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When a plague disease (Shi Yi) is complicated by Spleen Qi deficiency, it is difficult to treat; when complicated by Kidney Qi deficiency, it is even more difficult. Plague diseases belong to heat syndromes; if Kidney Qi is deficient, the hands and feet become cold. Plague diseases involve excess pathogens; if Kidney Qi is deficient, symptoms such as vertigo, palpitations, and flaccidity/weakness of the lower back and knees occur. Within Kidney deficiency, there are further distinctions between Yin deficiency and Yang deficiency. Plague diseases must be resolved through sweating (Han), purging (Xia), and clearing heat (Qing). If the patient has Yang deficiency, the application of sweating, purging, or clearing methods will immediately lead to signs of Yang collapse (Tuo Jue); if the patient has Yin deficiency, the application of sweating or purging methods will immediately lead to signs of Yin exhaustion. Therefore, careful observation is required at all times.

During the stage where the pathogen is in the exterior, if severe lower back pain, frequent urination, and coldness with weakness in the knees and shins are observed, one must inquire whether the patient historically suffered from strangury (Lin Zhuo) or impotence (Yang Wei), or had a history of seminal emission/nocturnal pollution (Yi Xie) and excessive sexual activity. This must be clarified clearly. In formulas for releasing the exterior, add Ren Shen (Ginseng Root) and Bai Shao (White Peony Root). For those with Yang deficiency, also add Du Zhong (Eucommia Bark); for those with Yin deficiency, also add Zhi Mu (Anemarrhena Rhizome), to protect Kidney Qi and prevent unexpected complications later. If the pathogen enters the interior requiring purging, Tao Shi's Huang Long Tang (Yellow Dragon Decoction) should be the primary formula; if clearing heat is required, Ren Shen Bai Hu Tang (Ginseng White Tiger Decoction) should be the primary formula. Or, if repeated clearing and purging result in intensified heat, a dry tongue without coating, black coating that grows longer despite clearing, or dry coating that becomes drier despite purging, these are all signs of Kidney deficiency. Upon examining the Yangming channel and finding no evidence of excess pathogens, treatment should proceed based on Kidney deficiency, using Liu Wei Di Huang Tang (Six-Ingredient Rehmannia Pill) with Sheng Di Huang (Rehmannia Root) replaced, and adding Zhi Mu and Huang Bo (Phellodendron Bark). As Wang Tai Pu (Wang Bing) stated: "If cooling does not cool, blame the lack of water"; this refers to strengthening the master of water (nourishing Kidney Yin) to control the solar flare (hyperactive Yang). If there is still no response, combine with Sheng Mai San (Generate the Pulse Powder) to nourish the upper source of water (Lung Yin); or use Si Wu Tang (Four Substance Decoction) to unblock the meridians. When heat spreads like a prairie fire, a cup of water cannot save the situation. One must prepare large quantities of decoctions, measuring herbs in *liang* (taels) and total liquid volume in *dou* (pecks), to have any chance of success. If recognized early, two or three out of ten may be saved; if exhaustion is already evident, it is hard to save one out of ten; if accompanied by signs of Spleen and Stomach failure, such as vomiting, hiccuping, dry heaving, or diarrhea, preventing oral intake of medicine, it is hard to save one out of a hundred.

There are three types of blood loss (Wang Xue) associated with plague syndromes.

First, prior to illness, if the patient has a history of chronic blood loss and Yin deficiency, once infected by the plague, the pathogenic heat will torment the deficiency, making Yin exhaustion most likely. In both exterior-releasing and interior-clearing treatments, care must be taken at every step to protect Ying Blood (Nutritive Blood). Examples include the use of Sheng Di Huang in Jiu Wei Qiang Huo Tang (Nine-Ingredient Notopterygium Decoction) and Ren Shen in Ren Shen Bai Du San (Ginseng Detoxification Powder).

Second, upon contracting the disease, sudden epistaxis (bi ni) or hematemesis (tu xue), uterine bleeding (beng lou) in women, or even syncope due to blood loss (xue yun) can occur, presenting a critical emergency. This is common in plague syndromes. Families often only fear the blood loss and fail to recognize the plague infection; physicians often overlook the external pathogen and focus urgently on stopping bleeding, cooling, and tonifying, which often leads to critical danger. They do not realize that the bleeding is forced by the plague pathogen; one should treat the plague, and once the pathogen is resolved, the bleeding will stop spontaneously. This syndrome does not typically appear when the plague is in the exterior, but rather after several days of fever, which is easier to recognize. However, when plague pathogens stagnate in the Yin channels and suddenly manifest this syndrome, it is difficult to identify because there are no external signs like headache or fever to rely on. But if slight aversion to cold is seen accompanied by severe vomiting, urgently observe the Qi, complexion, spirit, pulse, and tongue coating. If there is a white tongue coating and the complexion shows one or two signs of plague, it is undoubtedly plague toxin. Use Da Yuan Yin (Reach the Original Drink) as the main formula; add Huo Xiang (Patchouli) for vomiting, and Qing Pi (Citrus Peel) for distension. By treating only the plague toxin, the blood syndrome will resolve itself. If blood loss is too severe and Qi is about to collapse, add Ren Shen to consolidate Middle Qi. Wait until the plague syndrome transmits and settles into its respective channel, then treat according to the channel. This is the most critical case of plague complicated by blood loss.

Third, after the plague pathogen has surged vigorously, following periods of irritability, heat, dryness, and thirst, the appearance of blood loss syndromes is a normal pattern of plague, detailed in subsequent sections on blood syndromes.