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Sha disease has concurrent symptoms, similar symptoms, and transformed syndromes, which cannot be fully distinguished by the four diagnostic methods of inspection (Wang), auscultation and olfaction (Wen), inquiry (Wen), and palpation (Qie). Only by observing the "Sha veins" can it be identified. The Sha veins manifest as bluish-purple discoloration. The origin of Sha disease lies in the toxins within the blood. Since these blood toxins cannot be eliminated through conventional means, various diseases arise; therefore, treatment should naturally involve scraping (Guasha) or pricking to release blood. If scraping and bloodletting fail to completely remove the Sha, medication is appropriate: first eliminate the Sha toxin, then treat the underlying condition. In cases requiring concurrent treatment or prevention, careful examination is essential.

In cases where Shanghan (Cold Damage) presents with headache, aversion to cold, and fever, or when affected by summerheat, foul turbidity, or epidemic pestilence, if suddenly complicated by Sha disease, one must rely on pulse diagnosis and vein observation. Treatment must prioritize Sha disease first; only after the Sha recedes should Shanghan be treated. If hot soups or ginger juice are mistakenly ingested, the outcome may be manageable if the progression is slow, but if rapid, critical danger will appear immediately (see Formula Pao Wu).

A patient suffered from Shanghan for fourteen days and suddenly became comatose with heavy limbs, unresponsive to medical treatment. I stated: This coma is caused by Sha Qi rushing to the heart, and the inability to move results from Sha toxin entering the blood level and meridians. First, apply scraping and bloodletting using Formula Pao Wu. After the Sha receded, treat the Shanghan, resulting in recovery.

A female patient presented with headache and fever, classified as Taiyang disease (disease syndrome of the Foot-Taiyang Bladder channel). She took Qianghuo Chonghe Tang and improved slightly. By the fourth day, the medication ceased to work, and she developed a red face, body heat, restlessness, and oppression, with all six pulses being excessively flooding (Hongda). This was Shanghan complicated by Sha disease. Pricking the blue veins released black blood; other fine veins were faintly visible. After taking two doses of Formula Pao Er, symptoms eased slightly. The next day, the Sha veins appeared prominently; nine needles were applied, and after taking Formula Si Qi, she felt somewhat relieved. Later, sudden overeating caused recurrent fever and facial redness. Pricking the blue veins on both feet and administering two doses of Formula Pao Er led to slight improvement. Accidentally drinking warm tea induced immediate delirium. Drinking two bowls of cold well water, followed by several more doses, cleared the Sha Qi. However, due to prolonged illness and physical deficiency causing dizziness, she recovered after taking Ginseng Decoction.

Among the four types of symptoms resembling Shanghan in Shanghan texts, none are as fierce and violent as Sha disease resembling Shanghan. Shanghan headache, aversion to cold, and fever belong to the Foot-Taiyang Bladder channel, where cold pathogen enters from the muscle surface, so dispersing is the priority. In contrast, Sha headache is caused by toxic vapors attacking upward, not by external cold invasion. Although aversion to cold and fever manifest on the muscle surface, they result from seasonal epidemic qi entering via respiration, stagnating into heat-toxin, and battling the muscle surface. Internal heat causes external cold, hence the aversion to cold. Treatment should prioritize pricking the vertex to release Sha and drain toxin, using medications that open orifices, resolve toxins, and regulate Qi. Mistakenly using strong diaphoretic herbs like Qianghuo or Mahuang (Ephedrae Herba) will exacerbate the Sha fire, leading to swelling and immediate critical danger. It must be understood that Sha disease requires cooling, and Sha toxins can be resolved internally. Shanghan requires acrid dispersion to release cold externally; the two must not be confused (see Formulas Pao Liu, Pao Qi).

A patient presented with alternating chills and fever, coma, reddish-black complexion, and cyanotic fingertips, with a flooding and rapid pulse. Others diagnosed this as recent syncope, attributing it to a Yin syndrome. I disagreed: A flooding and rapid pulse indicates Sha toxin battle; cyanotic fingertips indicate toxic blood stasis; reddish-black complexion indicates Sha toxin rising to the three Yang channels of the head and face. Observing the Sha veins and performing bloodletting revealed slight purple-black blood. Using Formula Shi Er and Can Sha Tang (Mulberry Silkworm Frass Decoction), the patient gradually regained consciousness. Subsequent bloodletting flowed profusely. With persistent fever, heaviness, and shoulder/back pain, a large dose of Formula Pao Liu was used, allowing gradual mobility. For persistent fever and constipation, Houpo (Magnoliae Officinalis Cortex), Zhishi (Aurantii Fructus), Dahuang (Rhei Radix et Rhizoma), Maiya (Hordei Fructus Germinatus), and Taoren (Persicae Semen) were taken warm. Bowel movement restored, heat subsided, and recovery ensued.

A female patient presented with headache, aversion to cold, fever, restlessness, oppression, panting, thirst, profuse sweating on the head, black complexion, and cyanotic fingertips. The Qi Kou pulse was deficient with intermittent stops, while the left three positions were excessively flooding and rapid. Without Sha disease, such a pulse would likely be fatal. Pricking the vertex once and several points on the arms and legs failed to cure. As her illness began after a meal, Fan Tang (Alum Decoction) was used to induce vomiting, resolving restlessness, panting, and sweating. For remaining symptoms, two doses of Formula Pao Qi were administered, leading to relief after bowel movement. More than ten days later, severe abdominal pain and salivation occurred, triggered again by foul turbidity. Scraping and using Formula Jin Si cured her.