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(These words were) passed down after surviving the ravages of war, inevitably carrying the regret of loss and omission. Drawing inferences about other cases from one instance depends on the reader's ability to comprehend. Moreover, upon careful study of Zhang Zhongjing's works, one finds that their intent is subtly revealed.

The annotation states: When a warm disease (Wenbing, febrile diseases caused by warm pathogens) first manifests, Huangqin Tang (Scutellaria Decoction) should be used primarily to clear heat. If it is a cold damage (Shanghan, diseases caused by cold pathogens), it must transmit to the Shaoyang (Lesser Yang) channel, and only when the pathogenic heat gradually enters the interior can Scutellaria be combined with Bupleurum to resolve the condition. This is because Huangqin Tang is the principal formula for treating warm diseases; it is derived from Guizhi Tang (Cinnamon Twig Decoction) by replacing Cinnamon Twig with Scutellaria and removing Ginger. Cinnamon Twig treats exterior wind-cold, while Scutellaria treats interior wind-heat; this is an unchangeable rule. Ginger is acrid and dispersing, which is not suitable for warm-heat conditions, hence it is removed. One must understand the distinction between exterior-interior and cold-heat.

Zhou Yuzai annotated: The text explicitly mentions the Taiyang (Greater Yang) and Shaoyang channels, yet asks why medicines for these two channels are not used? This indicates it is not Shanghan. Shanghan proceeds from the exterior to the interior, whereas this condition originates from the interior and emerges outward. Without an exterior syndrome, how can one identify the involvement of the Taiyang and Shaoyang channels? Symptoms may include fullness in the hypochondrium, headache, bitter taste in the mouth with desire to drink, or fever without aversion to cold. Therefore, it cannot be called an exterior syndrome. In cases of combined syndromes in Shanghan, all are exterior diseases. Now, there is not only no exterior syndrome but also diarrhea indicating an interior syndrome. The heat-associated diarrhea in Shanghan must result from transmission through channels, unlike this condition where diarrhea occurs immediately. Why does warm disease cause immediate diarrhea? It is because the patient's Middle Qi (Spleen/Stomach energy) is inherently deficient, the pathogen has deeply latent within, and cannot be fully vented outward; thus, it inevitably moves downward causing diarrhea.

Wang Shixiong's clinical note: This discussion describes how warm pathogens, having been externalized for a short time, can move downward to cause diarrhea. The original text also contains the phrase "if vomiting occurs," does this not imply that warm disease can transform into Huoluan (cholera-like syndrome)? The clues have appeared here early on. Previously, when compiling *Wenre Jingwei* (Classic of Warm Heat), I added a note under this passage: The Wood of the Shaoyang Gallbladder, carrying rampant fire, causes vomiting due to upward rushing Qi, and diarrhea due to downward pressing Qi. It is not necessary for Middle deficiency to cause diarrhea; this is vomiting caused by fluid accumulation. Pinellia and Ginger specifically open fluid stagnation; if heat is blazing, Lianru (Scutellaria Root and Rhizome) should be substituted instead. Mr. Yang Suyuan commented: This annotation is precise and appropriate, surpassing previous scholars. For current treatments of warm disease transforming into Huoluan, this method should be followed as a standard. Shen'an was highly convinced after hearing this and sought further advice from experts, hoping for instruction.

(My opinion is that Gardenia seems applicable for this syndrome; for mild cases, Coptis might not be necessary, though I am unsure. However, Jujube Fruit should definitely be removed.)

On the third day of the fifth month, I arrived in Shanghai. Huoluan with tendon retraction had already become epidemic. I stayed at the residence of Mr. Zhou Caishan from Zhenhai, avoiding visitors to conceal my inadequacies and to avoid the fatigue of social obligations. On the eighth day, at the home of Jiashu, a close relative of Shaowu, two guests from Nanxun suffered from this illness simultaneously. One surnamed Han died within moments; the other, Ji Yunxiang, aged seventeen, was also critically ill. Caishan insisted I visit, saying, "How can we see death and not save?" However, the patients' hands and faces were black, eyes sunken with rolling pupils, limbs cold, voice hoarse, pulse hidden with no urination, tongue purple with greasy coating, extreme thirst with profuse sweating, and mental confusion, presenting all signs of critical danger. Although it was before the Mangzhong solar term and the season of summer-dampness had not yet begun, winter cold remained latent inside. Spring had been excessively cold, and even entering summer, it remained cool. Qi mechanism was depressed and unable to circulate freely. Thus, those who would develop warm diseases transformed into this syndrome. This shares the same outcome as cases of latent summerheat, differing only in the absence of abdominal pain. Since cold transforms into heat, it is ultimately distinct from summer-dampness. I urgently ordered acupuncture at Quchi (LI11) and Weizhong (BL40) to bleed until the blood resembled ink. The prescription used Huangqin (Scutellaria Root) as the sovereign drug, with Gardenia, Fermented Soybean, Coptis, Scutellaria Root and Rhizome, Coix Seed, and Pinellia as minister drugs. Mulberry Twig Ash, Reed Rhizome, and Loofah Network served as assistant drugs, with a small amount of Evodia as envoy. Decocted in Yin-Yang water (half boiled, half cold water), administered warm and slowly, vomiting ceased. The next day, the pulse slightly recovered.

After two more doses, the black color lightened slightly, elbows and knees became warmer, but red eyes and irritability appeared, indicating latent pathogens were venting outward. Evodia and Mulberry Twig Ash were removed; Forsythia, Motherwort, and Talc were added. Spots broke out over the body, the tongue coating began to resolve, limbs warmed, sleep returned, and urination resumed. Subsequently, herbs for clearing and resolving toxins were given, leading to recovery after several doses. Caishan urged me to detail the etiology and treatment methods for publication, naming the formula Huangqin Dingluan Tang (Scutellaria Stabilizing Cholera Decoction). Later, many others were treated successfully using variations of this method. For example, a guest from Dongting staying at Litai, who habitually smoked opium, contracted this illness. After several doses of this formula, he developed constipation, red eyes, thirst, sweating, and delirium. This too indicated long-latent pathogens attempting to emerge externally. I prescribed modified Zhuye Shigao Tang (Leaf of Bamboo and Gypsum Decoction), resulting in recovery. For cases with heavy dampness, Yinchen and Talc were added; for excess Qi, Zhiqiao (Aurantium and Magnolia Bark) were added; for fluid obstruction and food stagnation, Houpo and Radish were added; for Liver Qi stagnation, Perilla and Chinaberry Fruit were added; for thirst, Mugwort Root juice was used, or fresh Lotus Root juice was frequently administered. Treatment flexibility lies with the practitioner and cannot be exhaustively listed. Shaowu, in Tudian Market, obtained my formula and advised people to prepare and distribute it, totaling nearly a thousand portions.

(This formula's modifications follow specific rules and are even more appropriate than the previous ones. Reviewed by Xie Cheng.)

After Summer Solstice, there was still no intense heat, yet Huoluan with tendon retraction persisted. Although similar to pre-Mangzhong cases caused by latent pathogens, the etiology differed slightly, suggesting a deeper pathological level. Why? According to my late great-grandfather's *Chongqing Tang Suibi*: Warm diseases, heat diseases, and damp-warm diseases, if treated improperly, easily lead to death. Continuous spread becomes epidemic, just as failing to suppress bandits leads to their growth into roaming marauders. Heat Qi, pathogenic Qi, and corpse Qi mix to form toxic epidemic Qi. Is it truly that heaven and earth generate a unique abnormal Qi? Therefore, epidemics occur in densely populated areas. Human Qi generates the most heat. As Ji Wenda wrote in his miscellaneous poems: "Ten thousand homes' smoke and fire warm the clouds, melting the ancient ice of Tianshan Mountain." His self-note stated: Since Dihua established counties, infant smallpox resembles that of the interior regions. There, the climate is extremely cold, but now it gradually resembles the interior due to abundant human Qi. Ji's words reveal profound insight. Smallpox did not exist in antiquity but appeared in the Han Dynasty; nowadays, few escape it. With increasing population and heating earth Qi, ancients feared Cold Damage most, while moderns suffer more from Warm Heat.

Wang Shixiong's clinical note: This section... [Text fragment] ...can ascend, causing chaotic confusion, leading to the critical syndrome of vomiting, diarrhea, and tendon retraction. This occurs when latent pathogens attempt to erupt and external pathogens enter; the two pathogens clash, disrupting the intestines and stomach. Consequently, the Qi pathway closes instantly, blood vessels stagnate, limbs turn cold, and hands/faces darken. The Yangming channel, rich in Qi and Blood, presents such sudden symptoms not because Qi and Blood suddenly wither. Human form is constituted by Qi; without Qi circulation, flesh and blood die. Thus, initially, opening blockage is urgent to allow Qi and Blood flow, enabling pathogen expulsion and Zheng Qi restoration. Ignorant practitioners, unaware of the principle that deep heat causes deep cold (Re Shen Jue Shen), seeing cold limbs and hidden pulses, assume cold or collapse, fearing acupuncture and administering hot medicines. This traps pathogens, worsening cold. They claim that feeling cold after hot medicine proves the difficulty of restoring spring warmth. Repeating this method kills victims whose grievances go unheard. Some die with bleeding from seven orifices, yet remain unrepentant. Others suffer external collapse due to internal blockage preventing Zheng Qi retention. Yang collapsing from above causes excessive sweating and Qi loss; Yin collapsing from below causes excessive diarrhea and fluid loss. This is termed "internal blockage and external collapse." To prevent external collapse, internal blockage must be opened. Formulas like Zixue (Purple Snow), Jiangxue (Crimson Snow), and Xingjun San (Marching Army Powder) are excellent for opening blockage and venting latent pathogens. Feilong Duoming Dan (Flying Dragon Life-Grasping Pill) combines Xingjun San and Jiangxue with stronger potency, plus Renzhongbai (Calcined Human Bone Ash) to guide turbidity downward, possessing the power to break gates and seize life. Mr. Chen Xianggu from Shangyu prepared and distributed this, urging me to publish the details, saving many lives—a great merit.

Since curing Ji Yunxiang, many sought my help, achieving success often. However, post-Summer Solstice, illnesses involve both internal and external pathogens, making them more severe. Thus, Duoming Dan must first be used to open blockage. Post-recovery complications vary, requiring flexible response, demanding significant effort, unlike previous years' Huoluan where mere turning points led to quick recovery. The reason lies in displacement and hardship, losing will and exhausting spirit, causing prior internal injury and complex courses. Hence, post-recovery care requires extreme caution. Many in Shanghai are merchants prone to negligence once recovery begins. "Illness worsens during slight recovery," leading to failure. For instance, Mr. Chu Ziyun from Yuhang, my relative by marriage, had a maid suffering from this, already rigid. Upon visiting, I administered 2 fen of Duoming Dan gifted by Xianggu. She revived quickly. I then gave Jiedu Huoxue Tang (Detoxifying and Invigorating Blood Decoction); she survived after several doses. Later, traveling to Chongming, I heard she remained weak and eventually died. Another employee of Wang Dasheng Opium Shop, cured by me, regained appetite and urination, showed residual heat with facial boils, but suddenly died of mental confusion. Shi from Liiji Money Exchange, cured by me, had normal excretion for days, then complained of inability to swallow, stared upward, hiccuped, and died. Tao from Lvyin Bookstore, recovering, suddenly became trance-like and died despite medication. These accounts were narrated by Liyun. Also, Brother Chen Jiexiang from Siming, critically ill, recovered after my treatment, stopped medication for a month, then returned with sore throat, swollen cheeks, ulcerated tongue, locked jaw, phlegm cough, rib pain, red painful urination, and dark loose stools. Residual toxicity accumulated due to lack of clearing/resolving, spreading like wildfire. Poverty prevented proper convalescence. Pulse was wiry, tight, rapid, and difficult to treat; he died later. Recorded as a case to warn travelers. Some say local pharmacies are busy and make errors, causing sudden changes in patients who don't realize it. Both doctors and families must be vigilant. Reading *Lenglu Yihua*, I found a case: A boy in Chen Village, Yi County, had Huoluan. The doctor prescribed processed Pinellia, but the pharmacy mistakenly dispensed processed Aconite. He suffered severe abdominal pain, madness, oral bleeding, and death. The family blamed the doctor, who insisted the prescription was correct and suspected other causes. Examining dregs revealed Aconite. The case went to court, fined the pharmacy. This confirms the warning about pharmacy errors. If the family were timid and silent, or the doctor fled, or dregs were discarded, even Judge Gaoyao could not judge. How cautious must one be with medication!

Zhu Mingqi suffered diarrhea and tendon retraction. Seeing cold limbs, the doctor administered warming tonics. Vomiting occurred immediately after ingestion, followed by incessant hiccups. Intensifying tonics worsened the condition daily. By the ninth day, survival seemed impossible, and funeral arrangements were made. Ziyun, managing the household, asked for my aid. Left pulse was wiry and slippery; right pulse was weak and imperceptible. I prescribed Zhiqiao, Jiegeng, Huangqin, Huanglian, Lianru, Banxia, Zisu, Lianqiao, Lugeng, Pipaye, and Huashi to resolve phlegm, move food, soothe knots, and unblock Yang. Hiccups stopped after two doses, accompanied by widespread red spots. After two more doses, dry stool passed, coating resolved, urination resumed, right pulse strengthened. Clearing and regulating methods led to recovery.

When examining Zhu's case, Ziyun's disciple Fang Maocai was present. He asked, "For such a severe case, why do you consider the pathogen not severe?" I replied, "Most severe cases arise from misdiagnosis. Had this been treated correctly initially, it would have healed in one or two doses. Unfortunately, the world generally classifies diarrhea, vomiting, Huoluan, and Huoluan with tendon retraction as cold syndromes. Practitioners often fail to observe symptoms and administer hot medicines. Seeing cold limbs and a weak right pulse, they take it as definitive evidence of deficiency-cold. Furthermore, immediate vomiting and subsequent hiccups in Huoluan with tendon retraction leave no time to investigate further. Panicking at signs of deficiency-collapse, they intensify warming tonics. Even if the patient dies, the family bears no resentment, and the doctor feels no remorse. I often see local physicians, even for very mild illnesses, create grave diagnoses to avoid blame or seek credit. This practice is passed down, lamentable indeed. Additionally, chest/abdominal pain, malaria, asthma, menstrual obstruction, and postpartum conditions are often labeled as cold by laypeople. Though killed by hot medicines, neither side realizes it. Hiccups, in particular, cause many wrongful deaths. I once treated a courtesan with persistent hiccups. Early sexual activity caused deficiency, but blood loss injured Yin. Using warming/drying herbs to assist heat was wrong, leading to lower Jiao insecurity. She feared medicine, so I used only Egg Yolk consecutively, bringing relief.

Wu Zhuxi, recovering from seasonal infection, suffered hiccups for three days, audible to neighbors, considered critical. I used a method to unblock the Fu organs and move Qi; bowel movement and phlegm/spit discharge led to recovery.

Mr. Zhu Puxiang from Nanxun, aged 56, suffered from childhood consumption and hematemesis, abstaining from sex after thirty to prolong life. He normally passed hard, pellet-like stools, indicating severe Blood deficiency. Suddenly, this autumn, he developed hiccups. Consecutive doses of nourishing, sedating, warming, and grasping Qi medicines brought him to the brink of death. Scholar Lu Dingpu invited me to examine him. Pulse was wiry, slippery, forceful, and rapid; coating was thick, yellow, and greasy; bitter taste and red urine. Defying consensus, I prescribed large doses of cooling/moistening herbs: Xue Geng (Snow Broth), Trichosanthes Seed, Bamboo Juice, Loquat Leaf, Reed Rhizome, Scrophularia, Aster, Belamcanda, Patrinia, and Acorus. After multiple doses, passing red stools, he recovered. Even in old age with deficiency, hiccups caused by phlegm-heat are common; true deficiency-cold hiccups are rare. Yet doctors, ignoring differentiation and pulse diagnosis, blindly use Clove, Ginger, and Cinnamon as eternal remedies. Why?

Mrs. Xie, five months pregnant, suffered diarrhea for four days. A doctor prescribed Ginger, Aconite, Cinnamon, and Magnolia Bark. She developed numb/cold limbs, chest oppression, coma, urinary retention, profuse sweating, extreme thirst, and vomiting. Urgently summoned me. Pulse was not completely hidden. First, soy sauce soup was given, stopping vomiting. Then, Ginseng, Coptis, Scutellaria, Phellodendron, Scutellaria Root/Rhizome, Dendrobium, Honeysuckle, Lablab Leaf, Raisins, Reed Rhizome, and Mung Bean were decocted in Winter Melon Soup and taken warm slowly. External fumigation with charcoal and vinegar cured all symptoms. Next day, pulse wiry/slippery, diarrhea continued. Bai Tou Weng Tang was given with Ginseng, Licorice, Honeysuckle, Lablab, Dandelion, Raisins, and Amomum. Recovered after two doses.

Zhan Yaotang's son from Wuyuan, aged 20, had Huoluan. Several doses of Ginger/Cinnamon failed to stop diarrhea. Habitual opium smoker, suspected deficiency leakage, received tonics, worsening diarrhea. Finally consulted me. Extreme thirst, wiry/rapid pulse. Fortunately, onset was not due to summerheat, but Yin deficiency was inherent. Despite drinking cold/water chilling, hot medicines were excessive. Without diarrhea to dissipate drug power, fluids would have dried up. Bai Tou Weng Tang combined with Feng Sui Dan, plus Honeysuckle, Mung Bean, and Dendrobium. Improved after one dose, recovered after two.

Traveling to Shanghai via Shimen, Mr. Wu Renshan in Puyuan expressed concern: "Zhang Zhongyuan from Piling and Yang Xiaoxi from Xiushui have arrived from Chu to Shanghai handling official business. You should visit." Grateful, I declined politely. Having long heard of the Zhang family's scholarly medical heritage, including books in their Wanlin Study favoring warming tonics, I mentioned this to my old friend Wang Zineng from Taicang, also a skilled physician. He sighed: "Talent and learning vary; one cannot force attainment. Wang Anshi failed to become Chancellor, becoming merely a poet. Regarding the Zhangs, why discuss medicine? People trust their scholarship and extend that trust to their medicine, causing much harm. My brother Jixu, Zhang's brother-in-law, was misled by him. Alas! Words remain, but Zineng has been dead for over ten years."

Regarding the theory of supporting Righteous Qi and expelling Evil, it is like facing invaders without fighting, only guarding the city, leading to self-destruction. Mr. Zhang died in autumn. Later, Jiang Yin sent a letter praising my refusal to provide books. Formerly, a Vice Commissioner overseeing education in Zhejiang, considering himself a superior physician, asked Shao Weixi to request my books, which I also refused. Avoiding vulgar ridicule, I record this case, wishing people do not speak lightly of medicine and act only after careful consideration.

Yao Outing from Qiantang, returning to govern Chongming, heard I was in Shanghai. In early autumn, he instructed my brother HT An to deliver a letter inviting me. Due to a sudden severe diarrhea in early summer, followed by spleen constraint, bowel movements became infrequent (once every ten days, month, or even longer), difficult, hard initially then loose, with sweating and exhaustion. Over sixty years old, walking stiffly. Despite consuming cow's milk and moistening/laxative herbs, ineffective. Occasionally felt food stuck, vomited sour/spicy fluids, six pulses slow/weak, white moist coating, no thirst, clear copious urine, no abdominal distension/pain. This is true Middle Qi deficiency causing urinary/bowel changes. Can intestinal dryness/constipation be treated with moistening herbs? Not suitable for moistening, nor purging. Middle deficiency lacks control over opening/closing; fear that once opened, it won't close again. Nor should lifting/astringing be used. Sour vomiting/stuck food indicates downward blockage with upward rushing. Plus, habitual opium smoking risks complete closure if opened once. Prescription: Ginseng, Atractylodes, Tangerine Peel, Pinellia, Rotating Flower, White Peony, Chicken Gizzard Lining, Quince, Loquat Leaf. Six doses: two bowel movements, four pellets passed. Three more doses: fifteen-six pellets passed. Three more doses: nine pellets passed smoothly, not hard, not loose. No weakness felt; medicine matched syndrome. Left regulation method and departed. If sour vomiting/stuck food recurs, temporarily use Ginseng, Coptis, Tangerine Peel, Pinellia, Rotating Flower, Scutellaria Root/Rhizome, Perilla Leaf, Loquat Leaf, and Hematite to clear/ascertain. In August, intense autumn sun, Outing came to Shanghai on business, staying long. White coating covered tongue. Took Talc, Magnolia Bark, Mulberry Twig Ash, Lablab Leaf for two doses; heat subsided, mind cleared. Left pulse still wiry, Guan position high, sour vomiting, insomnia, limb tremors. External pathogen resolved, but Earth受 Wood oppression. Removed Talc, Magnolia Bark, Mulberry Twig Ash, Lablab Leaf; added Poria, Clam Shell, Seaweed, Mung Bean, White Cardamom. Three doses: coating resolved, sleep returned, hunger sensed, diarrhea reduced. Removed Cardamom, Clam Shell; added Acorus, Atractylodes. Five doses: recovered. Huoluan's opening/closing dysfunction is due to central hub disrupted by evil. This syndrome's lack of opening/closing control is due to Middle deficiency unable to preside. One excess, one deficiency, allowing mutual comparison. Post-recovery vomiting/diarrhea/tremors indicate wind-summerheat disturbing Middle due to deficiency, another Huoluan type. Thus, detailing my treatment for general reference.

Wang Xiecheng invited me to examine Mrs. Shi, mother of Sima Shiyutian from Wuyuan, nearly fifty, sudden Huoluan with tendon retraction, yellow coating, extreme thirst, irritability, syndrome belonging to latent summerheat. Pulse not unfavorable, but whole body cold sweat, fanning constantly, indicating Yang floating away. Dare not prescribe. Died soon. This case shows syndrome cannot rely solely on pulse. Next day, Zhai examined Father of Mr. Zhu Xuanquan, aged sixty, Huoluan with tendon retraction, mild syndrome, clear speech... Half a month later, Zhai contracted this at midnight, black blood bled out, rushed for me at dawn. Form and pulse both collapsed, profuse sweating like rain, sunken eyes, hoarse voice, no urine, greasy coating. Habitually drank alcohol, ate little grain, charitable, forgot labor. Summer-dampness accumulated internally, Zheng Qi scattered. Reluctantly gave Ginseng, but could not save. Regrettable!