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Shang Han Lun · Treatise on Cold Damage
3. General Principles of Cold Damage
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The Great Treatise on Yin and Yang says: spring qi is mild and warm, summer qi hot, autumn qi clear and cool, and winter qi bitterly cold. This is the sequence of the proper qi of the four seasons. In severe winter cold, the myriad creatures hide deeply. If the cultivated person keeps secure and well enclosed, cold does not cause injury. Only exposure that allows cold to strike is called cold damage. Injury from the qi of any season can cause illness. Cold damage is called toxic because its qi is especially capable of becoming destructive and deadly.
Being struck and immediately becoming ill is called cold damage. If illness does not occur at once, cold toxin remains stored in the skin and flesh, changing into warm disease in spring and summerheat disease in summer. Summerheat disease is extreme heat, more severe than warm disease. Thus those who labor hard often suffer warm and hot diseases in spring and summer; these all result from exposure to cold in winter, rather than from the currently circulating seasonal qi.
A circulating seasonal illness occurs when spring should be warm but is very cold, summer should be very hot but is very cool, autumn should be cool but is very hot, or winter should be cold but is very warm. Such qi appears outside its proper season. Thus, when old and young suffer similar illnesses during a year, this is the qi of a circulating seasonal illness.
To anticipate illnesses caused by the proper qi of the four seasons, and those caused by circulating epidemic qi, one should consult the Dipper calendar. After the Frost's Descent node in the ninth lunar month, cold should gradually increase, becoming severe toward winter; after the Rain Water node in the first month, it should begin to release. It is called Rain Water because ice and snow melt into rainwater. After the Awakening of Insects node in the second month, the qi gradually becomes mild and warm, growing very hot toward summer and cool upon the arrival of autumn.
From after Frost's Descent until before the Spring Equinox, immediate illness after exposure to frost or dew and the entry of cold into the body is called cold damage. In the ninth and tenth lunar months, cold qi is still slight and the resulting illness mild. In the eleventh and twelfth months, bitter cold is already severe and the illness serious. In the first and second months, cold is gradually releasing and the illness is again mild. Such illness arises when a person fails to regulate themselves in winter and happens to be injured by cold.
Unseasonable warmth in winter is called winter warmth. The toxin of winter warmth differs greatly from cold damage. Winter-warmth illnesses may also occur successively and overlap; they vary in severity and require different treatment, as described in later chapters.
After the Beginning of Spring, if there has been no sudden severe cold and no ice or snow, yet someone develops strong fever, this belongs to spring yang qi stirring cold that lay hidden from winter, transforming it into warm disease.
From after the Spring Equinox until before the Autumn Equinox, sudden cold weather produces circulating cold epidemics. If sudden cold occurs in the third or fourth lunar month, yang qi is still weak; when checked by cold, the heat of the illness remains mild. In the fifth and sixth months, yang qi is already abundant; when checked by cold, the heat of the illness is severe. In the seventh and eighth months, yang qi has already declined; when checked by cold, the illness's heat is again slight. These illnesses resemble warm disease and summerheat disease, but their treatments differ.
One qi period is reached every fifteen days. Each of the four seasons contains six such periods, making twenty-four qi periods in all. Yet a climatic influence may fail to arrive when due, arrive before it is due, or arrive in excess: all become disease-producing qi. The movements and stillness of Heaven and Earth, and the striking of yin and yang, each establish the qi proper to a period. Thus spring's warmth becomes summer's heat, and autumn's sternness becomes winter's fury. After the Winter Solstice, one yang line rises and one yin line descends. After the Summer Solstice, one yang qi descends and one yin qi rises. At the winter and summer solstices, yin and yang join; at the spring and autumn equinoxes, they separate.
As yin and yang exchange, people undergo changes of illness. Therefore the cultivated person nourishes yang in spring and summer and yin in autumn and winter, following the firmness and softness of Heaven and Earth. Those who expose themselves recklessly must suffer sudden illness. One must know in which channel the fierce toxic qi remains and what disease it produces, and examine this carefully before treatment.
Thus injury by wind in spring must bring diarrhea with undigested food in summer; injury by summerheat in summer must bring nüe fever in autumn; injury by dampness in autumn must bring cough in winter; and injury by cold in winter must bring warm disease in spring. This is presented as an inevitable course: how could it be left unexamined and unclear?
In cold-damage illness, formulas and treatment should follow the depth reached from day to day. People today may fail to treat it early, treat it in a way that does not match the illness, or let many days pass and only call a physician when exhausted. If the physician then also fails to treat in the proper sequence, the illness is not met appropriately. One should adapt and formulate treatment according to the circumstances at the time; the text says this invariably proves effective. We have now sought out Zhongjing's old discussions and recorded their presentations, pulse examinations, voice and complexion, together with the genuine formulas said to have remarkable efficacy for each illness, intending to prepare for urgent needs in the world.
Lands differ in warmth and coolness, elevation and depth; the nature of things differs in firmness and softness, and food and dwelling also vary. For this reason Huangdi asked about the four regions, and Qibo described the capabilities of four treatments, teaching later worthy people and opening what they had not understood. Practitioners facing illness should examine both sides carefully.
Injury by cold produces a heat illness. Even if the heat is severe, it does not cause death. But illness from simultaneous dual reception of cold must be fatal.
Floating pulses at both cun and chi mean Taiyang has received illness, which should manifest on the first or second day. Because its channel connects upward with Fengfu, there is pain of the head and nape and stiffness of the lower back and spine.
Long pulses at both cun and chi mean Yangming has received illness, which should manifest on the second or third day. Because its channel runs beside the nose and networks with the eyes, there is bodily heat, eye pain, a dry nose and inability to lie down.
Wiry pulses at both cun and chi mean Shaoyang has received illness, which should manifest on the third or fourth day. Because its channel follows the flanks and networks with the ears, there is chest and flank pain and deafness. When these three channels have received illness but it has not entered the bowels, sweating may bring it to an end.
Deep, fine pulses at both cun and chi mean Taiyin has received illness, which should manifest on the fourth or fifth day. Because its channel spreads through the Stomach and networks with the throat, there is abdominal fullness and a dry throat.
Deep pulses at both cun and chi mean Shaoyin has received illness, which should manifest on the fifth or sixth day. Because its channel passes through the Kidney, networks with the Lung and connects with the root of the tongue, there is dryness of the mouth and tongue with thirst.
Faint, relaxed pulses at both cun and chi mean Jueyin has received illness, which should manifest on the sixth or seventh day. Because its channel follows the genitals and networks with the Liver, there is agitated fullness and contraction of the scrotum. When these three channels have received illness and it has already entered the bowels, purging may bring it to an end.
With simultaneous dual reception of cold, Taiyang receives it on the first day together with Shaoyin, producing headache, dry mouth, agitated fullness and thirst. On the second day, Yangming receives it together with Taiyin, producing abdominal fullness, bodily heat, lack of desire to eat and delirious speech. On the third day, Shaoyang receives it together with Jueyin, producing deafness, contraction of the scrotum and reversal. Water and gruel cannot enter, and the person does not recognize others; death occurs on the sixth day. If all three yin and three yang, all five viscera and six bowels receive illness, nutritive and defensive qi cease to move, the bowels and viscera lose communication, and death follows.
If cold has not been received dually, does not transmit further through the channels, and no different qi is added, Taiyang illness declines on the seventh day and headache improves slightly. Yangming illness declines on the eighth day and bodily heat eases somewhat. Shaoyang illness declines on the ninth day and faint hearing returns despite deafness. Taiyin illness declines on the tenth day: the abdomen diminishes to its former state and appetite returns. Shaoyin illness declines on the eleventh day: thirst stops, the text mentions a dry tongue, and then sneezing occurs. Jueyin illness declines on the twelfth day: the scrotum relaxes, the lower abdomen settles slightly, the great harmful qi all departs, and the patient's spirit and awareness become clear.
If there is no respite beyond the thirteenth day and the cun and chi pulses sink away, the danger is great. If a further different qi is contracted and transforms the illness into another disease, treatment should follow the previously described ruined presentations.
If both yin and yang pulses are abundant and cold is contracted again, the illness transforms into warm-nüe. If the yang pulse is floating and slippery and the yin pulse yielding and weak, further exposure to wind transforms it into wind-warmth. If the yang pulse is surging and rapid and the yin pulse replete and large, exposure to warmth and heat transforms it into warm toxin; warm-toxin illness is the most severe. If the yang pulse is yielding and weak and the yin pulse wiry and tight, further exposure to warm qi transforms it into a warm epidemic. In this way, injury by cold in winter develops into warm disease. The changed pulse presentations, formulas and treatment are as described.
When people become ill, they may fail to seek treatment promptly, silently enduring in the hope of recovery, until a chronic illness forms. In children and women it may become still more severe. When seasonal qi is disharmonious, one should report symptoms early, seek the origin of the harmful influence and treat it promptly while it remains in the interstices; failure to recover is then rare. If the patient endures silently and speaks only after several days, harmful qi enters the viscera and becomes difficult to control. This is an essential precaution when someone in a household is ill.
In preparing decoctions and medicines, one should not avoid morning or night. Once illness is noticed, treatment should begin at once, without waiting for a particular time, making recovery easier. If there is delay, the illness transmits and changes; even if one wishes to remove it, doing so becomes difficult. Medicines should be taken exactly according to the prescribed method. If someone follows personal inclination and disobeys the master, the text says there is no need to continue treating them.
Cold-damage illnesses are mostly acquired from wind and cold. Wind and cold first strike the exterior; once they enter the interior, they no longer disperse there. The text says there has never been a case that should disperse under warm covering yet fails to do so; this lies outside the presentation-specific treatments. Even when an attacking treatment is intended, the exterior should first be released, and only then may purging be used.
If the exterior is released but the interior remains unresolved, without great fullness and with chills and fever still arising, the illness is not removed. If the exterior is released but the interior remains unresolved with great fullness and great repletion, hardness and dry stool, purging may remove it. Even by the fourth or fifth day, this need not cause harm.
If one attacks with purging when it is unsuitable, the interior becomes deficient and heat enters. Diarrhea accompanied by heat follows, with agitation, restlessness and more transformations than can be counted. Mild cases become critically exhausted; severe cases must die.
When yang is abundant and yin deficient, sweating causes death but purging brings recovery. When yang is deficient and yin abundant, sweating brings recovery but purging causes death. If this is so, how can Shendan be mistakenly used to provoke sweating, or Gansui recklessly used to attack? Treatments for deficiency and abundance lie a thousand li apart. The turning point between good and ill responds like a shadow or an echo: how could this be easy?
Indeed, when Guizhi passes the throat, someone with abundant yang may perish; when Chengqi enters the Stomach, someone with abundant yin may die. Life and death hinge on a moment: the body may be extinguished before there is time to count days. Yin, yang, deficiency and repletion cross in signs of extreme subtlety, while the contrary effects of sweating, vomiting and purging bring disaster with extreme speed. Yet practitioners with shallow, narrow skill, ignorant of the source of illness, treat mistakenly and cause patients to die, then call it their allotted fate. Wronged souls fill the dark roads and corpses fill the open fields. Seeing this, how could a humane person not grieve?
When dual-reception illnesses arise together, treatment has an order of priority: releasing the exterior and attacking the interior are intrinsically different. Yet those obstinately attached to reckless ideas say to combine Shendan and Gansui in one drink, claiming that it both releases the exterior and removes the interior illness. Their words are clever and seem right, but their reasoning is contrary to the principles.
The wise examine their actions carefully and cautiously; the foolish act decisively and hastily. How could the transformation between safety and danger be misrepresented? People of the world pursue the honor of fashionable agreement and fail to see the collapse into peril. Only the discerning naturally preserve their root, taking the lesson close at hand from their own bodies. What need is there to seek it far away?
When inducing sweating, take decoctions warm. Although a formula says to take it three times daily, if the illness is severe and unresolved, shorten the intervals: all three doses may be finished within half a day. If the medicine meets and checks the illness, a response will be noticed. In severe illness, observe the patient throughout an entire day and night. If the presentation remains after one preparation, make and take the same decoction again. Some people will not sweat until three preparations have been taken, after which the illness resolves. If sweat still will not emerge, the text calls it a fatal illness.
In a seasonal-qi illness, if by the fifth or sixth day there is thirst and a wish to drink, but the person cannot drink much, water should not be given. Why? Heat in the abdomen is still too slight to transform it, so it creates a further illness. By the seventh or eighth day, if there is great thirst and a wish for water, it should still be given according to the presentation. Always give less than the person wants, without indulging the desire fully. If they say they can drink one dou, give five sheng. If drinking produces abdominal fullness, difficult urination, panting or hiccups, do not give it. Sudden profuse sweating indicates spontaneous recovery.
In illness, an unexpected ability to drink water indicates approaching recovery. Those who do not understand illness merely hear that drinking water can bring spontaneous recovery, then force water on someone who is only slightly thirsty. The resulting disasters are too many to count.
In illness, if a stirring, rapid pulse associated with reversal becomes slower after decoction, a floating, large pulse diminishes and becomes smaller, or initial restlessness gives way to quiet, these are all signs of recovery.
In treating warm disease, fifty-nine points may be needled. The body has 365 points in all; moxibustion at thirty-nine of them causes harm, and needling at seventy-nine brings disaster. The closing phrase says that these also strike the marrow.
A pulse with fourfold diminution means death in three days. If the patient's pulse arrives once during four breaths of a healthy person, this is called fourfold diminution. Fivefold diminution means death in one day: the patient's pulse arrives once during five breaths of a healthy person. Sixfold diminution means death within one shi: the patient's pulse arrives once during six breaths of a healthy person.
An abundant pulse and cold body arise from cold damage; a deficient pulse and hot body arise from summerheat damage. If both yin and yang pulses are abundant and profuse sweating does not resolve the illness, the person dies. If both are deficient and heat does not cease, the person dies. A pulse arriving now sparsely, now rapidly means death. A pulse arriving like a twisting rope means death that day.
With delirious, disordered speech, slight bodily heat, a floating, large pulse and warm hands and feet, the person lives. With reversal cold and a deep, fine pulse, death occurs within one day. The preceding material gives the presentations of cold-damage heat illnesses.
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