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Diseases in the world are often said by people to be most difficult when they are Cold Damage (Shanghan, 伤寒), but this is not actually difficult. The greatest difficulty lies in the intermingling and mutual arrival of the Six Qi (Six Pathogenic Factors: Wind, Cold, Summer-heat, Dampness, Dryness, Fire). The Six Qi refer to Wind (Feng), Cold (Han), Summer-heat (Shu), Dampness (Shi), Dryness (Zao), and Fire (Huo). However, in winter, the pathogenic factors involve only three characters: Wind, Cold, and Fire. In spring, there are four: Wind, Cold, Dampness, and Fire. In summer, there are five: Wind, Cold, Summer-heat, Dampness, and Fire. In autumn, there are four: Wind, Cold, Dryness, and Fire. If there is Dryness or Dampness out of season, these are abnormal changes of heavenly Qi. Generally speaking, the more mixed the Qi, the more difficult the treatment. I will briefly clarify the Five Qi of summer to illustrate this point. Once the Five Qi are clear, the cases involving fewer factors can be understood without further explanation.

For instance, if the pulse is floating and slow, with spontaneous sweating, headache, fever, and aversion to wind, this is Wind Injury (Shangfeng, 伤风). If the pulse is floating and tight, with no sweating, headache, fever, and aversion to cold, this is Cold Damage (Shanghan, 伤寒). These are seasonal common colds, which inevitably occur even in the summer months. There are also cases where one seeks coolness and drinks cold substances, causing the internal organs to be invaded by Cold, leading to vomiting, abdominal pain, and diarrhea. The pulse is deep and slow, the hands and feet are cold, and the breath from the mouth and nose is cold. This is a presentation of Cold Strike (Zhonghan, 中寒) in summer, ironically caused by excessive avoidance of heat. As for Summer-heat Syndrome (Shuzheng, 暑症), it is the proper disease of summer, but it differs into Mild Summer-heat Injury (Shangshu, 伤暑), Severe Summer-heat Stroke (Zhongshu, 中暑), and Closed Summer-heat (Bishu, 闭暑). Mild Summer-heat Injury is the lighter condition, characterized by sweating, body heat, and thirst. Severe Summer-heat Stroke is the heavier condition, characterized by profuse sweating, unconsciousness and confusion, internal steaming heat, dry teeth, or irritability, panting, and delirious speech. Closed Summer-heat involves latent Summer-heat Qi internally, blocked externally by Wind and Cold. The symptoms of headache, body pain, fever, and aversion to cold belong to Wind and Cold; the symptoms of thirst and irritability belong to Summer-heat. If there is Cholera-like vomiting and diarrhea accompanied by muscle cramps (Zhuanjin, 转筋), this is caused by food stagnation and retained fluids due to Summer-heat. However, food stagnation and retained fluids constitute Dampness. Symptoms such as heavy body and pain, abdominal fullness and oppression, and uncontrolled diarrhea all belong to Dampness. When Wind, Cold, Summer-heat, and Dampness move, Fire follows them, constituting the Five Qi. This is what is meant by "summer involves five characters."

However, when each factor appears separately, treatment is easy; when all five factors intermingle, treatment is difficult. For example, when Wind and Summer-heat struggle together, it is named Summer-heat Wind (Shufeng, 暑风), characterized by frequent convulsions. When Summer-heat and Dampness struggle together, it is named Damp-Warmth (Shiwēn, 湿温), characterized by headache, spontaneous sweating, delirium, heavy body, abdominal fullness, and cold calves. When Wind and Heat struggle together, it is named Wind-Warmth (Fengwēn, 风温), characterized by spontaneous sweating, heavy body, excessive sleepiness, snoring respiration, and difficulty speaking. When Dampness combines with Wind, it is named Wind-Dampness (Fengshi, 风湿); when Dampness combines with Cold, it is named Cold-Dampness (Hanshi, 寒湿), characterized by painful joints and inability to turn over independently. Furthermore, Wind-Cold combined with Dampness can manifest as Gang Spasm (Gangjing, 刚痉) and Rou Spasm (Roujing, 柔痉), characterized by locked jaw and opisthotonos (body arched backward). Additionally, Damp-Heat attacking each other can cause the Five Wasting-Thirst syndromes (Wuwei, 五痿), characterized by flaccid paralysis of the four limbs and inability to grasp or hold objects. All these are cases where the Five Qi combine and appear simultaneously.

Moreover, Cold Damage contracted in winter may lie latent between the sinews and bones, and erupt in summer upon exposure to hot Qi; this is named Hot Disease (Rebing, 热病). Abnormal Qi of heaven that erupts out of season is named Epidemic Qi (Yiqi, 疫气). Even more so, diseases transmitted by pathogenic Qi, spreading through households and entire regions, are human-induced epidemics, which cause even greater harm. When these Hot Diseases and Epidemics transmit to the Zang-Fu organs and cause constipation, Dryness Qi follows, meaning that within the Five Qi, the Sixth Qi (Dryness) is additionally involved. Furthermore, conditions such as deficiency constitution, fatigue, and Xia Fatigue (Zhuxia, 注夏 - seasonal lethargy) are intricately interwoven among them. If one does not distinguish them carefully and prescribes medications rashously, the harm to life is profound.

Alas! Physicians, upon seeing fever, do not ask whether it is Summer-heat or Dampness, but generally apply dispersing and releasing methods. If dispersion fails, they switch to harmonizing methods. If harmonization fails, they switch to cooling methods. If cooling fails, they resort to tonification. Those who luckily recover attribute it to their own merit, while those who suddenly face danger blame it on fate. They do not realize that at the beginning of the disease, correct syndrome differentiation and medication yield quick results. But once the disease has lasted long and become deep, with all signs of collapse present, even skilled physicians cannot help. I, presumptuously, have written this treatise to first elucidate the Five Qi of summer, hoping that complex and mixed syndromes will not be confused, allowing for clear vision and appropriate treatment, which is one way to save the world. Sigh! Once the Five Qi are clear and the more complex ones distinguished, distinguishing the mixture of Three or Four Qi is not difficult. Moreover, regarding Cold Damage, exterior and interior can be distinguished, transmission versus direct attack can be differentiated, and the Upper, Middle, and Lower Jiao (Sanjiao, 三焦) can be assessed. What then is difficult? Therefore, I say: Cold Damage itself is not difficult; the difficulty lies in the intermingling and mutual arrival of the Six Qi.