1. Insights on the Treatment Methods of “Shang Han Lun”

Xin Zhike, Shaanxi Provincial Academy of Traditional Chinese Medicine

“Shang Han Lun” is written in a concise format, integrating theory, experience, and techniques. Its diagnostic and treatment methods rely on careful clinical observation, with its formulas and patterns rooted in the clinical practice of Traditional Chinese Medicine (TCM), supported by the experiences of ancient and modern physicians. Its remarkable clinical efficacy has impressed practitioners throughout history.
“Shang Han Lun” is the original work of Zhang Zhongjing on diagnosing and treating diseases, representing a relatively mature and complete clinical medical text. It is a foundational work of TCM clinical practice, holding milestone significance. Innovation is a relative concept; when a discipline or theory reaches a certain level of maturity and stability, further development and innovation tend to slow down. This is similar to the evolution of Tang poetry, Song lyrics, and Qing dynasty textual criticism. The medical theories and formulas established during the Han dynasty, including those in “Shang Han Lun,” are distinctive and possess lasting charm, making it difficult for later generations to surpass them in certain aspects, as “Shang Han Lun” itself is an original achievement. Therefore, for thousands of years, its development has mostly involved revisions, annotations, and organization, with little significant theoretical breakthroughs. A 30,000-word medical work that has survived for thousands of years and continues to be applied without being outdated is worthy of deep reflection and pride for contemporary practitioners, who should earnestly study and draw from its essence. The passage of time should not lead to viewing it as outdated. The age of its compilation and the formation of its theories are not standards for measuring advancement or scientific validity.
The treatment methods of “Shang Han Lun” are at the core of TCM, representing its unique advantages and key focus of contemporary TCM research. Discussing formulas without considering their corresponding patterns deviates from the spirit of “Shang Han Lun.” The treatment method is the essence and soul of “Shang Han Lun.” The formula-pattern relationship reflects the clinical indications for using a specific formula, reflecting the patient’s comprehensive and specific pathological state. It is not a theoretical deduction, nor is it a specific symptom of a disease as defined by modern medicine, nor is it a result derived from animal experiments. The pattern can represent one or multiple symptoms of a disease, forming a macro-syndrome group. As long as the pattern matches the formula used, it should be applied without doubt. The formula-pattern treatment method withstands repetition, clinical experimentation, and historical scrutiny, remaining timeless. The pattern is a comprehensive pathological state, both subjective and objective, summarized by Zhang Zhongjing and his predecessors through long-term clinical practice, with corresponding treatment formulas. In clinical practice, one must know the common patterns and recognize variations, dynamically differentiate patterns to strategize effectively.
The formula-pattern treatment method of “Shang Han Lun” is a dynamic process of treatment, intuitive and easy to learn, simple and quick, with strong operability. It is based on the pattern, and the formula is used according to the pattern, without any mysterious or obscure aspects. However, it is not a rigid application of formulas to patterns; one must integrate and apply the knowledge flexibly. For example, in the text regarding Guizhi Decoction, there are typical indications, main symptoms, accompanying symptoms, and variations, as well as the mechanisms of action, treatment methods, contraindications, and modifications of the formula. “Shang Han Lun” discusses 22 articles related to Guizhi Decoction, with 19 articles concerning variations and modifications of the formula. Guizhi Decoction is used most frequently in “Shang Han Lun” and best reflects Zhang Zhongjing’s pattern differentiation philosophy. The modifications of Guizhi Decoction follow certain principles and regularities while allowing for flexibility, with discernible patterns. Headache, fever, sweating, and aversion to wind are indications for Guizhi Decoction; sweating and aversion to wind are the main symptoms, while accompanying symptoms are based on the main symptoms. Without the main symptoms, there can be no accompanying symptoms. Attention should be paid to the coherence of the preceding and following texts, as the text includes using formulas to measure patterns, using patterns to measure formulas, using pulse to replace patterns, and using patterns to replace symptoms, with mutual use of details and summaries. In learning, one should grasp the simple while managing the complex, returning to the essence.
The formula-pattern treatment method of “Shang Han Lun” provides rules and standards. Modern medicine, influenced by analytical thinking, diagnoses diseases based on qualitative and quantitative standards, with imaging diagnostics being visible and measurable, and various tests expressed in numerical values. The application of the formula-pattern method in “Shang Han Lun” cannot be divorced from diagnostic standards. The patterns described in “Shang Han Lun” can be considered the gold standard for ancient disease diagnosis, formed under the influence of macro holistic thinking. For example, the indications for Guizhi Decoction are headache, fever, sweating, and aversion to wind. The indications for Xiao Chai Hu Decoction are fullness in the chest and hypochondria, dry throat, dizziness, lack of desire to eat, alternating chills and fever; the indications for Bai Hu Decoction are high fever, excessive sweating, thirst, and a rapid pulse; the indications for Si Ni San are desire to sleep, irritability, diarrhea, and pale urine; the indications for Wu Mei Wan are thirst due to upper heat and lower cold, heart pain, hunger without desire to eat, vomiting of roundworms, and persistent diarrhea. These are all diagnostic standards for using formulas, with each formula corresponding to its pattern, and patterns changing with formulas. Practitioners must master these diagnostic standards in clinical practice. The expression of standards differs between ancient and modern times. When applying formulas from “Shang Han Lun” in clinical practice, it is best to adhere to the standards set by “Shang Han Lun.” If one chooses formulas based on various modern testing data and modern disease names, it will be difficult to start, and the effects will certainly be poor. This is because “Shang Han Lun” focuses on the macro, comprehensive, holistic, and dynamically changing patient; modern medicine emphasizes anatomical analysis and the micro-level of pathological changes, pursuing the best outcomes for specific areas or systems, and focusing on the disease of the person. Therefore, without studying “Shang Han Lun,” it is difficult to become a master of TCM clinical practice.
The formula-pattern treatment method of “Shang Han Lun” is an ancient traditional method of treating diseases, highlighting the approach of a physician facing a patient. When faced with various symptoms presented by the patient, the physician selects corresponding formulas, contrasting with modern medicine, where multiple specialists address a patient, often using a process of elimination to clarify diagnoses, leading to different treatment choices. The human body is complex, life activities are variable, medical theories are continuously evolving, and treatment methods should be diverse, with TCM and Western medicine coexisting and complementing each other, benefiting without harm.

2. The Pattern Differentiation and Treatment Procedures of “Shang Han Lun”

——Discussion with the article “The Formula-Pattern is the Pinnacle of Pattern Differentiation”

Ma Wenhui, Second Hospital of Shanxi University of Traditional Chinese Medicine

Recognizing patterns is a perceptual understanding, elevating the complex patterns to rational understanding, achieving “knowing the reverse of the offense, treating according to the pattern” requires positioning, defining, establishing laws, and prescribing; this process is the pattern differentiation and treatment.
1. Positioning by Sections At the beginning of pattern differentiation, one must first identify the location of the disease, distinguishing between exterior patterns, interior patterns, and half-exterior half-interior patterns; this is the first step in pattern differentiation and treatment. Article 61 of “Shang Han Lun” states: “After purging, if sweating recurs, with daytime restlessness and nighttime calmness, no vomiting or thirst, no exterior pattern, pulse is deep and weak, and no significant fever, the prescription is Gan Jiang Fu Zi Decoction.” This example illustrates the method of determining patterns by location. There are two interior patterns: deficiency (Tai Yin) and excess (Yang Ming). No vomiting indicates no Tai Yin pattern, and no thirst indicates no Yang Ming pattern; the absence of an exterior pattern indicates no Tai Yang pattern. Thus, among the three locations, there is no exterior pattern and no interior pattern, leaving only the half-exterior half-interior pattern. Article 148 states: “If a person has had a cold for five or six days, with sweating, slight aversion to cold, cold hands and feet, fullness below the heart, lack of desire to eat, hard stools, and a thin pulse, this indicates a slight Yang blockage, with both exterior and interior patterns. The deep pulse is also in the interior. Sweating indicates slight Yang; if it were purely Yin blockage, there would be no exterior pattern, all would be in the interior. This indicates half in the interior and half in the exterior.” This article repeatedly differentiates patterns, determining by location. “Slight aversion to cold, cold hands and feet” indicates an exterior pattern; “fullness below the heart, lack of desire to eat, hard stools” indicates an interior pattern. “Sweating from the head” and “thin pulse” indicate half-exterior half-interior. Although the disease pattern is complex, it does not exceed the three categories of exterior, interior, and half-exterior half-interior. Zhang Zhongjing’s pattern differentiation must first be positioned by sections.
2. Defining Patterns According to Symptoms After positioning, the next step is to define the patterns. Each location’s symptom group reflects the dual nature of Yin and Yang, with positive responses indicating three Yang diseases and negative responses indicating three Yin diseases. Thus, based on the distinctly different Yin and Yang disease natures at each location, six categories of symptom groups are delineated, which is the six diseases. The outline for the six diseases is: first position, then define, thus Yin and Yang are separated, and the six diseases are clarified. The outline for differentiating Yin and Yang in the six diseases is found in Article 7: “If there is fever and aversion to cold, it is Yang; if there is no fever and aversion to cold, it is Yin.” Yin and Yang represent cold and heat, respectively. For example, Article 187 states: “In cold damage, if the pulse is floating and slow, and the hands and feet are warm, this indicates it is in Tai Yin… After seven or eight days, if the stools are hard, it is Yang Ming disease.” This article illustrates that after positioning, the next step is to define patterns, categorizing them into Yin and Yang. Article 279 states: “If it is a Tai Yang disease, and the physician purges it, resulting in abdominal fullness and pain, it belongs to Tai Yin; the prescription is Guizhi Decoction with Shao Yao; if there is significant pain, the prescription is Guizhi Decoction with Da Huang.” The exterior pattern entering the interior with abdominal fullness and pain belongs to Tai Yin, while significant pain indicates Yang Ming disease.
3. Pattern Differentiation to Determine Formulas Pattern differentiation aims at treatment, and treatment is the purpose of pattern differentiation. Clarifying the six diseases is merely understanding the disease, i.e., “knowing the reverse of the offense.” More importantly, it is to resolve the disease, “treating according to the pattern.” Pattern differentiation to determine formulas seeks to find the individuality of decoctions within the commonality of the six diseases. A disease pattern contains many decoction patterns; without understanding the decoction patterns, one cannot fully grasp the specific treatments for the six diseases. For example, regarding the Xiao Chai Hu Decoction pattern, Article 149 states: “If a person has had a cold for five or six days, with vomiting and fever, the Xiao Chai Hu Decoction pattern is present; if treated with other medicines, and the Xiao Chai Hu pattern persists, it should be treated again with Xiao Chai Hu Decoction.” Article 101 states: “If a person has a cold with wind, and there is a Xiao Chai Hu pattern, seeing one symptom is sufficient; it is not necessary to see all symptoms. If a person has a Xiao Chai Hu disease pattern and is treated with purgatives, if the Xiao Chai Hu pattern does not resolve, it should be treated again with Xiao Chai Hu Decoction.” From these two articles, it can be seen that the pattern does not change, and the formula does not change; one pattern corresponds to one formula. Additionally, a decoction pattern may sometimes include several symptoms; in such cases, seeing one symptom is sufficient, and it is not necessary to see all symptoms. This is a high-level summary of the essence of the disease. Thus, in pattern differentiation, one divides into three sections, from which the six diseases are categorized, and then the decoction patterns are listed, forming a complete process of pattern differentiation from analysis to synthesis and back to analysis.
4. Naming Patterns by Formulas In “Shang Han Lun,” there are names such as Guizhi pattern and Chaihu pattern; broadly speaking, all 112 formulas of Zhang Zhongjing can be named by their patterns. No formula treats a pattern, and no pattern uses a formula. The mutual verification of formulas and patterns complements each other, enhancing their effectiveness. Naming patterns by formulas is an innovation in Zhang Zhongjing’s pattern differentiation and treatment, summarizing the regularity of patterns and highly generalizing the formulas. The formula-pattern relationship is the final result of pattern differentiation and serves as the objective basis for treatment. The accuracy of pattern differentiation can only be indicated and proven by the formula, and the effectiveness of the formula can only be verified by the pattern. Therefore, only the formula can reveal the essence of the formula-pattern relationship (Yin and Yang singularity), reflect the disease’s severity (lightness and urgency), and validate the disease’s progression (length and complexity). The formula is a comprehensive embodiment of the pattern differentiation and treatment process.
For example, the Guizhi Decoction pattern indicates whether it is cold or heat, deficiency or excess; only the formula can reveal this. Guizhi Decoction is a warming and tonifying agent, harmonizing Ying and Wei, targeting exterior deficiency cold and Shao Yin disease. The Guizhi Decoction pattern is a pattern of slight deficiency and slight cold in the exterior; it only requires “to harmonize and resolve the exterior” to recover, without needing to warm and tonify excessively. Thus, using the formula to measure the pattern and naming the pattern by the formula, the mutual verification of formulas and patterns can test the correctness of the formula-pattern relationship. Only when the formula is clear and the pattern is distinct, can pattern differentiation and treatment yield immediate effects.
The formula-pattern relationship is the last link in the process of pattern differentiation and treatment; without the preceding positioning and defining, the formula-pattern relationship loses its theoretical guidance and devolves into purely experiential treatment. A lack of theoretical basis for the formula-pattern relationship would render it ineffective. Therefore, pattern differentiation and treatment are two interdependent aspects of a process, inseparable, and there is no issue of “pinnacle” and “lower end.”

3. The Application Patterns of Acupuncture in “Shang Han Lun”

Wang Yelong, Huangni Health Center, Laibang County, Anhui Province

In the various chapters of “Shang Han Lun” related to the six meridians, there are a total of 33 original texts concerning acupuncture therapy. Among them, there are 10 articles using acupuncture to treat diseases, including Articles 8, 24, 108, 109, 142, 143, 171, 216, 231, and 308; there are 7 articles using moxibustion to treat diseases, including Articles 117, 292, 304, 325, 343, 349, and 362; there are 10 articles discussing changes and complications caused by the misuse of acupuncture and moxibustion, including Articles 16, 29, 115, 116, 117, 118, 119, 153, 221, and 267; among them, Article 117 discusses changes caused by burning needles and moxibustion. Additionally, there are 6 articles on fire therapy changes, such as Articles 6, 111, 112, 113, 200, and 284. Since fire therapy includes fire needles, fire moxibustion, fire compresses, and fire fumigation, all articles on fire therapy changes that do not explicitly mention compresses or fumigation can be regarded as changes caused by the misuse of acupuncture or moxibustion. These original texts reflect the application patterns of acupuncture therapy in “Shang Han Lun,” the principles of point selection, methods of acupuncture application, and contraindications, which are of great significance for guiding clinical acupuncture practice.

1. Acupuncture is Mostly Used for Treating Three Yang Meridian Diseases, Heat Patterns, and Excess Patterns
Among the 10 articles using acupuncture therapy, 9 are found in the Three Yang Disease chapters, with 4 belonging to the variations of Three Yang diseases and 5 belonging to the primary patterns of Three Yang meridians. For example, Article 8 states: “In Tai Yang disease, if headache persists for more than seven days and resolves on its own, it is because the meridian has been fully traversed. If one wishes to induce another meridian, acupuncture at the foot Yangming point will prevent the Tai Yang evil from transmitting to other meridians, thus resolving it.” Article 24 states: “In Tai Yang disease, if after taking Guizhi Decoction, the person becomes agitated and does not resolve, first needle Fengchi and Fengfu, then administer Guizhi Decoction to achieve recovery.” This uses acupuncture to directly treat Tai Yang meridian disease. Articles 142 and 171 discuss the simultaneous occurrence of Tai Yang and Shao Yang diseases, with symptoms such as headache, neck stiffness, dizziness, and fullness below the heart; acupuncture points Dazhui, Feishu, and Gan Shu should be needled to treat both Tai Yang and Shao Yang diseases. Article 231 states: “In Yangming wind, if the pulse is wiry and floating, with shortness of breath, abdominal fullness, pain below the ribs, and persistent pressure, dry nose, inability to sweat, drowsiness, and yellowing of the body and eyes, needle Xiaochaihu.” Among the 10 articles using acupuncture, only one is found in the Three Yin Disease chapter, which is Article 308: “In Shao Yin disease, if there is diarrhea with pus and blood, acupuncture may be used.” This suggests that acupuncture is predominantly used for treating Three Yang diseases, and in terms of acupuncture points, the selected points such as Fengchi, Fengfu, Dazhui, Feishu, and Gan Shu are all Yang meridian points. The acupuncture points mentioned in Article 8, “needle at the foot Yangming,” and Article 231, “for swelling in front of the ears, needle Xiaochaihu,” also select Yang meridian points. In contrast, for treating variations, the liver meridian’s Mu point, Qimen, is selected, while Article 308 treats Shao Yin disease with diarrhea and pus and blood using acupuncture points from Yin meridians, which is rare. Therefore, it can be concluded that “Shang Han Lun” has a pattern of selecting Yang meridian points for acupuncture therapy.
2. Acupuncture is Mostly Used for Heat Patterns and Excess Patterns
Among the 10 articles using acupuncture in “Shang Han Lun,” aside from the aforementioned 5 articles on primary Three Yang diseases, the remaining 4 articles on variations also belong to heat or excess patterns. For example, Articles 143 and 216 discuss heat patterns with blood stasis, which are heat excess patterns, with symptoms such as fullness below the chest and ribs, resembling a mass, delirium, but with sweating from the head, etc.; Article 143 states: “Needle Qimen, taking into account the actual condition”; Article 216 states: “Needle Qimen, taking into account the actual condition to drain it,” indicating that the purpose of acupuncture is to drain excess and address the actual condition. Article 108 uses acupuncture to treat liver invading spleen, which is a case of liver fire invading the spleen, with symptoms of abdominal fullness and delirium, indicating a heat excess pattern; Article 109 uses acupuncture to treat liver invading lung, which is due to excessive wood fire invading the lung, with symptoms of fever, aversion to cold, extreme thirst, and abdominal fullness, also indicating a heat excess pattern. As for Article 308, the acupuncture treatment for “Shao Yin disease, diarrhea with pus and blood” is based on the principle that “needling is to unblock the obstruction and stasis; when the obstruction is cleared, the pus and blood will resolve on their own.” According to Qian Huang’s “Shang Han Su Yuan Ji,” it states: “If the evil enters Shao Yin and causes diarrhea, then the lower jiao is obstructed and does not flow, leading to the corruption of qi and blood into pus and blood; therefore, acupuncture is used to drain the evil and unblock the meridians, thus resolving the disease.” Liu Duzhou’s commentary on “Shang Han Lun” states: “In ancient acupuncture and moxibustion methods, it is generally said that acupuncture is used to drain heat and excess, while moxibustion is used to expel deficiency cold. Now, in Shao Yin disease, if there is diarrhea with pus and blood, treating with acupuncture and not moxibustion indicates it is a heat diarrhea and not a cold diarrhea. Shao Yin disease is characterized by Yin deficiency and Yang excess, with the evil qi transforming into heat, which burns the Yin meridians and leads to pus and blood; thus, acupuncture is used to drain the evil and unblock the meridians, allowing the disease to resolve.” Based on the opinions of most commentators, Article 308 should also be classified as a heat excess pattern. Therefore, it can be concluded that the use of acupuncture for excess and heat patterns is also a pattern in Zhang Zhongjing’s acupuncture therapy.
3. Acupuncture Can Be Used for Disease Prevention and Interrupting the Transmission of Evil Qi
“Shang Han Lun” also applies acupuncture to interrupt the disease process or prevent the transmission of evil qi through the meridians. A typical example is Article 8: “In Tai Yang disease, if headache persists for more than seven days and resolves on its own, it is because the meridian has been fully traversed. If one wishes to induce another meridian, acupuncture at the foot Yangming point will prevent the Tai Yang evil from transmitting to other meridians, thus resolving it.” Seven days is the period when the Tai Yang disease’s evil weakens and should resolve on its own. For “wanting to induce another meridian,” commentators interpret it as wanting to transmit to the Yangming meridian or to other meridians; or as the disease process wanting to enter the second seven days. However, acupuncture at the foot Yangming point can invigorate the Yang of the stomach, unblock the meridian qi, support the righteous qi, and expel the evil, thus preventing the disease from transmitting. The acupuncture point selected is mostly believed to be Zusanli. Zusanli is a key health point that can enhance the body’s immune capacity and has a strong strengthening effect. Therefore, whether the Tai Yang disease’s evil qi wants to transmit to Yangming or other meridians, or if the Tai Yang disease’s evil qi has not weakened and the disease process has entered the second seven days, acupuncture at the foot Yangming point can achieve the effect of disease prevention and interruption of transmission.

4. Moxibustion is Mostly Used for Treating Three Yin Meridian Diseases, Deficiency Patterns, Cold Patterns, and Yang Deficiency Yin Excess Patterns
Among the 7 articles concerning moxibustion therapy, 3 are from the Shao Yin chapter and 3 from the Jue Yin chapter. Only Article 117 is from the Tai Yang chapter, and it only discusses using moxibustion to treat changes caused by the misuse of burning needles, where the needling site is affected by cold, resulting in a lump and redness, and is not used to treat the primary Tai Yang pattern. Thus, it can be seen that the moxibustion therapy in “Shang Han Lun” is mostly used for treating Three Yin meridian diseases, which is one of its patterns.
2. Moxibustion is Mostly Used for Treating Deficiency Patterns, Excess Patterns, and Yang Deficiency Yin Excess Patterns
(1) Yang deficiency and Yin condensation, using moxibustion to assist Yang and eliminate Yin: Article 304 states: “In Shao Yin disease, if after one or two days, the mouth is warm, but the back feels cold, moxibustion should be applied, and the prescription is Fuzi Decoction.” This indicates kidney Yang deficiency, with Yang not being sufficient, leading to cold damp Yin evil stagnating in the skin and joints; moxibustion is used to assist Yang, eliminate Yin, and dispel cold damp.
(2) Yang deficiency with Qi sinking, using moxibustion to raise Yang and lift sinking: Article 325 states: “In Shao Yin disease, if there is diarrhea, with a weak and rough pulse, vomiting and sweating, and the person must change clothes frequently, if the person is weak, moxibustion should be applied to the upper body.” This indicates kidney Yang deficiency, with Yang not being able to contain Yin, and also accompanied by insufficient Yin blood, leading to Qi sinking and a state of deficiency cold; moxibustion is applied to the upper body points to assist Yang, dispel cold, and raise Yang. Commentators mostly believe that Baihui should be used for moxibustion.
(3) Yang deficiency with Yin excess, using moxibustion to restore Yang and rescue from reversal: Article 343 states: “In cold damage for six or seven days, if the pulse is weak, and the hands and feet are cold, with agitation, moxibustion should be applied to Jue Yin. If the cold does not return, the person will die.” This indicates Yang deficiency with Yin excess, where the righteous qi cannot overcome the evil; moxibustion is used to assist Yang and eliminate Yin, restoring Yang and rescuing from reversal. Article 362 states: “If there is diarrhea, with cold hands and feet, and no pulse, moxibustion should be applied.” This indicates that Yang qi is weak, the extremities are cold, and the Yin blood is insufficient, leading to a lack of pulse; moxibustion is used to restore Yang, rescue from reversal, and eliminate cold to restore the pulse.
(4) Yin excess with Yang stagnation, using moxibustion to unblock Yang and reach the exterior: Article 292 states: “In Shao Yin disease, if there is vomiting and diarrhea, with cold hands and feet, but the person feels hot, they will not die. If the pulse is absent, moxibustion should be applied to Shao Yin seven times.” This indicates that internal Yin cold is excessive, causing vomiting and diarrhea, leading to Yang qi being unable to connect, resulting in an absent pulse; moxibustion is used to eliminate cold and unblock Yang, allowing Yang qi to reach the exterior. Article 349 states: “In cold damage, if the pulse is rapid, and the hands and feet are cold, moxibustion can be applied.” Zhang Luyu’s commentary on “Shang Han Lun” states: “Due to the rapid pulse, it is known that Yang qi is obstructed and not deficient; therefore, moxibustion is used to unblock Yang.” This indicates that moxibustion is also effective in unblocking Yang.
These patterns of Yang deficiency with Yin excess, Yang deficiency with Qi sinking, Yang deficiency with Yin condensation, and Yin excess with Yang stagnation are all deficiency cold patterns, and many are severe or urgent cases. In these cases, moxibustion is used not only to assist Yang and eliminate Yin but also to imply urgent rescue to restore Yang, reflecting the pattern of using moxibustion in emergencies. The acupuncture points for urgent rescue, according to commentators, can include Baihui, Dazhui, Qihai, Guanyuan, Shenque, Taixi, Fuliu, and Yongquan, among others, which can be selected as appropriate.
(5) Cold obstructing meridian points, using moxibustion to eliminate cold and unblock the meridians: Article 117 states: “If burning needles cause sweating, and the needling site is affected by cold, resulting in a lump… moxibustion should be applied to the lump.” Cheng Wuyi’s commentary on “Shang Han Lun” states: “If the needling site is affected by cold, Qi gathers and forms a lump… moxibustion should be applied to disperse the cold.” Zhang Xugu’s commentary on the essence of “Shang Han Lun” states: “If the needling site is affected by cold, the cold obstructs the meridian and forms a lump… moxibustion should be applied to unblock the cold.” This indicates that moxibustion is used to eliminate cold and unblock the meridians.

5. Analyzing the Treatment of Cough in “Shang Han Lun”

Shang Xue Rui, Huixian City Hospital of Traditional Chinese Medicine, Henan Province

In the 398 articles of “Shang Han Lun,” there are 10 articles mentioning cough, occurring 13 times, involving various causes and multiple organs.
1. Cough Caused by Fluid Evil
Cough caused by fluid evil is an important pathogenic mechanism mentioned in “Shang Han Lun.” The metabolism of body fluids is closely related to the lungs, spleen (stomach), kidneys, triple warmer, and bladder. When external evils invade or the primary organs are Yang deficient, it leads to abnormal fluid metabolism, resulting in fluid retention. If there is internal fluid retention, it can easily attract external evils, leading to a combination with heat evils, thus flooding the organs.
(1) External Wind-Cold Invoking Internal Fluid
When wind-cold invades the exterior, the Wei Yang is obstructed, and the Qi flow is impaired. If the person has a history of fluid retention, or if the Tai Yang bladder meridian Qi is obstructed, leading to impaired fluid metabolism, it will certainly result in external cold and internal fluid issues, which can invade the lungs and cause cough. Article 40 states: “If the exterior of a cold damage does not resolve, and there is water Qi below the heart, with dry vomiting, fever and cough, or thirst, or diarrhea, or difficulty urinating, or fullness in the lower abdomen, or wheezing, the prescription is Xiao Qing Long Decoction.” Article 41 states: “In cold damage, if there is water Qi below the heart, cough with slight wheezing, and fever without thirst… the prescription is Xiao Qing Long Decoction.” These articles elucidate the pathogenic mechanism, main symptoms, and treatment formulas for cough caused by external cold and internal fluid. The symptoms include cough, clear and thin phlegm, exacerbated by cold, along with aversion to cold, fever, no sweating, vomiting, or difficulty urinating, or diarrhea, with a thin and slippery tongue coating and a floating tight pulse; the treatment should be warming and dispersing to resolve the exterior, and the formula used is Xiao Qing Long Decoction. The ingredients such as Ma Huang, Gui Zhi, Shao Yao, Jiang, and Xin disperse the exterior and resolve the fluid, with Wu Wei Zi used to restrain the lungs and stop cough, and Ban Xia to descend and transform phlegm; thus, both the external evil and internal fluid are eliminated, and the cough resolves.
(2) Yang Deficiency with Fluid Overflowing, Fluid Evil Invading the Lungs
Article 316 states: “In Shao Yin disease, if it does not resolve after two or three days, and after four or five days, there is abdominal pain, difficulty urinating, heaviness and pain in the limbs, and diarrhea, this indicates the presence of water Qi. The person may cough, or have difficulty urinating, or diarrhea, or vomiting; the prescription is Zhen Wu Decoction.” Article 197 states: “In Yang Ming disease, if there is no sweating and difficulty urinating for two or three days, with vomiting and cough, and cold hands and feet, there must be a headache.” These indicate that Yang deficiency leads to fluid invading the lungs, causing cough. The former indicates that the evil invades the Shao Yin, with kidney Yang deficiency, cold water retained internally, and the fluid flooding up and down with the Qi flow, invading the lungs and causing cough, with symptoms of cough, heaviness in the limbs, abdominal pain, diarrhea, pale tongue, and a deep or thin pulse; the treatment should focus on warming Yang and promoting fluid metabolism. The latter indicates that Yang Ming is cold, with the middle Yang injured and losing its healthy function, leading to fluid not being able to disperse, invading the lungs and causing cough, with symptoms of cough, vomiting, headache, cold hands and feet, and no sweating. The treatment should focus on warming Yang and promoting fluid metabolism; for the former, Zhen Wu Decoction with ginger, Xin, and flavoring should be used to tonify Yang, promote fluid metabolism, and restrain the lungs to stop cough; for the latter, the original text does not mention formulas, but based on the symptoms, Wu Zhu Yu Decoction with dried ginger and Wu Wei Zi should be selected to warm Yang, dispel cold, and descend to stop cough. Thus, Yang should be strong, and the fluid should be transformed to stop the cough.
(3) Yin Deficiency with Heat, Water and Heat Intermingling
When the evil invades the Shao Yin, it damages the true Yin, leading to an imbalance of Yin and Yang, with kidney Qi unable to stabilize, resulting in fluid retention. If there is pre-existing fluid, combined with Yin deficiency and internal heat, it can easily lead to water and heat intermingling, causing disease. When water Qi is problematic, it invades the lungs, leading to cough, and if it invades the stomach, it leads to vomiting, with insufficient distribution of fluids leading to thirst, and if it disturbs the spirit, it leads to irritability and insomnia. Article 319 states: “In Shao Yin disease, if there is diarrhea for six or seven days, cough and vomiting, with thirst and irritability, the prescription is Zhu Ling Decoction.” The treatment should focus on nourishing Yin, moistening dryness, and clearing heat to promote fluid metabolism. Zhu Ling Decoction uses Zhu Ling, Fu Ling, and Ze Xie to promote dampness and fluid metabolism, with E Jiao to nourish and moisten dryness, and with Shi Gao to clear heat and dispel dampness. If cough is severe, Wu Wei Zi can be added.
The aforementioned Zhen Wu Decoction and Zhu Ling Decoction both have cough and diarrhea; one must differentiate their Yin and Yang strengths and weaknesses for appropriate treatment, and one must not use sweating methods. Forcing sweating will lead to delirium and difficulty urinating. Therefore, Article 284 warns: “In Shao Yin disease, if there is cough and diarrhea, with delirium, it is due to the fire qi’s influence. There must be difficulty urinating, as forcing Shao Yin to sweat will lead to adverse outcomes.”

6. The Formula-Pattern is the Pinnacle of Pattern Differentiation

Feng Shilun, China-Japan Friendship Hospital

Research on the formula-pattern in TCM has always been a hot topic in the field of TCM. Here, I would like to share some insights on the formula-pattern in “Shang Han Lun.”
1. The formula-pattern is a major component of “Shang Han Lun”
It is well known that the main content of “Shang Han Lun” discusses the concept of the six meridians and their clinical applications, but the formula-pattern is also a major component. Differentiating formulas and patterns is a key feature of the classical formulas and the pattern differentiation and treatment in “Shang Han Lun.”
2. The concept of formula-pattern
In “Shang Han Lun,” there are names such as Guizhi pattern and Chaihu pattern, which serve as examples of naming patterns by formulas. “Shang Han Lun” contains a total of 112 formulas, with the pattern named by the formula, and the name established by the pattern; for every pattern, there is a corresponding formula. This formula-pattern relationship forms the main system of formulas and patterns in “Shang Han Lun.” The main content of “Shang Han Lun” consists of 112 formulas and their corresponding indications, discussing the indications of a certain formula, which is referred to as a certain pattern, such as Guizhi Decoction pattern, Mahuang Decoction pattern, Baihu Decoction pattern, etc. This naming of patterns by formulas is not only a scientific summary of the long-term medical experiences of ancient practitioners but also a necessity of the writing method, and it reflects the characteristics of the content and theoretical system of “Shang Han Lun.”
3. The origins of “Shang Han Lun” are ancient formulas and patterns
There has been much debate regarding the origins of Zhang Zhongjing’s writing of “Shang Han Lun.” Recently, with the development of archaeology and textual criticism, it has become increasingly clear that “Shang Han Lun” belongs to the classical formula school of “Shen Nong’s Materia Medica” and “Tang Ye Jing Fa.” Notably, the main content of “Shang Han Lun” is derived from the formulas and their indications in “Tang Ye Jing Fa,” such as the small and large formulas, and the six divine formulas. For example, the Guizhi Decoction pattern is derived from the small Yang formula, the Mahuang Decoction pattern is derived from the small Qinglong formula, the small Qinglong formula is derived from the large Qinglong formula, the Huangqin Decoction pattern is derived from the small Yin formula, the Xiao Chai Hu Decoction pattern is derived from the large Yin formula, the Baihu Decoction pattern is derived from the small Baihu formula, the Zhuye Shigao Decoction pattern is derived from the large Baihu formula, and the Huanglian Ejiao Jizhi Huang Decoction pattern is derived from the small Zhu Niao (sparrow) formula, and the Zhen Wu Decoction pattern is derived from the small Xuanwu formula, etc. Regarding Zhang Zhongjing’s reasons for changing the names of formulas and patterns, Tao Hongjing clearly states: “Zhang Ji wrote “Shang Han Lun” to avoid Daoist terminology, so his formulas are not properly named, but are named after certain medicines for identification.” In Tao Hongjing’s work “Fu Xing Jue Zang Fu Yong Yao Fa Yao,” it is clear that the main content of “Tang Ye Jing Fa” is a record of the formulas and their indications used by predecessors, and Zhang Zhongjing primarily based his work on these formulas and patterns to compile “Shang Han Lun.”
4. Zhang Zhongjing categorized formulas and patterns into six categories, leading to the differentiation of the six meridians
By comparing “Shang Han Lun” with “Tang Ye Jing Fa,” one can observe the trajectory of Zhang Zhongjing’s compilation of “Shang Han Lun.” From “Tang Ye Jing Fa,” it can be seen that its main content is a record of the experience formulas and their indications used by predecessors. The accumulation of rich formulas and indications nurtured the formation of classical formula theory. By the time of Zhang Zhongjing, people recognized that each formula’s ability to cure diseases is not only related to the characteristics of symptoms but also to the nature of the disease (cold, heat, deficiency, excess) and the location of the disease (exterior, interior, half-exterior half-interior). Thus, categorizing formulas and patterns leads to six different categories of formulas and patterns:
1. Mahuang Decoction pattern, Guizhi Decoction pattern, Guizhi plus Gui Decoction pattern, Guizhi plus Shao Yao Decoction pattern, Guizhi plus Gegen Decoction pattern, and Gualou Guizhi Decoction pattern, all of which have symptoms of fever, aversion to cold, body aches, and floating pulse. “Shang Han Lun” considers these patterns to be located in the exterior, with the nature being heat, excess, and Yang, thus referred to as exterior Yang patterns, with the common characteristic being: “floating pulse, headache, and aversion to cold,” which is the essence of Tai Yang disease.

6. “Shang Han Lun” and the Regulation of Yin and Yang

Yang Feng, First People’s Hospital of Nanyang City, Henan Province

Based on the philosophical thought of Yin-Yang harmony established in “Nei Jing,” the heat disease system first proposed the theory of harmonization in treatment. Zhang Zhongjing promoted this theory in “Shang Han Lun” and applied it in medical practice. Master Zhang guided by the dual points of Yin and Yang, using the six meridians to discuss cold damage, revealing the transmission and transformation patterns of externally contracted heat diseases, summarizing and classifying them, integrating principles, methods, formulas, and medicines, using the “harmonization method” to regulate Yin and Yang through the following means.
1. Expelling Evil and Supporting Righteousness
The human body is an organic whole with a balanced and harmonious Yin and Yang. “When Yin is balanced and Yang is secret, the spirit is treated.” If the body is invaded by pathogenic evils, the evil and righteous qi contend, leading to pathological and physiological changes due to the imbalance of Yin and Yang. The treatment must harmonize Yin and Yang to restore a harmonious and balanced state. Master Zhang first created Guizhi Decoction for externally contracted heat diseases, as stated in Article 52 of “Shang Han Lun”: “In Tai Yang wind, if Yang is floating and Yin is weak, Yang floating indicates heat is self-releasing, and Yin weakness indicates sweating is self-releasing, aversion to cold, and slight fever, with dry vomiting; the prescription is Guizhi Decoction.” The symptoms mentioned in this article mainly reflect the pathological changes of external evils invading the exterior, leading to disharmony of Ying and Wei, thus Guizhi Decoction is used to treat it. The ingredients in the formula, such as Guizhi, are warming and dispersing, expelling wind, while Sheng Jiang is warming and dispersing to stop vomiting, assisting Guizhi in harmonizing Wei; Shao Yao is slightly cold and sour, harmonizing Yin and nourishing; Dazao is sweet and tonifying, harmonizing the stomach, while Gan Cao tonifies and supports, pairing with Guizhi to disperse Yang; and pairing with Shao Yao to harmonize Yin. This formula nourishes Yin and Yang, harmonizing Ying and Wei, thus the evil is expelled, and the righteous qi recovers, leading to recovery. Therefore, Guizhi Decoction is honored as the “crown of classical formulas.”
2. Resolving Both Exterior and Interior
When the human body is affected by external evils, it leads to an imbalance of Yin and Yang, resulting in complex pulse patterns and diverse symptoms. Master Zhang uses abstract thinking to analyze and summarize the complex symptoms of externally contracted heat diseases, identifying the internal and external transmission patterns, and categorizing symptoms as either exterior, interior, or both. For example, in Article 163 of “Shang Han Lun”: “In Tai Yang disease, if the external symptoms are not resolved, and purging is performed, it leads to heat and diarrhea, and if diarrhea does not stop, with fullness below the heart, and the exterior and interior are unresolved, the prescription is Guizhi Ren Shen Decoction.” This pattern indicates that the external evil has not been resolved, leading to the internal pattern of spleen and stomach deficiency cold; thus, Guizhi Ren Shen Decoction is used, with Guizhi to resolve the exterior and expel the evil, and using the Li Zhong Decoction (Ren Shen, Gan Jiang, Bai Zhu, Gan Cao) to warm the interior and eliminate cold, resolving both exterior and interior, harmonizing the qi of Yin and Yang, leading to recovery.
3. Using Cold and Heat Together
Externally contracted heat diseases represent a contradictory process, where the evil and righteous qi contend, causing continuous changes in the pulse and symptoms, which may be cold, heat, or a mixture of both. Master Zhang addresses this with a pattern differentiation perspective, recognizing both external and internal causes, emphasizing local conditions while considering the whole, looking beyond the surface to the essence, and focusing on the main contradiction for treatment. When externally contracted heat diseases present mixed cold and heat pulse patterns, it is necessary to use corresponding medicines to harmonize Yin and Yang. For example, Article 38 states: “In Tai Yang wind, if the pulse is floating and tight, with fever, aversion to cold, body aches, and no sweating but agitation, the prescription is Da Qing Long Decoction.” This pattern indicates that wind-cold binds the exterior, obstructing Wei Qi, while internally there is evil heat, leading to stagnation of Ying and Wei, thus the heavy use of Ma Huang, paired with Guizhi and Sheng Jiang, to disperse the exterior evil, while Shi Gao’s cooling nature clears internal heat, with Dazao harmonizing, and Xing Ren assisting Ma Huang in inducing sweating, achieving a proper balance of cold and heat to resolve the disease. Another example is Article 173: “In cold damage, if there is heat in the chest, evil qi in the stomach, abdominal pain, and a desire to vomit, the prescription is Huang Lian Decoction.” This pattern indicates that heat evil binds the chest, while cold evil obstructs the stomach, leading to abnormal qi flow and an imbalance of Yin and Yang; thus, the use of cold and heat medicines, with sweet and bitter combined, harmonizes the stomach and promotes the proper flow of qi, leading to the resolution of heat and cold, restoring the balance of Yin and Yang.

4. Draining Heat and Attacking Downward
In the process of transmission of externally contracted heat diseases, the evil may enter the interior, leading to patterns of excess evil. Master Zhang uses the method of draining heat and attacking downward to expel the evil. Article 135 states: “In cold damage for six or seven days, if there is a hard mass in the chest, with a tight pulse and pain below the heart, the prescription is Da Xian Xiong Decoction.” This pattern indicates that water and heat are mutually binding in the chest, obstructing qi and blood, leading to an imbalance of Yin and Yang and the appearance of the mass in the chest; thus, Da Xian Xiong Decoction is used to drain and unblock the water, allowing the qi to flow smoothly. If the heat evil enters the Yangming large intestine, leading to constipation and obstruction, Master Zhang established the “Three Cheng Qi Decoctions” to be selected based on the severity of the condition. For example, Article 220 states: “If both Yangming diseases are present, and the Tai Yang disease has resolved, but there is only tidal fever, with sweating of the hands and feet, and hard stools, purging will resolve it; the prescription is Da Cheng Qi Decoction.” This indicates a transition to Yangming internal excess. Article 250 states: “In Tai Yang disease, if there is vomiting, diarrhea, or sweating, and slight agitation, with frequent urination, and hard stools, the prescription is Xiao Cheng Qi Decoction.” This indicates that after the external heat disease is mismanaged, the fluids are damaged, leading to heat binding; thus, Xiao Cheng Qi Decoction is used to drain. Article 248 states: “In Tai Yang disease, if after three days of sweating, the fever does not resolve, and there is a steaming heat, the prescription is Tiao Wei Cheng Qi Decoction.” This is used to clear internal heat and harmonize the stomach. It can be seen that the appropriate use of the three Cheng Qi Decoctions yields effective results, allowing the evil to be expelled and the qi to flow smoothly, restoring the balance of Yin and Yang.

5. Treating Different Diseases with the Same Method and Treating the Same Disease with Different Methods
“Shang Han Lun” developed the philosophical thinking of “observing the location of Yin and Yang and adjusting it to achieve balance” from “Nei Jing,” harmonizing Yin and Yang, correcting the functional state of diseases, becoming a unique feature of pattern differentiation and treatment. In clinical practice, it combines disease differentiation with pattern differentiation, seeking commonalities in differences and differences in commonalities. This established a new treatment method of treating different diseases with the same method and treating the same disease with different methods. Article 243 states: “If there is a desire to vomit after eating grains, it belongs to Yangming, and the prescription is Wu Zhu Yu Decoction.” Article 309 states: “In Shao Yin disease, if there is vomiting and diarrhea, with cold hands and feet, and agitation, the prescription is Wu Zhu Yu Decoction.” Article 377 states: “If there is dry vomiting, with foamy saliva and headache, the prescription is Wu Zhu Yu Decoction.” Although these three articles describe different disease patterns, the pathogenic mechanism is the same, all indicating deficiency of stomach Yang, with Qi flow being abnormal due to the cold and damp Yin evil rising. Therefore, all use Wu Zhu Yu Decoction. If the main symptoms are the same but the pathogenic mechanisms differ, the treatment methods will vary accordingly. For example, regarding the pattern of reversal, Article 330 states: “For all four reversals, do not purge, even if it is deficiency.” This indicates that Yang deficiency leads to reversal, requiring warming and tonifying, and should not be purged. Article 335 states: “In cold damage, if there is fever after one or two days, and if there is a reversal, the previous heat will lead to a reversal; if the reversal is deep, the heat will also be deep; if the reversal is slight, the heat will also be slight. The reversal should be purged, but if sweating is performed, the mouth will be injured and ulcerated.” This indicates that the heat is excessive, and the Yang is obstructed, requiring purging.
In summary, the 397 methods and 112 formulas in “Shang Han Lun” all reflect Master Zhang’s profound understanding of the “harmonization method,” which is worthy of our study, exploration, and promotion in clinical practice.

7. The Integration of Disease Differentiation, Pulse Differentiation, Pattern Differentiation, and Treatment in “Shang Han Lun”

Zhang Xikui, Fujian University of Traditional Chinese Medicine

A brief analysis of the structure of disease differentiation in “Shang Han Lun” reveals that it is an organic system that integrates disease differentiation, pulse differentiation, pattern differentiation, and treatment.
1. Tai Yang Disease
“The disease of Tai Yang is characterized by a floating pulse, headache, and aversion to cold.” This is the outline of Tai Yang disease, which also serves as the diagnostic standard. Tai Yang is the barrier of the six meridians, governing the exterior of the body, and its function is to protect the exterior. Therefore, when external evils invade the body, Tai Yang is the first to be affected. When the evil invades Tai Yang, the righteous qi rises to resist the evil, leading to the conflict between the righteous and the evil, which is the essence of Tai Yang disease. The floating pulse reflects the invasion of the evil and the rise of the righteous qi, indicating the struggle at the exterior; it also reflects that the righteous qi is not deficient. If it is an externally contracted disease, and the pulse is not floating but deep, it indicates that the righteous qi is already deficient, and it is not simply a Tai Yang disease, thus sweating should not be used. Headache and neck stiffness occur because the Tai Yang meridian runs from the forehead to the vertex and descends to the neck; when the Tai Yang is affected, the flow of qi is obstructed, leading to headache and neck stiffness. Aversion to cold is a common symptom of Tai Yang disease, as the external evil binds the exterior, and the Wei qi is obstructed, preventing it from performing its function of “warming and distributing flesh,” leading to aversion to cold, which is a symptom that runs through Tai Yang disease.
Fever is a reflection of the Wei qi’s resistance against the evil in Tai Yang disease, often appearing alongside aversion to cold. However, sometimes at the onset of the disease, the Wei Yang is obstructed and has not yet expanded, which may lead to a temporary absence of fever, with only aversion to cold; thus, “Shang Han Lun” does not list fever as a basic manifestation of Tai Yang disease. The presence of both fever and aversion to cold is a characteristic of Tai Yang disease and a major distinguishing point from other meridian diseases.
The floating pulse, headache, and aversion to cold reflect the invasion of the evil into Tai Yang, the obstruction of qi flow, the disharmony of Ying and Wei, and the struggle between the righteous and the evil at the exterior, which is the essence of Tai Yang disease. Whenever the above pulse and symptoms are observed, treatment should be based on Tai Yang disease. The treatment for Tai Yang disease should involve sweating to expel the evil, but since there are differences between wind-cold and wind-heat, the sweating methods include warming, cooling, and moistening, thus “Shang Han Lun” also categorizes the differentiation of wind, cold damage, and warm diseases, etc., with specific prescriptions such as Guizhi Decoction, Mahuang Decoction, Guizhi plus Fuzi Decoction, Guizhi plus Gegen Decoction, Da Qing Long Decoction, Xiao Qing Long Decoction, and Guizhi plus Ma Huang Decoction, etc., ensuring that the specific treatment is effectively implemented.

2. Yangming Disease
“The disease of Yangming is characterized by fullness in the stomach.” The stomach refers to the stomach and intestines, and fullness indicates the presence of excess evil. This includes both the dry heat excess pattern of Yangming and the cold excess pattern of Yangming. It is precisely because Yangming disease has both cold and heat categories, with different characteristics within each category, that it is described in the outline by the pathogenic mechanism, which is unique in the outline of the six meridians. Yangming disease is located in the interior, specifically in the middle jiao of the stomach and intestines, and its nature is excess, distinguishing it from Tai Yin disease.

3. Shao Yang Disease
“The disease of Shao Yang is characterized by bitter taste in the mouth, dry throat, and dizziness.” When the evil invades Shao Yang, the pivot is not functioning properly, leading to gallbladder fire rising, resulting in a bitter taste in the mouth. The burning of the fluids leads to a dry throat. The foot Shao Yang pulse originates at the eye’s corner, and the liver and gallbladder are interrelated; when gallbladder heat is internally constrained, it disturbs the liver, leading to dizziness. In terms of its nature, Shao Yang disease still belongs to the heat and excess category, reflecting the essence of the evil invading Shao Yang and the dysfunction of the pivot, leading to gallbladder fire rising. Compared to Tai Yang disease, its location is in the interior, and the heat evil is initially transforming but has not yet reached the dryness level of Yangming disease, thus its treatment should not solely rely on sweating, nor should it be heavily purged or tonified; it should be harmonized. Due to its further development, it can either transform into heat and enter Yangming or lead to deficiency of the righteous qi and enter the three Yin diseases, thus “Shang Han Lun” only presents the Xiao Chai Hu Decoction, while others are based on different trends, leading to combinations with exterior patterns such as Chaihu Guizhi Decoction, combinations with Yangming patterns such as Da Chai Hu Decoction, Chaihu plus Mangxiao Decoction, and combinations with Tai Yin patterns such as Chaihu Guizhi plus Ganjiang Decoction, etc.

4. Tai Yin Disease
“The disease of Tai Yin is characterized by abdominal fullness and vomiting, lack of appetite, diarrhea, and abdominal pain that occurs at times; if purged, there will be hardness below the chest.” Tai Yin disease often belongs to the deficiency cold damp pattern of the middle jiao, with the disease limited to the middle jiao spleen, and the symptoms are lighter than those of Shao Yin and Jue Yin, making it easier to treat. Article 277 states: “If there is diarrhea without thirst, it belongs to Tai Yin, due to the cold in the organ, it should be warmed, and the prescription is to take the Four Reversal Decoction.” “Diarrhea without thirst” is its characteristic, indicating that this disease is not a heat pattern, and it also distinguishes it from Shao Yin diarrhea, which is more severe. The disease is limited to the middle jiao spleen and has not yet affected the lower jiao, allowing fluids to still be distributed upwards, which is different from the case of “six or seven days of diarrhea and thirst, which belongs to Shao Yin, as the deficiency leads to self-rescue by drawing water.” Thus, the difference between deficiency cold diarrhea and non-thirsty diarrhea serves as a measure of the severity of the disease. “Due to the cold in the organ” indicates that the main pathogenic mechanism of Tai Yin disease is the deficiency cold damp of the middle jiao spleen, and the treatment should be to warm it, thus the prescription is to take the Four Reversal Decoction, which includes ingredients like Fuzi and Ganjiang. Why are specific formulas not mentioned? Because the spleen’s deficiency cold damp pattern can lead to various symptoms, including vomiting, diarrhea, jaundice, and edema, which cannot be treated by a single formula. Under the premise of “taking the Four Reversal Decoction,” if there is vomiting, it should be paired with anti-vomiting herbs; if there is diarrhea, it should be paired with anti-diarrheal herbs; if there is jaundice, it should be paired with herbs to clear jaundice; if there is edema, it should be paired with diuretics, thus demonstrating both specificity and flexibility, indicating a living method of treatment.
Tai Yin disease often belongs to the pattern of spleen Yang deficiency, but there can also be patterns of spleen Yin deficiency. Article 279 states: “If it is a Tai Yang disease, and the physician purges it, leading to abdominal fullness and pain, it belongs to Tai Yin; the prescription is Guizhi plus Shao Yao Decoction; if there is significant pain, the prescription is Guizhi plus Da Huang Decoction.” This article has been debated extensively; in fact, it indicates a pattern of spleen Yin deficiency. The main symptom of “abdominal fullness and pain” first positions the diagnosis, indicating a middle jiao disease; if it is not Yangming, it is Tai Yin. Observing this pattern, there is no tidal fever, no delirium, and no thirst, red tongue, or little moisture, indicating that it is not Yangming disease. Thus, it is classified as Tai Yin. However, compared to the Tai Yin Yang deficiency cold damp pattern, it does not present with diarrhea or vomiting, indicating that it is not solely a pattern of spleen Yang deficiency. The nature of the disease indicates that the spleen governs the abdomen, and if the spleen Yin is insufficient, the spleen meridians will contract, leading to abdominal pain. If the spleen’s function is impaired, the Qi flow will be obstructed, leading to “abdominal fullness and pain.” The treatment should nourish the spleen Yin, harmonize the middle jiao, and promote the spleen’s function. The formula should include ginger and dates to harmonize the spleen and stomach, with six taels of Shao Yao combined with Gan Cao to nourish the Yin and promote the spleen’s function, while Guizhi is used to promote the spleen’s function and assist in distributing the Yin. If there is significant pain, Da Huang should be added to strengthen the effect of promoting the spleen’s function and relieving the obstruction. However, since the pattern of spleen Yin deficiency is ultimately a deficiency pattern, if there is a history of insufficient spleen and stomach function, the dosage should be reduced. Thus, Article 280 continues: “If Tai Yin is present, and the pulse is weak, and the person continues to have diarrhea, if it is necessary to use Shao Yao and Da Huang, the dosage should be reduced, as the person’s stomach qi is weak and easily disturbed.”

5. Shao Yin Disease
“The disease of Shao Yin is characterized by a weak and thin pulse, with a desire to sleep.” The outline of Shao Yin disease has been interpreted differently throughout history, with some believing it to be a heat pattern and others a cold pattern. The key issue lies in the punctuation; previously, it was often read as “weak and thin pulse” together, leading to misunderstandings. First, the symptom “desire to sleep” indicates a state of mental fatigue, resembling a state of being neither fully awake nor fully asleep, indicating a pre-stage of mental fatigue. This symptom can be seen in both cold and heat patterns. In the case of cold patterns, Yang qi is weak, often accompanied by mental fatigue; in the case of heat patterns, severe insomnia and lack of energy are observed. Next, regarding the pulse, it should be read as “weak and thin”; weak indicates extremely soft and faint, often indicating Yang qi deficiency, while thin indicates a pulse like a thread, often indicating insufficient Yin blood. If the pulse is weak and there is a desire to sleep, it indicates the early stage of a cold pattern; if the pulse is thin and there is a desire to sleep, it indicates the early stage of a heat pattern. Shao Yin disease is characterized by deficiency, and the treatment should focus on tonifying. In the case of cold patterns, Yang deficiency should be warmed and tonified, while in heat patterns, Yin deficiency should be cleared and tonified, requiring further differentiation.
Shao Yin is internally related to the heart and kidney, and Shao Yin disease often transforms with the body. In the case of cold patterns, it often indicates insufficient Yang qi, leading to internal cold, while in heat patterns, it indicates that kidney water is deficient below, and heart fire is excessive above. Due to these slight differences, there are various formulas such as Si Ni San for warming Yang and rescuing from reversal, Tong Mai Si Ni San for breaking Yin and restoring Yang, and Bai Tong Decoction for breaking Yin and restoring Yang while connecting the interior and exterior, and Zhen Wu Decoction for warming Yang and eliminating dampness, and Fuzi Decoction for warming Yang and relieving pain, etc. In the case of the three urgent patterns, it indicates that dryness and stool are internally bound, and true Yin is about to be exhausted, thus requiring Da Cheng Qi Decoction for urgent purging to preserve Yin; while Ma Huang Fuzi Xixin Decoction and Ma Huang Fuzi Gan Cao Decoction are typical cases of Tai Shao dual invasion, indicating that the body is originally deficient in Shao Yin Yang qi, and then is invaded by wind-cold, thus requiring external resolution of Tai Yang and internal warming of Shao Yin, representing a method of treating both exterior and interior simultaneously.

6. Jue Yin Disease
“The disease of Jue Yin is characterized by thirst, qi rising to the heart, heat in the heart, hunger without desire to eat, and vomiting of roundworms, with persistent diarrhea.” The nature of Jue Yin disease has also been a focal point of debate among practitioners throughout history. I believe that Jue Yin represents the intersection of two Yin, characterized by the emergence of Yin leading to the birth of Yang, and the return of extremes. The period of Jue Yin is a critical stage; comprehensively analyzing the content of Jue Yin disease, the evil enters Jue Yin, transforming from cold to heat, leading to cold patterns and extreme cold patterns, such as Danggui Si Ni Decoction, Danggui Si Ni Decoction with Wu Zhu Yu and Sheng Jiang, and Tong Mai Si Ni Decoction, etc. When transforming from heat, it leads to extreme heat patterns, such as heat reversal, Bai Tou Weng Decoction, etc. When the disease reaches Jue Yin, the extremes must return; extreme cold leads to heat, and extreme heat leads to cold, thus the characteristics of mixed cold and heat are evident. The symptoms described in the outline, such as thirst, qi rising to the heart, heat in the heart, hunger without desire to eat, and vomiting of roundworms, are specific manifestations of the characteristics of mixed cold and heat in Jue Yin disease, as stated in “Zhu Bing Yuan Hou Lun”: “Yin and Yang each tend to their extremes; when Yang reaches the top, it becomes heat, and when Yin reaches the bottom, it becomes cold.” Based on the differences in pathogenic mechanisms, there are also formulas such as Wu Mei Wan, Gan Jiang Huangqin Huanglian Ren Shen Decoction, and Ma Huang Sheng Ma Decoction, etc. When the disease reaches Jue Yin, the righteous and evil qi contend, leading to the growth and decline of Yin and Yang; when Yin is excessive, it leads to reversal, and when Yang is excessive, it leads to heat, thus the Jue Yin disease chapter contains various articles discussing the differentiation of heat and reversal.

In summary, the various standards for pattern differentiation and symptom differentiation in “Shang Han Lun” serve as a network, with the organic combination of outlines and networks forming a comprehensive system for diagnosing and treating diseases.

8. The “Chronopharmacology” of “Shang Han Lun”

Zhu Zhiyou, Hongya County Hospital of Traditional Chinese Medicine, Sichuan Province

The human body’s response to drugs varies with time, and the effects of drugs on the body and its diseases exhibit temporal effects, which can be expressed and regulated through prescriptions and medical advice from clinical physicians and pharmacists. The biological time effects within the human body are beneficial for the meridian and targeted actions of drugs, as well as the progression of diseases. Various functions within the body change with time. Many activities of living organisms exhibit cyclical patterns. Wang Haogu noted in his “Brief Discussion on Yang Diseases: The Timing of Taking Medicine According to Yin and Yang” that “taking Yang medicines during the day is more effective than taking Yin medicines, while taking Yin medicines at night is more effective than taking Yang medicines.”
Zhang Zhongjing proposed the “desired time for resolution” in “Shang Han Lun,” indicating the time frame when a disease may resolve, improve, or lessen, which aligns closely with contemporary chronopharmacology. The “Huangdi Neijing” states: “Man corresponds with heaven and earth, and with the sun and moon;” “Following the timing of heaven, the disease can be treated accordingly. Following is skilled, while going against is crude;” “When the moon is new, do not purge; when the moon is full, it is for tonification; when the moon is waning, do not treat; this is called treating according to the timing.” The discussion of the timing of drug administration in “Shang Han Lun” is even more abundant, marking it as the ancestor of clinical pharmacology in TCM.
For example, the prescription for Shi Zao Decoction states: “Yuanhua, Gansui, and Dajie in equal parts. The three ingredients are crushed and filtered, with one liter and five cups of water, first boiling ten large dates, taking eight cups, removing the residue, and adding the powdered medicine, forcing the patient to take one qian, while the weak patient takes half a qian, and it should be taken warm at dawn. If it does not work, increase by half a qian the next day, and after achieving a quick effect, nourish with porridge.”
Shi Zao Decoction is a representative formula for treating “suspended fluid,” and aside from the detailed boiling method, the administration method emphasizes and highlights “taking it warm at dawn.” Firstly, dawn refers to the time of day when the sun rises. At this time, the body is empty, and no food has been ingested, making it conducive for rapid absorption of the medicine, thus enhancing clinical efficacy. Taking Shi Zao Decoction at this time enhances its ability to expel water. Secondly, suspended fluid refers to the condition where water is retained outside the lungs, resulting in symptoms such as fullness in the chest and pain below the ribs. According to TCM organ theory, this area corresponds to the liver and gallbladder meridians, thus suspended fluid often presents with symptoms of obstruction in the liver and gallbladder meridians. At dawn, the Qi of the Jue Yin and Shao Yang meridians is at its peak.
In “Shang Han Lun,” it states: “In Shao Yang disease, the desired time for resolution is from Yin to Chen;” “In Jue Yin disease, the desired time for resolution is from Chou to Yin.” This indicates that the Qi of these two meridians is at its peak around dawn. At this time, taking Shi Zao Decoction allows the medicinal properties (active ingredients) to reach the disease site through the meridian Qi, and under the influence of the strong Qi of the meridian, it can fully exert its effect in expelling the retained water. Thirdly, water and fluid are Yin evils, often resulting from Yang deficiency, and for water and fluid to be absorbed, transported, and excreted from the body, it must occur under conditions where Yang qi is gradually increasing. Dawn is the time when Yang qi begins to rise, and Yin qi begins to decline, thus taking Shi Zao Decoction at this time can leverage the rising Yang qi to assist the medicinal effects, promoting the expulsion of retained water.
XU DACHUN in “Medical Source Flow” stated: “The recovery of a patient does not only depend on the formula matching the disease, but also on the method of administration; if the method is incorrect, it will not only be ineffective but may also be harmful; this must be understood.” This emphasizes the importance of the timing of administration. The timing of drug administration in TCM should align with the natural rhythms of Yin and Yang, the functional rhythms of the organs, and the trends of pathological changes.

1. Essence of Shang Han: 100 Key Points on Shang Han