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The young son of a family surnamed He in Liaoning, aged five, suffered from Wind-Warmth complicated by panting and shortness of breath.

Etiology In the late stage of the last month of spring (late spring), he played outdoors, sweated, and was exposed to wind, thereby developing Warmth Disease (Wen Bing). Due to inappropriate treatment, after seven or eight days, panting and shortness of breath were added.

Symptoms The face was red, the body was hot, breathing was extremely rapid and forced, with rattling phlegm sounds in the throat, and the eyes seemed unblinking. The pulse was floating and slippery, and forceful upon heavy pressure. There was a purple pattern on the fingers extending up to the Qi Gate (Qiguan). Upon opening the mouth, the tongue coating was white and moist. Inquiry into his bowel and bladder movements revealed that he had not passed stool for two days, urine was slightly yellow but flowed freely.

Diagnosis Observing this condition, it appeared critical to the extreme; however, the slippery pulse, although indicating phlegm, also sufficiently attests to sufficient Yin fluid. Furthermore, seeing his robust and plump physique, it is known that it is still treatable. It is appropriate to use Xiao Qing Long Jia Shi Gao Tang (Minor Green Dragon Decoction plus Gypsum) from *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), adding Xing Ren (Apricot Seed) and Chuan Bei Mu (Fritillaria Bulb) to benefit Lung Qi.

Prescription Ma Huang (Ephedrae Herba, 1 qian)
Gui Zhi Jian (Cinnamomi Ramulus, 1 qian)
Sheng Hang Shao (Paeoniae Radix Alba, 3 qian)
Qing Ban Xia (Pinelliae Rhizoma Preparatum, 2 qian)
Xing Ren (Armeniacae Semen Amarum, 2 qian, peeled and crushed)
Chuan Bei Mu (Fritillariae Cirrhosae Bulbus, 2 qian, crushed)
Wu Wei Zi (Schisandrae Fructus, 1 qian, crushed)
Gan Jiang (Zingiberis Rhizoma, 6 fen)
Xi Xin (Asari Radix et Rhizoma, 6 fen)
Sheng Shi Gao (Gypsum Fibrosum, 1 liang, crushed fine)
Decoct together in one large cup of water, divide into two doses, and take warm.

Formula Analysis Xiao Qing Long Jia Shi Gao Tang (Minor Green Dragon Decoction plus Gypsum) from *Jin Gui* originally treats Lung Distension (Fei Zhang) with cough, upward rushing of Qi, irritability, and panting. However, in that original formula, the dosage of Shi Gao (Gypsum) was only two-thirds of that of Ma Huang (Ephedrae Herba) and Gui Zhi (Cinnamomi Ramulus) (Note: The original dosage of Gypsum in *Jin Gui*'s Xiao Qing Long Jia Shi Gao Tang contained an error, which has been discussed in detail elsewhere). In this prescription, the amount of Sheng Shi Gao (Raw Gypsum) is ten times that of Ma Huang and Gui Zhi. This is indeed because the patient presented with a red face, body heat, and a forceful pulse; without such a heavy use of Gypsum, the warming properties of Ma Huang, Gui Zhi, Gan Jiang, and Xi Xin could not be effectively utilized. Additionally, according to the modification examples of Xiao Qing Long Tang (Minor Green Dragon Decoction) in *Shang Han Lun* (Treatise on Cold Damage), when there is panting, Ma Huang is removed and Xing Ren is added. Here, Xing Ren is added but Ma Huang is not removed because the heavy use of Sheng Shi Gao controls and restrains Ma Huang, allowing Ma Huang to remain.

Follow-up Visit After completing one dose of the medicine, the panting decreased by more than half, but phlegm remained abundant, the skin was still burning hot, stool had not yet been passed, and the pulse remained forceful. It was planned to continue treatment with herbs that clear heat and promote the draining of phlegm.

Prescription Sheng Shi Gao (Gypsum Fibrosum, 2 liang, crushed fine)
Gua Lou Ren (Trichosanthis Semen, 2 liang, stir-fried and crushed)
Sheng Zhe Shi (Ochra, 1 liang, ground fine)
Decoct together in two cups of water, divide into three doses, and drink slowly while warm.

Outcome After taking the medicine in three divided doses, the heat subsided, phlegm dissipated, stool was passed, and the disease was completely cured.

Commentary This case was published in *Quan Guo Ming Yi Yan An Lei Bian* (Compilation of Verified Cases by Famous Physicians Nationwide). He Lianchen commented on this case: "Wind-Warmth attacking the Lung causing distension and panting is particularly common in children, and the disease is most dangerous. Pediatric experts often refer to this as 'Ma Pi Feng' (Horse Spleen Wind). This case was diagnosed as external cold binding internal heat. Mimicking Xiao Qing Long Jia Shi Gao Tang from *Jin Gui*, plus Bei Mu (Fritillariae Bulbus) to open and clear, followed by a subsequent prescription using Er Shi Gua Lou Ren (Ochra and Trichosanthis Seeds) to clear, settle, and descend, resulting in recovery. The steps of first opening then descending were orderly. However, it is surprising that a five-year-old child could tolerate such heavy dosages. This shows that the climate in the North is vigorous and constitutions are robust, unlike the delicate constitutions of people in the South. Precisely because they can tolerate heavy agents, rapid results are achieved."

Regarding He Lianchen's commentary, although he praised this case, he ultimately felt the dosages were too heavy, leading to speculation about regional differences. He did not realize that if the dosages in this prescription were taken at once, treating a five-year-old would indeed be excessive. If divided into three doses, regardless of North or South, any robust child could take them. Consider recent medical books: there are cases of treating Postpartum Warmth Disease using half a jin (approx. 500g) of Sheng Shi Gao in one dose, recorded in Liu Weichu's *Yu An Zhai Zheng Zhi Cong Lu*; Liu was originally from Xiangshan, Guangdong. There are also cases of treating Plague (Shu Yi) using half a jin of Sheng Shi Gao in one dose, recorded in Li Jianyi's *Shu Yi Xin Pian*; Li was originally from Pingtan, Fujian. If treating such conditions in the North, could the dosages be increased further? From this, we know that physicians should not hold fixed views regarding North-South differences when prescribing. Moreover, I have traveled south to Hangan (Hubei region) and practiced medicine there, finding no difference from the North, except that when using exterior-releasing agents, sweating occurs more easily in the South, so dosages should naturally be lighter. However, this is due to the relationship of local climatic warmth and cold, not the strength of the constitution. Thus, for the same individual, releasing sweat in winter versus summer requires significantly different dosages.

Having carefully observed the transformation of Heaven and Earth's Qi, it changes every few decades. When Zhang Zhongjing first wrote *Shang Han Lun* (Treatise on Cold Damage), and later *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), Xiao Qing Long Tang (Minor Green Dragon Decoction) in *Shang Han Lun* originally had five modifications, but none included adding Shi Gao (Gypsum). This was because there were no diseases at that time requiring the addition of Gypsum. By the time *Jin Gui* was written, Xiao Qing Long Jia Shi Gao Tang existed, suggesting that diseases requiring Gypsum had already appeared. I recall when I was in my twenties, I saw physicians curing exterior-contracted phlegm-panting cases simply by administering the original Xiao Qing Long Tang. A few years later, when I encountered similar cases, Xiao Qing Long Tang alone was ineffective; I had to add several qian of Sheng Shi Gao for efficacy. Several years after that, I had to add around one liang, or even two liang, of Sheng Shi Gao for efficacy. From this, we know that physicians must adapt to the shifting transformations of Qi and adjust accordingly, rather than rigidly adhering to established formulas without flexibility.