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Li Dongyuan said: The spleen and stomach are damaged by overwork, and diet is again irregular. After being ill for a long time, when affairs cease and the mind is at peace, excessive fullness causes the disease to flare up severely. Previously, in the Renchen year (the first year of Xingding era of Jin Dynasty, 1221), the capital was under martial law. By late March, those under siege had endured for half a month. After the siege was lifted, among the city dwellers, not one or two out of ten thousand remained uninfected. Those who fell ill and died followed each other without ceasing. There were twelve gates in the city walls; each day, the number of corpses transported through each gate ranged from more than two thousand to no less than one thousand. Such conditions lasted for nearly three months. Could it be that all these million people contracted wind-cold external pathogens? Generally speaking, people within the besieged city suffered from irregular diet and damage due to overwork, which goes without saying. Due to their pattern of morning hunger and evening fullness, irregular daily routines, and improper adaptation to cold and heat, after two or three months, the Stomach Qi had been deficient for a long time. Once they ate too much, they became susceptible to pathogenic factors, and due to improper treatment—some using sweating methods, others using purgative methods—the condition transformed into Jie Xiong (Chest Binding) and Jaundice. Furthermore, using formulas like Xian Xiong Tang (Trap Chest Decoction) and Yin Chen Hao Tang (Artemisia Capillaris Decoction) to purge them resulted in death in every case. Initially, it was not Shang Han (Cold Damage); rather, mistreatment made it resemble true Shang Han syndromes. This was entirely the fault of the medication. Therefore, based on his lifelong experience of effective treatments, he wrote an essay titled "Differentiation between Internal Injury and External Contraction."

Yu Zhen commented: This refers to the situation where a great plague follows a major war. Reading this treatise clarifies the etiology of diseases caused by overwork and irregular eating; indeed, these are internal injuries. For such plagues, tonification is indicated rather than purgation. Using Da Yuan Yin (Origin-Reaching Powder), Bai Hu Tang (White Tiger Decoction), or Cheng Qi Tang (Descending Qi Decoction) would precisely violate Li Dongyuan's criticism. Historical records indicate this occurred in the first year of Tianxing era of Jin, following the retreat of Mongol troops. Soon after, physicians, monks, Taoists, and coffin sellers profited excessively from selling coffins post-plague. The court ordered authorities to double taxes to aid state finances. The people's suffering at that time must have been extreme. In contrast, in today's peaceful times, people live in comfort and warmth. Even if there is overwork or dietary irregularity, it usually affects only those engaged in arduous business. If not complicated by external contraction, illness does not occur abruptly. Thus, great plagues are non-existent, and cases fitting Li Dongyuan's theory of internal injury are also rare. However, with satiety comes lust, leading to early internal injury of True Yin. Consequently, deficiency syndromes within external contraction diseases are actually quite common.

*Weisheng Baojian* (Precious Mirror of Health) records: The Commander-in-Chief, near seventy years old, passed through Yangzhou during a southern campaign. He captured over ten thousand people and selected four beautiful maidens approaching adulthood to keep by his side. I said, "The newly captured individuals harbor qi of shock and anxiety internally. Coupled with irregular diet, they are prone to disease. Close contact leads to transmission of pathogenic qi, causing maximum harm. Moreover, given his advanced age and weak constitution, he should exercise extra caution." The Commander did not listen. In the twelfth lunar month, upon returning from campaign, heavy snow fell. The new captives, suffering from cold and hunger, all developed headaches, coughs, spontaneous diarrhea, and abdominal pain, leading to many deaths. In the first lunar month, upon reaching Bianjing, the Commander attended celebratory banquets and drank heavily several times, subsequently falling ill. His pulse was deep, fine, and wiry, with a pause every three or four beats. His presenting symptoms were identical to those of the captives. He died three days later. *Neijing* states: "When encountering the deficiency of the annual luck, the emptiness of the moon phase, and the disharmony of the seasons, and thereby contracting pathogens, the qi penetrates to the bone. Can one not fear this?"

Yu Zhen commented: Yu Jiayan, in his *Yi Bing Lun* (Treatise on Plagues), cites Zhang Zhongjing's *Ping Mai Pian* regarding the section "when both yin and yang pulses at the Cun position are tight," elucidating profound principles. He posits that clear pathogens enter from above via the nose into the Yang aspect, while turbid pathogens enter from below via the mouth into the Yin aspect. Involvement of Yang manifests as fever, headache, neck stiffness, and cervical spasms; involvement of Yin manifests as cold feet and knees, and involuntary urination and defecation. Generally, Shang Han pathogens enter from the exterior surface and transmit sequentially through the Six Channels. Plague pathogens enter via the mouth and nose and directly reach the San Jiao (Triple Burner). When the San Jiao becomes mixed, internal and external communication is blocked, leading to oral ulcers, tongue severance, throat obstruction, abscesses with pus, lower bleeding, and severe umbilical pain. The treatment method involves pre-emptively administering aromatic qi-regulating herbs before illness to prevent pathogen entry. If pathogens have already entered, removing turbidity is the primary principle. This aligns implicitly with Wu Youke's theories. It differs significantly from the Luo family's descriptions of diseases caused by overwork, worry, shock, cold, and hunger. The assertion that death results from the mixing of disease qi and corpse qi with incorrect qi, creating various foul accumulations that leave no escape, is a common feature of all plagues. However, traditional anti-plague methods, such as using realgar in the nose, consuming garlic and liquor, or wearing thunderbolt wood in the hair, show variable efficacy. It is recorded that during the Chongzhen 16th year (1643), from August to October, a great plague struck the capital, causing sudden deaths beyond medical intervention. Later, officials from other provinces arrived who could identify the disease: swelling of tendons behind the knee indicated prognosis; purple color meant incurable, red color required immediate bloodletting to avoid disaster. People flocked to get checked; over 200,000 had already died.

Wang Shishan treated a young man who, after sexual activity, suddenly experienced aversion to cold, spontaneous sweating, and fever. Pain affected the head, back, and epigastrium. His lips were red, tongue stiff, and he vomited. The eyelids were bluish. A physician administered Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction). In the afternoon, he developed delirium and aversion to heat, with long urine stream. On the first day, the pulse was fine, weak, and rapid. On the second day, it was floating, wiry, and rapid. Upon palpating the hypogastrium, pain was elicited, suggesting the use of purgatives. Wang Shishan stated, "This is a plague. Plague can involve both aspects simultaneously; here, internal injury is severe, and external contraction is mild. Hypogastric pain indicates Kidney Water deficiency. Using draining medicines would be fatal. We should combine tonification and descending methods. Use Qing Shu Yi Qi Tang (Clear Summerheat and Augment Qi Decoction), remove Cang Zhu, Ze Xie, and Wu Wei Zi, add Sheng Di Huang, Huang Qin, and Shi Gao. After taking more than ten doses, he recovered."

Yu Zhen commented: Contracting plague after sexual activity corresponds to Yu's concept of Taiyang-Shaoyin simultaneous contraction. Wang Gong defines simultaneous contraction as internal and external injury, differing in meaning. Although Bu Zhong Yi Qi Tang and Qing Shu Yi Qi Tang share similar ingredients, one led to deterioration while the other succeeded; the妙 (subtlety) lies in the modifications.

Hu Xianweng treated Scholar Zhang, who suffered from seasonal plague. Other physicians found both hands' pulses hidden (Fu). They stated, "Yang syndrome presenting with Yin pulse is untreatable," and intended to use Yang Du Sheng Tang (Yang Toxin Ascending Decoction) to lift the pulse. Hu Xianweng said, "This is extreme wind-heat; fire excess causes the pulse to hide; it is not a Yin pulse. Lifting it will cause death." Ultimately, he used Lian Qiao Liang Ge San (Forsythia Cooling the Chest Decoction), resulting in recovery after one dose.

Yu Zhen commented: This case demonstrates that for warm plague, clinical signs should take precedence over pulse alone.

Yu Hengde treated a woman who, in March, had suffered from plague symptoms for three days when her menstruation began, causing fever to intensify. By the seventh or eighth day, the condition worsened. She experienced throbbing chest pain preventing sleep. Physicians exhausted their skills. At night, Yu was summoned. The patient instructed her maid to continuously massage her chest. All six pulses were faint, rapid, chaotic, resembling shrimp swimming. Yu asked, "Is this because premature purgation led to Jie Xiong?" The host replied, "No." Yu said, "Menstruation starting on the third day indicates interior deficiency and downward flow." He combined Si Wu Tang (Four Substances Decoction), Huang Long Tang (Yellow Dragon Decoction), and Xiao Xian Xiong Tang (Minor Trap Chest Decoction) into one dose, adding Ginger and Jujube. The host asked the name of the medicine. Yu replied, "San He Tang (Three Combined Decoction)." After one dose, all symptoms subsided.

Yu Zhen commented: Using Da Huang, Huang Lian, Sheng Di Huang, and Ren Shen together is a common modern method for treating heat diseases.

Wu Youke stated: Zhu Haichou, aged forty-five, contracted plague and presented with Fu Syndrome (Excess Syndrome requiring purgation). His limbs could not move; he lay still as a statue, eyes closed, mouth open, with prickles on the tongue coating. Unable to answer complaints, his son reported that three doses of Cheng Qi Tang had been given, each containing approximately one liang of Da Huang, without effect. With no other options, they sought a prognosis of death. I diagnosed that although the pulse retained spirit (Shen), the pathology was deep while the medication was shallow. I initially administered one liang and five qian of Da Huang. His eyes moved slightly. Upon re-administration, the tongue prickles lost their sharpness, his mouth opened gradually, and he could speak. After three doses, the tongue coating decreased, and mental clarity improved. On the fourth day, he took Chai Hu Qing Zao Tang (Bupleurum Clearing Dryness Decoction). On the fifth day, prickles reappeared, and irritability/heat increased; another purge was performed. On the seventh day, Cheng Qi Yang Rong Tang (Descending Qi Nourishing Blood Decoction) was given, reducing heat slightly. On the eighth day, Da Cheng Qi Tang (Major Descending Qi Decoction) was used, allowing slight limb movement. Over half a month, he consumed a total of twelve liang of Da Huang and recovered. Several days later, he resumed consuming congee. After two and a half months of regulation, he fully recovered. Among a thousand patients treated, such cases accounted for only three or four.

Yu Zhen commented: The conclusion "three or four out of a thousand" implies this method should not be applied routinely. The absence of coma and delirium in the record suggests that severe cases often cannot be saved. This patient was not in a terminal state. Regrettably, the pulse's excess or deficiency was not recorded, but "pulse retaining spirit" likely refers to Tao's definition of strength indicating spirit.

*Zhe Geng Lu* records that after Yuan General Bayan conquered Song, he seized dozens of carts of Da Huang (Rhubarb) and took them away. Returning past the Huai River, captured civilians, surrendered soldiers, and northern troops all contracted plague. Treating them with Da Huang saved many lives. *Song-Yuan Tongjian* attributes this to Yelü Chucai destroying Xia, confirming Da Huang as an excellent remedy for plague. Wu Youke praised Da Huang as a miraculous drug reviving the dying, which was not fabricated. However, this contrasts sharply with Li Dongyuan's views. Both schools possess valid logic; understanding Luck Theory and mastering pulse-symptom differentiation allows practitioners to utilize either approach effectively.

Sun Dongsu's servant, Sun An, ate three bowls of noodles while traveling, suffering from fatigue, plague contraction, and noodle stagnation. Exterior and interior were both hot, causing confusion, delirium, headache, body ache, and abdominal pain. A physician used Yu Xian Dan (Encounter Immortal Pill) to purge him, resulting in thirty to forty bowel movements. The pathogen sank inward, causing heat-binding diarrhea. The tongue was dark brown; forehead hurt, mouth dry, thirst, irritability, and drowsiness prevailed. Left pulse was wiry and rapid; right pulse was large and rapid but lacked fullness. Recognizing this as a mishandled condition due to erroneous purgation, Sun prescribed Chai Hu and Shi Gao (3 qian each), Bai Shao, Huang Qin, Zhu Ru, Ge Gen (1 qian each), Hua Fen, Gan Cao (5 fen each), Shan Zhi, Zhi Shi (7 fen each), and Cong Bai (5 stalks). After decoction and ingestion, he vomited one roundworm around midnight and slept briefly. Next morning, he had two more bowel movements, vomited sour water, and abdominal pain persisted. The formula was changed to Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Hua Shi and Zhu Ru. Night fever intensified; he was given one bowl of Loofah juice. Spirit cleared instantly. Shortly after, as the medicinal effect waned, irritability returned. Another large bowl of Loofah juice induced severe shaking chills. Sun Dongsu noted this was not cold chills but a sign of impending sweating. Sweat emerged shortly after, yet heat remained. Recalling *Huo Ren Shu*: "If heat persists despite repeated sweating and purging, use Ren Shen Bai Hu Tang plus Cang Zhu." Accordingly, Yuan Shen, Sheng Ma, Chai Hu, Bai Shao, and Huang Lian were added. After ingestion, macules appeared on the body: purple first, then red. He slept after midnight, and heat dissipated. Macules faded. Mild abdominal pain, borborygmus, and thirst remained; right pulse was slippery, left pulse harmonized. Ye Zhu Gao Shi Tang (Bamboo Leaf and Gypsum Decoction) plus Bai Shao and Cang Zhu was administered. Sleep improved, but mild abdominal pain persisted. Chai Hu and Bai Shao (1 qian each), Ren Shen, Jiu Qin, Chen Pi, Ban Xia (6 fen each), Gan Cao (3 fen), and one W Mei (Dark Plum) reduced abdominal pain until cure. Only bilateral hip pain preventing movement remained, attributed to tendon malnourishment due to excessive sweating post-major illness. Treatment involved Ren Shen, [missing character, likely Huang Qi], Bai Shao, Gou Qi, Yi Yi Ren, Mu Gua, Shu Di, Dang Gui, Chuan Bai, Niu Xi, and Sang Ji Sheng for recuperation, leading to full recovery.

Yu Zhen commented: Heat persisting after battle sweat is critical. Citing *Huo Ren Shu* is excellent. The judicious use of Shi Gao and Ren Shen, along with the thorough management of hip pain, demonstrates high expertise.

A female relative of the Cheng family, whose husband died of plague, contracted the disease seven days after becoming a widow. Symptoms included high fever, headache, thirst, and bursting chest/hypochondriac pain. A physician prescribed Xiao Chai Hu Tang. That night, she dreamt of intercourse with her deceased husband, ejaculated in the dream, woke up with profuse cold sweats, flaccid limbs unable to move, coma, delirium, sallow complexion, and black, dry, hard tongue. Sun Dongsu diagnosed the pulse as deep, wiry, and rapid in all six positions, with constipation. He stated, "This resembles Yin-Yang Exchange syndrome." Post-plague occurrence of this syndrome is extremely critical. He used Sheng Mai San (Generate Pulse Powder) plus Chai Hu, Huang Qin, Gui Zhi, and Gan Cao. After consumption, limb movement returned gradually, and slow introduction of congee led to recovery.

Yu Zhen commented: Dream-induced Yin-Yang Exchange is rare; using the deceased husband's burnt underwear powder (Shao Kun San) would be even more ingenious.

Zhang Luyu stated: Plagues include Toad Plague, Cormorant Plague, Lump Plague, and Melon Pulp Plague, each with distinct manifestations. Pang Anchang mentioned Tortoise Shell Plague. [Name missing] experienced pain, rumbling intestines, and frequent urge to defecate without success. Black patches appeared on the nose and upper lip, shiny like lacquer, resembling tortoise shell. Observers were terrified. Diagnosis revealed panting, sweating, rapid pulse, and confused spirit. Despite critical signs, the presence of a fresh red halo around the lesions, resembling pockmark roots tightly attached like a thread, while surrounding skin remained normal, indicated treatability. Initially, Ge Gen Huang Qin Huang Lian Tang (Kudzu, Scutellaria, and Coptis Decoction) was given with Xi Jiao, Lian Qiao, Jing Jie, Fang Feng, Zi Jing Pi, and Ren Zhong Huang to resolve exterior toxin. Once the blackness surfaced, Liang Ge San plus Ren Zhong Huang, Zi Jing, and Xi Jiao was used for mild purgation twice. Then, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) plus Ren Zhong Huang was used for regulation, leading to recovery after half a month.

Yu Zhen commented: Ge Cunju's *Bu Tian Shi* describes Yellow Ear and Red Diaphragm syndromes. Red Diaphragm involves headache, body ache, fever, but specifically red/swollen diaphragm or eruptions. Jing Fang Bai Du San minus Ren Shen plus Xi Jiao, Qin, Lian, Zi Jing Pi is used. After exterior resolution, if stool is dry, Liang Ge San is applied. Zhang's case is based on this. However, the described plagues are rarely seen now. Thus, Tu Su Yin is obsolete, and formulas like Lao Jun Shen Ming San, Wu Cheng Zi Ying Huo Wan, Tai Cui Gong Bi Wen Dan, and Li Zijian Sha Gui Wan are unheard of. Only Wu Wen Dan, Xiao Du Wan, Hei Nu Wan, Ren Zhong Huang Wan, Xiang Su San, and Qing Liang Jiu Ku San remain in use due to their safety and simplicity.

*Wai Ji* records that on Goao Island, a plague occurred. Physician Bu Jiade ordered massive fires to be lit throughout the city for a day and night. After the fires extinguished, the disease ceased. Since plague is caused by pathogenic invasion, the fierce fire energy burns away pathogens; once pathogens are gone, the disease resolves. This contains profound truth.