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(Wet-warmth combined with cold, also known as wet-warmth accompanied by cold).

[Etiology] Latent dampness within the body ferments and transforms into warmth. The onset is triggered by a new contraction of violent cold. It commonly occurs during early summer and early autumn. Wet-warmth belongs to latent pathogens (pathogens lying dormant in the body), while cold is a new pathogen (recently contracted). The simultaneous occurrence of old and new pathogens results in a disease where cold, dampness, and warmth are mixed. This is largely similar to cases of summer-heat-dampness combined with cold, where summer-heat-dampness is the latent qi and cold is the new contraction. The difference lies in that in wet-warmth combined with cold, cold and dampness are heavy, and the transformation into warmth is slow; whereas in summer-heat-dampness combined with cold, damp-heat is heavy, and the signs of cold are relatively mild.

[Symptoms] At the initial stage: headache, heaviness of the body, aversion to cold, absence of sweating, chest and epigastric stuffiness, lower back pain, limb fatigue, vexatious pain in muscles, dullness in the stomach, abdominal fullness, loose stools, and scanty urination. The tongue coating is white and slippery, or even white, greasy, and swollen.

[Pulse] The right pulse is slow and sluggish; the left pulse is wiry and tight. This indicates that wet-warmth combined with cold obstructs the qi mechanism of the exterior and the upper/middle jiao, causing simultaneous disease of the Foot-Taiyang Bladder Meridian and the Foot-Taiyin Spleen Meridian.

[Treatment] Initially, aromatic, bland, and acrid-dispersing methods should be used. Huoxiang Zhengqi Tang (Agastache Powder for Regulating the Middle) added with Scallion White (Congbai) and Fermented Soybean (Chidou) harmonizes the middle and releases the exterior, dispelling the external cold binding the surface. Subsequently, acrid, bland, draining, and promoting methods should be used. Daju Pi Tang (Great Tangerine Peel Decoction) added with Houpo (Magnolia Bark, 1.5 qian), Cardamom Powder (6 fen taken with liquid), promotes qi circulation and diuresis, resolving the internally stagnant and latent dampness. Once the cold is dispersed and dampness removed, the fermenting warm pathogen loses its basis for attachment, and the heat clears naturally. If residual heat remains, simply remove Cangzhu (Atractylodes Rhizome) and Guigui (Cinnamon Twig) from Daju Pi Tang, add Jiaoshanzhi (Charred Gardenia Fruit) and Mianyincheng (Herba Artemisiae Scopariae, each 3 qian) to rectify it. For details, refer to the section on "Shanghan transmitting to Taiyin with Fire Transformation."

[Commentary by Xiu] Wet-warmth combined with cold shares the same general principle as Shanghan combined with dampness. Treatment must be adjusted according to whether the dampness has transformed into heat, and whether there is accompanying phlegm or food stagnation, to avoid mismanagement.

[Commentary by Lian] Wet-warmth combined with cold may occur during the plum rain season of early summer or the osmanthus steam period of mid-autumn. One must guard against latent heat from spring-warmth in the former, and latent summer-heat in the latter. Although the causes differ between warmth and summer-heat, long-term latency and fermentation inevitably lead to fire transformation. Coupled with external cold binding, the depression becomes severe, leading to sudden and violent onset. The key lies in the first one or two days: using Huoxiang (Agastache), Houpo (Magnolia Bark), Congbai (Scallion White), and Chidou (Fermented Soybean) to ventilate the middle and release the exterior, allowing cold-dampness to exit via slight sweating; using Kouren (Cardamom), Fuling (Poria), Huashi (Talcum), and Tongcao (Tetrapanax Pith) for aromatic penetration and bland渗利, allowing damp-heat to exit via urination. Sweating and diuresis proceed together, resolving both exterior and interior. Naturally, cold disperses, dampness opens, and latent heat reaches the exterior, making treatment easier. Subsequently, distinguish between more dampness than heat (focusing on Taiyin, using bitter-acrid-bland-warm method) and more heat than dampness (focusing on Yangming, using bitter-acrid-bland-cool method). If dampness and heat are both abundant, treat both Taiyin and Yangming, employing opening-draining and heat-clearing methods. These methods are detailed in the commentary on Shanghan combined with dampness and are not repeated here.

[Commentary by Rongzhai] "Wet-warmth Shanghan" is a major syndrome; Mr. Yu's description is insufficient. Mr. Xiushan's commentary correctly emphasizes adjusting treatment based on heat transformation and accompanying phlegm/food. The *Shaoxing Medical Health Report* published Mr. He Lianchen's *Treatment Methods for Wet-Warmth and Epidemic Diseases*, which aligns well with these requirements. Excerpts follow for supplementation: Wet-warmth must be distinguished by whether dampness or heat predominates. Symptoms and treatments diverge accordingly.

**Predominant Dampness (Dampness heavier than Heat):** Originates from the Lung and Spleen of Taiyin, often accompanied by wind-cold.

[Tongue] Coating is invariably white and greasy, or white-slippery and thick, or white with grey tones, sticky and slippery, or white with black spots and sticky, or with black cracks and sticky, or fully covered, thick like accumulated powder, adherent and stiff.

[Pulse] Vague and unclear, or deep-thin resembling hidden, irregular and uneven.

[Expression] Often lethargic and drowsy.

[Symptoms] Severe aversion to cold, possibly cold feet, distending and painful headache with heaviness, feeling wrapped or covered, body pain preventing flexion/extension, body heaviness preventing turning, painful and vexatious joints/muscles, sore and acid legs/feet, chest/diaphragm stuffiness, thirst without desire to drink, or no thirst at all, afternoon chills and fever resembling yin-deficiency, short/scanty yellow-hot urine, loose but unsatisfactory stools, or even watery diarrhea.

[Treatment] Focus on lightly opening Lung Qi. The Lung governs the qi of the whole body; when Lung qi transforms, Spleen dampness transforms. Even if accompanied by other pathogens, they transform with it. Use Huopo Xia Ling Tang (Agastache, Magnolia, and Poria Decoction) to vent the middle and release the exterior, expelling wind-cold through skin pores, and using aromatic-bland diuresis to expel dampness via the Kidney and Bladder. Sweating and diuresis act together, resolving exterior-interior. However, damp-heat emerging internally often knots in the Middle Jiao causing stuffiness, mixed with phlegm and food. Add Xingxiang Da Tan Wan (Star-Aromatic Phlegm-Guiding Pill) for phlegm stagnation; Chenxiang Baixiao Qu (Agarwood Hundred-Resolve Leaven) for food stagnation; or fresh radish juice mixed with ginger juice. This opens turbid closure and eliminates phlegm/food retention. If accompanied by mental vexation and confusion due to extreme damp-heat steaming and clouding the clear orifices, remove Cardamom and Magnolia Bark from the formula, add Xixin (Asarum, 2-3 fen), Baijiezi (White Mustard Seed, ~1 qian), and fresh Shichangpu root/leaves (1.5 qian) for acrid-moist water-moving and phlegm-resolving opening. Add Shuilu (Reed Rhizome, 2-3 liang) and Dengxin (Juncus Effusus, 1 qian) for light-clear sweet-bland heat-draining and damp-guiding. If constipation occurs due to damp obstruction/qi stagnation or phlegm-fluid, remove Agastache, Magnolia, and Soybean; add Cardamom with crushed Trichosanthes Seed, and Perilla Seed with crushed Prunus Spinosa Kernel. These are acrid and slippery, smoothing qi mechanism; once qi moves, stool passes and sweat appears.

**Predominant Heat (Heat heavier than Dampness):** Occurs mostly in Yangming Stomach/Intestines. Though externally accompanied by wind, it is essentially heat knotting internally, with heat in both exterior and interior. Qi-level pathogenic heat depresses and scorches fluids, not yet coagulating in the Blood level.

[Tongue] Coating is invariably yellow and greasy; tongue edges/tips red-purple lacking fluid; or white base with yellow overlay, turbid; or pure purple with little white; or yellow-rough with prickles; or white coating with crimson base, yellow with black, floating-slippery-sticky; or white turning yellow-grey-black. In severe latent cases, coating is thick, full, adherent, and stiff.

[Pulse] Rapid, sluggish, and irregular.

[Complexion] Oily or soot-like.

[Symptoms] Mental vexation and thirst, thirst without desire to drink; severe cases: deafness, dry retching, foul breath, hot/full chest-abdomen, burning to touch, or painful on pressure.

[Treatment] Initially use Zhishi Zhizi Chi Tang (Gardenia, Immature Bitter Orange, and Fermented Soybean Decoction) combined with Liu's Jiegeng Tang (Platycodon Decoction), plus Yinchen (Artemisiae Scopariae Herba) and Guanzhong (Cyathulae Radix) for clearing fragrant detoxification, connecting interior-exterior, resolving latent pathogens via sweat and urine. If transforming to dryness with severe thirst, large pulse, and rough breathing, heavily add Shigao (Gypsum), Zhimu (Anemarrhenae Rhizome), and Lugenzhi (Reed Juice) to clear Lung qi and nourish sources. Next, use Qingfen Biyi Tang (Fragrant-Epidemic-Expelling Decoction): acrid-cool, fragrant-intense, light-clear sweet-bland, draining heat, resolving dampness, exiting via Bladder or Bai Fei (white miliary rash), or eruption. If pathogens transmit to Heart Meridian causing confusion/delirium, check tongue: if yellow-greasy, it is still Qi-level damp-heat clouding Pericardium/clear orifices. Use Changyang Xiexin Tang (Calamus Heart-Draining Decoction) with Zhu Li (Bamboo Sap) and Jiangzhi (Ginger Juice) to reach, descend, and drain turbid damp-heat, opening closure. For extreme cases, add Taiyi Zijin Dan. For confusion with cold limbs, use Juezheng Fanhun Dan. If tongue is purple-dry, pure crimson, round-hard, or black, with delirium, laughter/spasms, syncope, or closed eyes/silence, this is wet-warmth transforming to fire, entering collaterals, sinking into Heart, stirring Liver Wind. Use large doses of Xidi Qingshen Tang (Rhino-Corn & Rehmannia Spirit-Clearing Decoction) with Guashuang (Melon Frost) and Xuexue (Snow Snow/Calomel variant) to clear Heart, penetrate collaterals, drain Liver, extinguish wind. Or use Jiajian Shenxi Tang combined with Xipo Zhibao Dan to clear Ying-nourish, detoxify, open blood-orifices. With proper emergency care, 30-40% survival is possible. Editor's experience: Confusion/spasms often stem from Stomach heat steaming the Brain, causing neuritis, leading to mental clouding, head shaking, eye staring. Spinal brain inflammation leads to limb spasms, opisthotonos. The Stomach is the sea of five zang and six fu organs; clear qi ascends to eyes, fierce qi rushes to head, enters brain via eye system. Brain is the mansion of Primordial Spirit; thus Stomach heat steaming brain manifests as neurological diseases. Check tongue: if yellow-dry/black-dry with texture, it is Stomach-Intestine excess fire blocking clear orifices. Use Xilian Chengqi Tang urgently to purge blockage. For yin deficiency, add Shengdihuang (Rehmanniae Radix Fresh), Yuanshen (Scrophulariae Radix), Huoshuilugen (Living Reed Rhizome), Dongguazi (Winter Melon Seed) for light-clear slippery nourishment. Avoid excessive cloying tonics which injure yin further. If tongue is yellow-thick-slippery, pulse deep-rapid, epigastrium tender but soft, constipation, this is sticky damp-heat clashing with solid waste. Use Xiao Xiongtang (Minor Chest Trap Decoction) combined with Puhuang Wan, or Zhishi Daozhi Wan to slowly resolve. For severe cases, Shenxiong Daoshui Wan or Lushi Runzi Wan to grind away. Do not use harsh purgatives blindly, or you will damage healthy qi and cause bad syndromes. If tongue is yellow like agarwood or yellow-black-dry, pulse deep-solid-small or deep-micro-hidden, cold limbs, thirst for hot drinks, epigastric pain, with fullness, dryness, solidity, hardness: damp-heat knotting (fullness) vs dry feces (dryness/solidity/hardness), steaming Heart/Brain, scorching Liver/Kidney, causing restlessness/delirium, curled tongue/shrunk scrotum. Use Xilian Chengqi Tang urgently. For yin injury, add Shengdihuang, Yuanshen, Zhimu, Chuanbai. Purging quickly preserves fluids. If tongue is black-moist, lower abdomen tender, black tarry stools easy to pass, manic laughter, dark urine freely passing: this is Blood stasis in Stomach/Intestines affecting Bladder. Use Tao Ren Chengqi Tang urgently, or combine with Xijiao Xiang Dihuang Tang to cool blood and drive out stasis. For jaundice, difficult urination, abdominal fullness, use Yinyin Hao Tang for gentle purging. For Qi deficiency with excess pathogens suitable for purging: Canhuang Tang. For Yin deficiency with excess pathogens: Qianjin Shengdihuang Tang (remove Mangxiao) or Yangrong Chengqi Tang gently. For extreme weakness unable to tolerate purging: use Xue Geng (Watermelon rind & Fern decoction) with juices of Shengdihuang, Donggua, Yuanshen, Gua Lou, Honey, and slight Ginger Juice. Salty-slippery to remove adherence, acrid-moist to clear dryness. Do not fail to purge when indicated, relying only on cloying tonics which trap pathogens and injure yin. Do not hesitate, or you lose the chance to purge, allowing pathogens to flourish and healthy qi to decline, making future purging impossible. Above are the treatment methods for Wet-Warmth Shanghan.