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(Commentary on the manuscript by disciple Wu Yuchun)

Someone asked: Regarding medical texts on pseudodiphtheritic croup (Baihou, 白喉), it is advocated to nourish Yin and avoid exterior-releasing methods, specifically using large doses of sweet-cool moistening medications. Are the methods for treating throat diseases truly limited to this? Can all previous exterior-dispersing prescriptions be discarded? I reply: The key to treating disease lies in syndrome differentiation; the principle of syndrome differentiation lies in pursuing precision. For throat syndromes that are suitable for temporary exterior-releasing treatment, there must necessarily be symptoms such as headache with a heavy sensation, nasal congestion with runny nose, and hoarse or muffled voice. This indicates external cold enveloping internal heat, representing a mild and superficial stage of throat syndromes. Dispersing with acrid-cool medications will lead to recovery. Recent physicians, having observed the efficacy of acrid dispersal, insist on using these methods even for severe throat syndromes. When ineffective, they consider acrid-cool methods too mild and subsequently employ acrid-warm methods. This view has been passed down orally without alternative approaches. Examining ancient texts, there is no such rationale. Among medical books, *Shanghan Lun* (Treatise on Cold Damage) and *Jingui Yaolue* (Essential Prescriptions from the Golden Cabinet) are closest to ancient traditions. Their discussion on sore throat focuses exclusively on the Shaoyin channel (Foot-Shaoyin Kidney Meridian), because the Shaoyin meridian ascends along the throat, serving as the pathway for the circulation of body fluids. The first symptom pattern presents chest fullness and mental restlessness, treated with Zhufu Tang (Pig Skin Decoction) plus white honey, revealing the intent of clearing, moistening, and sweetly nourishing. If there is only sore throat without fullness or restlessness, the Shaoyin heat is not intense, so Gancao Tang (Licorice Decoction) is used to harmonize gently. If accompanied by an exterior pathogen and the condition does not improve, Jiegeng (Platycodonis Radix) is added to form Jiegeng Tang (Platycodon Decoction). The addition is made only when the condition fails to improve, demonstrating such caution regarding the use of exterior-releasing methods. If the condition is not caused by blazing heat in the Shaoyin but by a mixture of cold and heat leading to ulceration, such as Ru'e (Mandibular tonsillitis/Tonsillar hypertrophy) described in formularies, Kujiu Tang (Vinegar Decoction) is the primary treatment. If the pain is caused by cold invading the Kidney, Banxia San Ji Tang (Pinellia Powder and Decoction) is available. Later scholars analyzed the symptoms, stating that it starts suddenly, with no redness or swelling, but extreme pain, sudden aphonia (loss of voice), and a pulse that is often wiry-tight or extremely rapid. This indicates severe cold invading the Kidney, treated with Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction). However, this syndrome occurs in less than one percent of cases; this method is merely recorded for reference. Nevertheless, Zhufu Tang (Pig Skin Decoction) stands in correspondence with Yangyin Qingfei Tang (Nourish Yin and Clear Lung Decoction) found in texts on pseudodiphtheritic croup. Indeed, pseudodiphtheritic croup originates from fire-heat arising internally, scorching within the Shaoyin channel, while wind from the Shaoyang channel (Liver Wind/Internal Wind) is stirred accordingly. Fire borrows the momentum of wind, and wind enhances the power of fire, putting the "Source of Tianyi" (Kidney Yin) of the Shaoyin into near desiccation. To seek its belonging to assist it, strengthening the master of water (Kidney Yin) is insufficient to control the sunlight (deficient fire); Yangyin Qingfei Tang seeks its belonging to assist it. Therefore, in the initial stage, there is dryness and astringency in the throat, obstruction and pain upon swallowing, mental restlessness and heat in the heart, and a feeling of baking heat in the mouth, nose, and face, with absolutely no signs of exterior cold. However, the disease remains in the original Shaoyin channel; without wind assistance, the fire's momentum is not yet intense. When the fire reaches extremity and stirs the Shaoyang wind, dizziness and blurred vision occur, along with disharmony in the chest and hypochondrium. The meridians become scorched, possibly presenting with pulling or twitching sensations, as wind and fire combine to blaze violently. Blazing affects the Yangming channel (Stomach Channel), steaming turbid qi in the stomach into putrefaction; blazing affects Metal of the Lung (Lung Organ), boiling the fluids within Yin into phlegm. The clear and spacious regions of the Lung and Stomach have become a prairie fire. Lung failure leads to nasal congestion, aphonia, panting, and rising phlegm. Stomach failure leads to epistaxis with foul-smelling discharge, and confusion of the spirit/mind. At this stage, even a wise person cannot devise a strategy. I say: Not so. Severe cases of pseudodiphtheritic croup often present with bone and joint pain, severe chills and high fever in the initial stage, resembling cold damage. If not complicated by an exterior pathogen, how could it be like this? I reply: The "exterior infection" in pseudodiphtheritic croup is contracting warm-heat pathogens in winter and spring, which lie dormant in the Shaoyin and transform into warm-toxin; it is not wind-cold. Even if slight external pathogens are touched at the onset, they only suffice to stir the Shaoyang wind. Shaoyang refers to the internally generated wind (Internal Wind) in the human body. Once internal wind moves, the external wind is lost, and the Shaoyin fire becomes even more intense. Thus, the chills and fever of cold damage begin with a chilling sensation and fear of cold, limb fatigue, generating heat from cold. The chills and fever of pseudodiphtheritic croup begin with scorched and dry skin and limbs, vexing pain in joints, generating cold from extreme heat. I say: Extreme heat generating cold is mentioned in classical teachings, but the rationale seems vague and unsubstantiated. I reply: The conflict of hyperactive Yin and Yang can be understood by observing wind and thunder in nature. For example, during midsummer, scorching heat lingers unresolved, causing the sun and moon to darken, all apertures to roar, and thunder and lightning to erupt violently. The human body is similar. When Yang hyperactivity reaches its peak, a thread of Yin Qi attempts to connect but fails, resulting in a phenomenon of chills and fever交战 (battle). How can this be compared to the chills and fever of cold damage? Then, do Houbi (Sore Throat) and Chanhou (Entangling Throat) differ from this? I reply: Houbi with redness and swelling is excess fire, belonging to the Jueyin channel (Liver Channel). Chanhou with swelling and closure is phlegm-fire, belonging to the Yangming channel (Stomach Channel). Pseudodiphtheritic croup appears pale white, with mild swelling and pain initially, indicating deficient fire, belonging to the Shaoyin channel (Kidney Channel). The fierce agents in this book, such as Shenxian Huoming Tang (Immortal Life-Saving Decoction), can treat the fire of Jueyin and Yangming. Additionally, there is the syndrome of Lanhou Dansha (Rotting Throat with Scarlet Rash). When the rash has not yet erupted, exterior release is necessary. Chuwen Huadu Tang (Eliminate Pestilence and Transform Toxin Decoction) in this book contains Gegen (Puerariae Radix) and Bohe (Menthae Haplocalycis Herba), which are fully competent. Because latent pathogens in Shaoyin reach Shaoyang and must return to Yangming to exit through the muscles, *Shanghan Lun* states: Yangming is Earth, the destination of all things. Using acrid-warm drying agents like Mahuang (Ephedrae Herba), Guizhi (Cinnamomi Ramulus), Qianghuo (Notopterygii Rhizoma et Radix), and Fangfeng (Saposhnikoviae Radix) would cause toxic heat to scatter everywhere, surging uncontrollably. Moreover, Gegen and Bohe are acrid-cool and sweet-moistening, distinct from acrid-warm drying agents. In the Shaoyin chapter of *Shanghan Lun*, Zhufu Tang precedes Jiegeng Tang; in this book, Shengdi (Rehmanniae Radix) precedes Gegen. These three formulas stand in tripartite balance, directly tracing Zhang Zhongjing's (Zhang Nan-yang) methodology. They should not be viewed merely as divination. If all medical books could adhere to such consistent rules and clear contraindications, each disease would have a fixed prescription, avoiding the worry of indiscriminate medication. Analyzing details meticulously and expounding thoroughly without omission, this demonstrates mastery of Zhang Zhongjing's works and divine adaptability. He is not only a merit-maker for the syndrome of pseudodiphtheritic croup. *Yuji Wei Yi* discusses Houbi, stating: "One word summarizes it: Fire." It further states: "Jun Fire (Monarch Fire) is like human fire; Xiang Fire (Minister Fire) is like dragon fire. Human fire burning wood is slow; dragon fire burning wood is fast." Their urgency in treating fire is the same.