome, or simply Zhonghan. Modern times commonly call it Lengsha (Cold Sand) acute syndrome. Cases with curled legs and contracted tendons are named Diaojiao Sha (Hanging Foot Sand); those with sunken eye sockets are named Xiandie Sha (Sunken Eye Sand); those with vomiting, diarrhea, and abdominal pain are named Huoluan Sha (Cholera Sand) or Tuxie Sha (Vomit-Downfall Sand). Names are derived from appearance for popular understanding, but pathology is often ignored. My experience shows this disease occurs mostly in summer and autumn during droughts and intense heat, suddenly triggered by heavy rain and strong winds. Mountainous yin-toxic stagnant water and household sewage are washed into rivers by these floods. Anyone washing rice/vegetables or cooking tea/water that consumes this contaminated source contracts the toxin. Onset is sudden. Mild cases present as Han Nue (Cold Malaria) or Leng Xie (Cold Diarrhea); severe cases as Yin Huoluan (Yin Cholera) with distinguishable Three Yin symptoms. Urgent cases involve liver, kidney, spleen, and stomach contamination by toxins/bacteria; treatment must prioritize saving the Spleen and Stomach. Regarding Fuzi (Aconiti Lateralis Radix Praeparata), although it treats Yin-toxic cold, raw Fuzi is rarely available; only Dan Fuzi (Lightly Prepared Aconite) is sold, which only warms and dries damp-cold but lacks power to break Yin and restore Yang. Its efficacy is far inferior to Ginger, Cinnamon, Pepper, and Evodia. Since its high heat and toxicity are well-known, success is credited to other herbs, while failure is blamed on Fuzi. Therefore, I discard it and employ new methods verified over time. Initial treatment resolves Yin toxin to stop vomiting, diarrhea, and pain: use 4 liang fresh Shengjiang (Zingiberis Rhizoma Recens), 10 original Hulao (Piperis Longi Fructus), and 1 qian Zijinpian (Calami Rhizoma? Note: Specific local herb), crush to extract juice, and drink cold (1-2 cups). Apply residue mixed with 1 qian each of Hei/Bai Jiezi (Brassicae Semen Nigrum/Sinapis) and 10 fresh Congbai (Allii Fistulosi Bulbus) as a cake. Place 5 li of She Xiang (Moschus) and 1 fen of Rougui (Cinnamomi Cortex) in the umbilicus, cover with the cake, and apply heat via a small iron pot with charcoal to promote Qi and Blood circulation. Reapply with ginger/onion juice, liquor, and pine resin oil if dry. Survival is indicated by warm limbs and cessation of vomiting/diarrhea. Additionally, rub elbows with fermented rice lees crushed with Artemisia mugwort leaves until limbs warm and tendons relax. If vomiting/diarrhea cause Yuan Qi collapse with deep/faint/imperceptible pulses or ceased pulse, urgently grind Guang Muxiang (Aucklandiae Radix) in ginger juice (1 spoon), mix with Dangmenzi (Moschus, 5 li), and 3 qian Biezhi Shen (Korean Ginseng), decoct warm and administer. Pulse return indicates survival; absence indicates death. True pulse cessation requires no pulse at all, even with heavy pressure to the bone. If the pulse is hidden yet intermittently visible upon deep pressure, it is merely Sunken Pulse (Mai Xian Xia), not true cessation.