The Treatise on Cold Damage (Shang Han Lun) is one of the four great classics of Traditional Chinese Medicine (TCM) and serves as a specialized text on exogenous diseases that closely integrates theory and clinical practice. Its established system of “tang fang” (decoction formulas) for pattern differentiation and treatment has become a hallmark of TCM, effectively guiding our clinical practice to this day. The main body of the Treatise is as follows:1. Cold DamageIn ancient times, exogenous febrile diseases were referred to as “shi bing” (seasonal diseases), which are closely related to time. The method of naming and classifying exogenous febrile diseases based on time is a significant characteristic of TCM. The relationship between seasonal changes and the occurrence of these diseases is closely linked, such as cold damage, warm diseases, strokes, damp warmth, febrile diseases, and rheumatism, which are named according to the five movements and six qi (wind, cold, heat, dampness, dryness, fire) (as seen in the “Nei Jing”, “Nan Jing”, and “Wen Bing Tiao Bian”). Zhang Zhongjing rejected the method of naming diseases based on the six excesses, instead opting to name them based on clinical symptoms. All exogenous diseases primarily characterized by “fever” and “chills” are collectively referred to as cold damage, while others are termed miscellaneous diseases and given different names, such as cholera, chest binding, jaundice, hidden binding, malaria, and yin-yang transformation.
As stated in the “Mengzi”: “Receiving the root without knowing, it manifests with time.” What kind of pathogenic factor does the patient actually experience? It is determined by the patient’s clinical manifestations, not the season. The phrase “Cold Damage x days” in the Treatise refers to the patient’s main complaint today: fever, chills for x days. The “Suwen: Discussion on Heat” states: “All heat diseases are types of cold damage… When a person is harmed by cold, it results in heat disease.” Since it emphasizes that cold damage is primarily characterized by fever, the “Discussion on Heat” only includes heat excess patterns. Later generations of the warm disease school, influenced by this, adopted the differentiation of wei, qi, ying, and blood, which also only includes heat patterns. In clinical practice, exogenous diseases can present both heat excess and deficiency cold. This has led to the so-called “cold-warm” debate, a phenomenon caused by the naming of exogenous diseases.2. Six Diseases (Taiyang Disease, Yangming Disease, Shaoyang Disease, Taiyin Disease, Shaoyin Disease, Jueyin Disease)The sequence of days and the development of exogenous diseases (seasonal diseases) are closely related, such as the progression of cold damage from the exterior to the interior, from superficial to deep, from above to below, and from yang to yin, following the transformation rules of Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, and Jueyin (as seen in the “Suwen: Discussion on Heat”), as well as the transformation trends of the later warm disease school regarding wei, qi, ying, and blood. Zhang Zhongjing, based on clinical practice, rejected the traditional seasonal naming method for cold damage (such as spring warmth, summer heat, autumn dryness, winter cold) and the “daily transmission of a channel” theory (such as cold damage occurring on the first day of Taiyang), opting instead to classify and name based on the three yin and three yang (six times) throughout the day. The sequence of days and the onset, manifestation, and resolution of seasonal diseases are closely related; within a single day, diseases can vary in severity, with symptoms being more pronounced or hidden, or transmitted or not transmitted. This is crucial for identifying, differentiating pulse patterns, and predicting diseases, such as fever being more pronounced at night when heat enters the blood level, Yangming tidal fever being worse in the afternoon, and wind-cold exterior syndrome having more pronounced fever around noon. This method of classifying exogenous febrile diseases based on the different heat types and timing of onset is a unique contribution of Zhang Zhongjing, existing solely in the Treatise on Cold Damage, and due to its brevity, it has often been misunderstood by later generations, becoming a mystery in the TCM community for a millennium.1All “six diseases” are related to “cold and heat”. Cold damage characterized by “fever” is called three yang disease; cold damage characterized by “chills” is called three yin disease. “If there is fever and chills, it arises from yang; if there is no fever and chills, it arises from yin” (7). The latter part of this statement, “no fever and chills,” should be interpreted as “chills and fever” due to the frequent occurrence of fever in three yin disease. Three yang disease’s commonality is “fever”; the difference is “chills” or “no chills”; three yin disease’s commonality is “chills”; the difference is “fever” or “chills and fever”.1.1Distinguishing the degree of cold and heat: In ancient times, there were no thermometers, and the degree of fever relied entirely on the doctor’s perception. To differentiate the degree of fever, doctors often used terms like “fever”, “high fever”, “strong fever”, “burning fever”, “irritable heat”, “violent fever”, “steaming fever”, “tidal fever”, “slight fever”, “mild fever”, “intermittent fever”, “periodic fever”, “like malaria”, “alternating chills and fever”, “facial complexion showing heat”, “chills and fever”, etc. The Treatise on Cold Damage involves nearly 130 articles related to fever. When describing “chills”, Zhang Zhongjing also used terms like “slight chill”, “great chill”, “shivering chill”, “chills”, “body coolness”, “chills and curling up”, “no chills”, “aversion to wind”, etc., with nearly 70 articles involved. Since “cold and heat” are closely related to “sweating”, there are over 120 articles related to “sweating”, such as “great sweating”, “slight sweating”, “spontaneous sweating”, “night sweating”, “head sweating”, “no sweating”, etc.1.2Distinguishing subjective and objective symptoms of cold and heat: “If the patient feels great heat but desires clothing, the heat is in the skin, and the cold is in the marrow; if the body feels great cold but does not want to be near clothing, the cold is in the skin, and the heat is in the marrow” (11). This statement is not about distinguishing “true and false cold and heat” but is a guideline for distinguishing subjective and objective symptoms. “Fever”, “great heat”, “heat in the skin”, “great cold”, “cold in the skin”, “body coolness”, “aversion to cold”, “desire for clothing”, “no desire for clothing”, “cold in the marrow”, “heat in the marrow”, “hands and feet warm”, “hands and feet cold”, “irritable heat”, etc. are objective symptoms; “chills”, “aversion to wind”, “aversion to heat”, “desire for clothing”, “no desire for clothing”, “cold in the marrow”, “heat in the marrow”, “hands and feet self-warming”, “hands and feet cold”, “irritable heat”, etc. are subjective symptoms.1.3Distinguishing the location of cold and heat: The discussion includes “skin”, “marrow”, “exterior and interior”, “limbs”, “hands and feet”, “whole body”, “chest and abdomen”, etc. In the Treatise, there are over 50 articles specifically addressing coldness in the hands and feet and limbs, and nearly 20 articles regarding warmth in the hands and feet. It is evident that Zhang Zhongjing placed great importance on distinguishing the location of cold and heat.1.4Characteristics of cold and heat in the six diseases: The heat characteristics of Taiyang disease are “fever and aversion to cold”; the heat characteristics of Yangming disease are “tidal heat, not aversion to cold, but aversion to heat”; the heat characteristics of Shaoyang disease are “fever and thirst, not aversion to cold” or “alternating chills and fever”; the cold characteristics of Taiyin disease are “aversion to cold”, “abdominal fullness with pain”, “limb discomfort”, “hands and feet self-warming”, “due to cold in the organs”; the cold characteristics of Shaoyin disease are “aversion to cold and curling up, sometimes irritable”, “due to deficiency cold in the lower jiao”; the cold characteristics of Jueyin disease are “cold hands and feet” or “reversal of heat and cold”, “when yin and yang qi do not connect, it results in reversal”.2All “six diseases” correspond to “six times”.2.1The concept of six times: The “Suwen: Discussion on the Flow of Qi” states: “Yang qi governs the exterior for one day, at dawn life qi arises, at noon yang qi declines, and at dusk yang qi is exhausted.” This divides the day into three parts: dawn, noon, and dusk. The “Suwen: Discussion on the True Words of the Golden Coffer” also states: “From dawn to noon, it is the yang of heaven, the yang within yang. From noon to dusk, it is the yang of heaven, the yin within yang. From dusk to rooster crowing, it is the yin of heaven, the yin within yin. From rooster crowing to dawn, it is the yin of heaven, the yang within yin.” The ancients divided the day into twelve time periods, with the yang of the day starting at dawn and ending at dusk. The yin of the day starts at dusk and ends at dawn. Dawn corresponds to the time of Yin, noon corresponds to the time of Wu, dusk corresponds to the time of Xu, and rooster crowing corresponds to the time of Chou. Yang rises from Yin and ends at Xu, while Yin rises from Xu and ends at Yin. Dawn, noon, dusk, rooster crowing, and night are the “heavenly times”, while the twelve time periods are the “time markers”. The human biological clock corresponds to heavenly time; the time markers are merely a mechanical clock, a method for recognizing and marking time. Mechanical clocks (time markers) do not change with seasons or regions, while “heavenly time” is a dynamic concept of time. The manifestations, onset characteristics, and rhythms of seasonal diseases synchronize with the diurnal rhythm; the three yang occupy two-thirds of the day, while the three yin occupy one-third, reflecting the idea of the unity of heaven and man, and that humans are subject to heavenly numbers.
2.2Six diseases and the times of their resolution: The Treatise on Cold Damage does not explicitly state the times of the six diseases, but it discusses the times of their resolution. “For Taiyang disease, the time of resolution is from Si to Wei”; (9) “For Yangming disease, the time of resolution is from Shen to Xu”; (193) “For Shaoyang disease, the time of resolution is from Yin to Chen”; (272) “For Taiyin disease, the time of resolution is from Hai to Chou”; (275) “For Shaoyin disease, the time of resolution is from Zi to Yin”; (291) “For Jueyin disease, the time of resolution is from Chou to Yin”. (328) The term “time of resolution” has a double meaning: first, it refers to recovery and resolution; second, it refers to the onset, manifestation, and exacerbation of the disease. As stated by You Zai in the “Shang Han Guan Zhu Ji”: “During the times of Shen, You, and Xu, it is the afternoon, and Yangming tidal heat arises in the afternoon; the resolution of Yangming disease also occurs in the afternoon. Thus, Shen, You, and Xu are the times of Yangming, during which the pathogenic qi arises, and the time of resolution is when the righteous qi recovers.” Therefore, the six diseases manifest, present, worsen, and resolve during six specific time periods. For example, Taiyang disease manifests from “Si to Wei”. “Taiyang disease may present with fever and chills at Si or Wei, accompanied by body pain, vomiting, and a tight pulse, is termed cold damage.” This means that whether fever and chills occur at Si or Wei, accompanied by body pain, vomiting, and a tight pulse, it is termed Taiyang cold damage. “Yi” is a typographical error for “Si”.There has been significant debate among physicians throughout history regarding the times of resolution for the six diseases, as they believe it does not align with clinical practice. The organization of the Treatise on Cold Damage is based on the six diseases, with each section titled “Differentiation of Certain Disease Pulse Patterns and Treatments”, and many articles are prefixed with “certain disease”. All six diseases present with fever, and their heat types and timing of pain have specific characteristics and rules. Ma believes that “the six diseases are closely related to the times of the six diseases.” The Treatise does not mention the times of the six diseases, only six articles discussing the times of resolution. So, what is the relationship between the times of the six diseases and the times of resolution? Yao believes: “The time of resolution must not be in the original time zone but in another time zone, and the time of resolution will not be in the original time, but in the next time zone.” This viewpoint cannot be realized in clinical practice. Zang believes that “the time of resolution for Taiyang disease is from Si to Wei… The meaning is to clarify and understand the concept of the time of disease contained in the term Taiyang disease… From Si to Wei actually supplements the time of disease for Taiyang disease.” “Time of disease refers to the main time of suffering (i.e., a specific time within the six times), while the disease course refers to the days and dates after the disease (involving the transmission, recovery, or death of the disease). The time of disease has its specificity, and the disease course has continuity with the time of disease. Each of the six diseases has a specific time of disease and a specific location of disease, as well as a date process of disease development, which is the basic meaning of the times of the six diseases.” Changing the reading of “解” (jie) to “解” (xie) may be acceptable, but it is lacking. Ma further argues: “The times of the six diseases and the times of resolution are two aspects of the same entity; if the time of disease worsens, it indicates disease progression; conversely, if the time of disease improves, it indicates disease regression, thus aligning the times of resolution with clinical practice, and providing a reasonable explanation for the times of disease and resolution in the Treatise on Cold Damage.” Therefore, a certain disease manifests during a specific time period, presenting as a certain disease. For instance, Taiyang disease manifests during the natural “heavenly time” from Si to Wei, with the disease presenting as progressive and unresolved.Conversely, if it lessens, it indicates the time of resolution; the same applies to others. Thus, the occurrence, development, and resolution of exogenous febrile diseases are organically unified, and the times of the six diseases and the times of resolution are merely different manifestations at different periods of the same time, following the changing of “heavenly time” (i.e., seasons) rather than “time markers” (i.e., mechanical clocks). This has significant implications for diagnosis, treatment, and prognosis. The times of the six diseases provide an important basis for diagnosis and offer a method of treatment that adapts to the situation, treating according to the time. This method, which allows the medicinal power to be assisted by righteous qi to expel pathogenic factors, achieves a remarkable effect of using a small effort to yield great results. Additionally, it can also predict the times of resolution based on the severity of the six diseases and their manifestations.2.3The six diseases are closely related to the concept of time. “Certain disease” refers to the onset of a disease during a specific time period. In the Treatise on Cold Damage, all entries prefixed with six diseases indicate a concept of time, meaning that any pulse pattern appearing during the Taiyang time is termed Taiyang disease. Any pulse pattern appearing during the Shaoyin time is termed Shaoyin disease. For example, the Shaoyin disease Chengqi Decoction syndrome occurs during the Shaoyin time. The Taiyang disease Taohua Chengqi Decoction syndrome and Wuling Powder syndrome occur during the Taiyang time, indicating blood accumulation and water accumulation. The Yangming disease Wu Zhu Yu Decoction syndrome and Mahuang Decoction syndrome occur during the Yangming time.3Six Times as a Dynamic Natural Time.The “Zhou Bi Suan Jing” states: “When the sun reaches the time of You, it travels westward; when the sun reaches the time of Yin, it travels eastward… On the winter solstice, the sun rises at Chen and sets at Shen… On the summer solstice, the sun rises at Yin and sets at Xu.” This means that the length of day and night varies throughout the four seasons. During the spring and autumn equinoxes, day and night are equal; the pointer of the ancient water clock (used for timekeeping) is at the midpoint of the west at sunset, and at the midpoint of the east at sunrise; during the winter solstice, the pointer reaches Chen when the sun rises, and just reaches Shen when the sun sets; during the summer solstice, the pointer just points to Yin when the sun rises, and only sets at Xu. The “Nei Jing” states: “When treating diseases, one should examine twice.” Different seasons and locations result in variations in the time periods governed by the six times. Therefore, the six times in the Treatise on Cold Damage represent a dynamic heavenly time. From Yin to Chen, in different seasons and locations, it is a starting time, existing “above” rather than in between, and the disconnection of the six times can also serve as evidence for this point.3. Six Qi (Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, Jueyin)Six qi refers to the three yin and three yang, which have various meanings in the “Nei Jing”. In the Treatise on Cold Damage, it specifically refers to disease locations. Ma believes: The ancients believed that the operation of six qi must follow certain pathways and boundaries, and the spatial positions governed by six qi vary at different times. The Treatise on Cold Damage inherits the spatial disease location view of the three yin and three yang from the “Nei Jing”, but rejects the views of “meridian disease locations” and “six meridian transformations”, establishing a three-part disease location view of exterior, interior, and half-exterior half-interior. In the Treatise on Cold Damage, many instances of the independent use of the names of the three yang and three yin refer to specific locations or systems, such as Taiyang being affected, Taiyang wind, Taiyang initially becoming ill, Taiyang following the meridian, Yangming internal binding, transforming to Yangming, belonging to Yangming, Yangming residing in the center governing earth, transforming to Taiyin, Taiyin being affected, Taiyin being ill, belonging to Taiyin, Shaoyin sweating, Jueyin wind, etc. The qi of the three yang governs the exterior, the Yangming governs the interior, and the Shaoyang governs half-exterior half-interior, which is clearly stated in the Treatise on Cold Damage. The positioning of the three yin is not very clear in the Treatise, and collectively referring to the three yin as interior patterns is extremely inaccurate, causing significant confusion regarding the positioning of the three yin. The “Suwen: Discussion on Yin and Yang Separation and Combination” states: “Taiyin opens, Jueyin closes, Shaoyin is the pivot.” Zhang Jingyue states: “Taiyin opens, residing in the exterior of the yin division; Jueyin closes, residing in the interior of the yin division; Shaoyin is the pivot, residing in the center of the yin division; opening governs exit, closing governs entry, and pivot governs both exit and entry.” Thus, Taiyang is the beginning of the three yang, and Jueyin is the end of the three yin; one opens and one closes, one enters and one exits, yin and yang intersect, opposing yet coexisting, both belonging to the exterior. Yangming is the end of the three yang, and Taiyin is the beginning of the three yin; one opens and one closes, one exits and one enters, yin and yang connect, opposing yet coexisting, both belonging to the interior. Shaoyang is the pivot of the two yang, and Shaoyin is the pivot of the two yin, connecting the exterior and interior, linking the inside and outside, both belonging to half-exterior half-interior. This forms the three-part six-position view of the Treatise on Cold Damage. 4. Six Patterns4.1The concept of six patterns. Six patterns are the specific pulse patterns that occur due to pathological changes in the time and location governed by six qi. Six patterns are what later generations refer to as the outline patterns; they are special manifestations of the six diseases, representing the unity of time and location of disease patterns. In the Treatise on Cold Damage, there are Taiyang patterns, Yangming patterns, Shaoyang patterns, Shaoyin patterns, etc. The pulse patterns of the six diseases, termed “XX as a disease”, are the six patterns. The outline patterns of the six diseases in the Treatise on Cold Damage have historically been a topic of great debate; Zhang Zhongjing’s six patterns not only differentiate based on time and location but also possess disease characteristics. For example, “Taiyang as a disease presents with a floating pulse, stiff neck, and aversion to cold” is a specific pulse pattern that unifies the disease location at the exterior and the disease time at the Taiyang time, which can also be termed a typical Taiyang disease.4.2Six diseases and six patterns are two different concepts. Six diseases only have a temporal aspect, while six patterns possess both temporal and spatial aspects, representing the unity and specificity of the six diseases’ time and location. Six patterns are typical of the six diseases, while six diseases are atypical of the six patterns. Therefore, in each of the six diseases in the Treatise on Cold Damage, various formulas and patterns may appear, either only pertaining to the time of disease or only to the location of disease, consistent with the six patterns. Conversely, the same formula may present differently due to different times of disease. For example, the Wu Zhu Yu Decoction syndrome presents differently during Yangming disease, Shaoyin disease, and Jueyin disease; the Da Chengqi Decoction syndrome presents differently during Yangming disease and Shaoyin disease. This is crucial for accurately identifying the manifestations of formulas and patterns at different time periods. In other words, the same formula may present differently due to different times.4.3Pulse patterns of the six patterns. Ma believes: “Taiyang as a disease presents with a floating pulse, stiff neck, and aversion to cold.” This is the outline pattern of Taiyang disease. “Taiyang as a disease” is a special expression technique for “Taiyang as a disease”. The character “之” (zhi) is a structural particle that removes the independence of the sentence, making “Taiyang as a disease” the subject of the entire sentence. Thus, the first statement can be translated as: The exterior Taiyang location has been affected by cold damage, resulting in a floating pulse, stiff neck, fever, and aversion to cold. The Taiyang pattern is a typical Taiyang disease, representing the unity of time, location, and disease characteristics within Taiyang disease. In the Taiyang disease section, all formulas and patterns prefixed with Taiyang disease exhibit the characteristic of manifesting during Taiyang time, with the heat type being fever and aversion to cold. Some are exterior patterns, some are non-exterior patterns, some are heat patterns, some are cold patterns, some are excess patterns, and some are deficiency patterns, all aimed at differentiating from the Taiyang pattern. Similarly, the Yangming pattern is a typical Yangming disease, representing the unity of time, location, and disease characteristics within Yangming disease. In the Yangming disease section, all entries and formulas prefixed with Yangming disease exhibit the characteristic of manifesting during Yangming time, with the heat type being tidal (moist) heat, not aversion to cold, but aversion to heat. Some are interior patterns, some are non-interior patterns, some are heat patterns, some are cold patterns, some are excess patterns, and some are deficiency patterns, all aimed at differentiating from the Yangming pattern’s solid stomach. The Shaoyang pattern is a typical Shaoyang disease, representing the unity of time, location, and disease characteristics within Shaoyang disease. In the Shaoyang disease section, all entries and formulas prefixed with Shaoyang disease exhibit the characteristic of manifesting during Shaoyang time, with the heat type being fever or alternating chills and fever. Some are half-exterior half-interior patterns, some are non-half-exterior half-interior patterns, some are heat patterns, some are cold patterns, some are excess patterns, some are deficiency patterns, and some are mixed cold and heat patterns, all aimed at differentiating from the Shaoyang pattern’s fever or alternating chills and fever, bitter mouth, dry throat, and dizziness. The same applies to the three yin diseases and three yin patterns.4.4Formulas and patterns. Between the six patterns and formulas, there is a related concept called “similar patterns”, which later generations also refer to as “similar formulas”, such as Gui Zhi Decoction type, Mahuang Decoction type, Chai Hu Decoction type… Zhang Zhongjing borrowed the names of cold damage, wind stroke, rheumatism, warm diseases, etc., just as he borrowed the names of Taiyang disease, Yangming disease, and the six diseases, but the content is entirely different. Taiyang disease cold damage is equivalent to the Taiyang disease Mahuang Decoction type, Taiyang disease wind stroke is equivalent to the Taiyang disease Gui Zhi Decoction type, and Taiyang disease warm disease is equivalent to the Taiyang disease Mahuang, Xingren, Shigao, and Gancao Decoction type…Distinguishing between aversion to cold and aversion to wind: Both are subjective symptoms; aversion to cold is when adding clothing does not alleviate the cold, while aversion to wind is when clothing alleviates the cold, but exposure to wind exacerbates it. Distinguishing between dry heat and moist heat: Both are objective symptoms; fever without sweating indicates dry heat, while fever with sweating indicates moist heat. The fever and sweating of Gui Zhi Decoction is mild, termed slight fever; the fever and sweating of Chengqi Decoction is high, termed steaming fever. Sweating and wheezing without high fever (not aversion to cold, but aversion to heat) versus sweating and wheezing with fever and aversion to cold: one is Taiyang disease warm disease Mahuang, Xingren, Shigao, Gancao Decoction, and the other is Taiyang disease cold damage Mahuang Decoction. Sweating and wheezing without high fever (not aversion to cold, but aversion to heat) versus sweating and wheezing with fever and aversion to wind: one is Taiyang disease warm disease Mahuang, Xingren, Shigao, Gancao Decoction, and the other is Taiyang disease wind stroke Gui Zhi plus Houpo and Xingzi Decoction. Fever and aversion to cold, with heat on the exterior (heat in the skin) and cold on the interior (cold in the marrow), or cold limbs with heat on the interior (heat in the marrow), with a floating slippery pulse and fever with sweating, and aversion to wind with a slow pulse: one is Taiyang disease warm disease Baihu Decoction; the other is Taiyang disease wind stroke Gui Zhi Decoction. Fever and aversion to wind, with sweating and thirst or not aversion to cold, but aversion to heat, with a large pulse and fever with sweating, and aversion to wind with a slow pulse: one is Taiyang disease wind warm Baihu plus Ren Shen Decoction; the other is Taiyang disease wind stroke Gui Zhi Decoction.Fever and aversion to wind, with body pain and lower back pain, joint pain, without sweating and wheezing, and with wind dampness, joint pain, and severe pain that cannot be flexed or extended, with proximity causing severe pain, sweating and shortness of breath, difficulty urinating, and aversion to wind without wanting to remove clothing: one is Taiyang disease cold damage Mahuang Decoction; the other is Taiyang disease wind dampness Gancao and Fuzi Decoction. Continuous sweating, aversion to wind, difficulty urinating, limbs slightly urgent, difficulty flexing or extending, with wind dampness, body pain, and inability to turn or shift: one is Taiyang disease wind stroke Gui Zhi plus Fuzi Decoction; the other is Taiyang disease wind dampness Gui Zhi plus Fuzi Decoction. Fever without thirst, aversion to cold without sweating, cough with slight wheezing versus sweating and wheezing without high fever and thirst (not aversion to cold, but aversion to heat): one is Taiyang disease cold damage Xiao Qinglong Decoction; the other is Taiyang disease warm disease Mahuang, Xingren, Shigao, Gancao Decoction. Stiff neck and back, sweating and aversion to wind versus stiff neck and back without sweating and aversion to wind: one is Taiyang disease wind stroke Gui Zhi plus Gegen Decoction; the other is Taiyang disease cold damage Gegen Decoction.5. Clinical Case Example: Ms. Xu, 52 years old, accountant, visited on December 23, 2003. The patient had been coughing and wheezing for over 4 months, worsening in the late night, unable to sleep, with a large amount of white phlegm, thirsty, drinking a lot, frequent urination, overweight, red tongue, white and dry coating, and a deep pulse. After repeated treatments with various hospitals using both Western and Chinese medicine without effect, interstitial pneumonia was suspected (bronchoscopy not performed). Prescribed Zhu Ling Decoction for 6 doses. On January 1, 2004, during the second visit, the cough had reduced but not significantly. Upon further inquiry about the timing of the illness, it was found that the cough worsened daily from 5-7 AM, producing a large amount of white foamy phlegm, even leading to urinary incontinence, sweating, shortness of breath, throat pain, chest pain, and regurgitation after drinking. The prescription was modified to Mahuang Shengma Decoction combined with Zhu Ling Decoction. On January 10, 2004, during the third visit, the cough and wheezing had significantly improved, with no chest pain. However, the cough still produced foamy phlegm from 5-7 AM, with sticky phlegm and excessive sweating. The prescription was adjusted to use only Mahuang Shengma Decoction, adding Huangqi (Astragalus) (10g), Zhimu (Anemarrhena) (10g), Yuzhu (Polygonatum) (10g), Baishao (Paeonia) (3g), Ganjiang (Dried Ginger) (3g), Tiandong (Asparagus) (3g), Guizhi (Cinnamon Twig) (3g), Fuling (Poria) (3g), Baizhu (Atractylodes) (3g), Mahuang (Ephedra) (6g), Shengma (Cimicifuga) (6g), Danggui (Angelica) (6g), Wuweizi (Schisandra) (3g), Gancao (Licorice) (10g), and Kugen (3g), totaling over 1 month of medication, with all symptoms resolved. On September 18, 2004, she returned for a follow-up, stating that she had not experienced any issues for six months after recovery. Recently, while traveling abroad, swimming, and becoming fatigued, she developed a cough, and after receiving treatment from other doctors with both Western and Chinese medicine for over a month, her condition worsened. The prescription was again adjusted to Mahuang Shengma Decoction, removing Ganjiang and Guizhi, and she recovered after 12 doses. Note: This case was initially misdiagnosed as Shaoyin disease cough, treated with Zhu Ling Decoction, which was ineffective. Later, based on the timing of Jueyin disease, Mahuang Shengma Decoction was prescribed, leading to successful treatment. This highlights the significant value of the timing of the three yin and three yang in differentiation within the Treatise on Cold Damage. The essence of the three yin and three yang in the Treatise on Cold Damage has been debated for nearly a thousand years, with many viewpoints being forced interpretations by later scholars. In reality, its content is quite simple, representing a concept of time and location. The six diseases discuss time without involving disease characteristics, while the six patterns discuss space, unifying time and location, relying solely on pulse patterns for differentiation. The three yin and three yang represent a time and location differentiation. Understanding the essence of the three yin and three yang in the Treatise on Cold Damage is beneficial for inheriting Zhang Zhongjing’s valuable clinical experience.
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