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The *Suwen: Liuyuan Zhengji Dalun* states: "When the Qi of Earth is stagnant and erupts, it manifests as vomiting and cholera."

The eruption of all types of stagnation must transform into heat. Stagnation of Earth (excessive dampness in the Middle Jiao) occurs when dampness in the Middle Jiao is excessive, obstructing the mechanism of ascending and descending. Its eruption is often caused by inhaling summer-heat turbid pathogens or by food stagnation, leading to the interference between clear and turbid Qi, causing chaos within moments, resulting in upper vomiting and lower diarrhea. The treatment method involves using formulas like Ran Zhao Tang (Illuminating the View Decoction) to vent Earth stagnation and separate Yin and Yang.

Although vomiting has already occurred, one should still use salt water to induce vomiting, expelling all accumulated food from the stomach, and then regulate with formulas such as Jia Qing Tang (Light Riding Decoction) or Zhi He Tang (Harmonizing Harmony Decoction).

It also states: "If one does not stay away from heat, heat will arrive; when heat arrives, the body becomes hot, accompanied by vomiting, diarrhea, and cholera."

This clearly indicates that there is cholera caused by heat pathogens. Regrettably, texts such as *Zhubing Yuanhou Lun* (Treatise on the Pathogenesis and Symptoms of All Diseases) and *Sanyin Jiyi Bingzheng Fanglun* (Formulas for the Three Causes of Diseases) all claim that cholera originates from wind-cold, thereby fixing the perspective of later generations. Those suffering from Heat Cholera are mostly misdiagnosed and mistreated with drugs. Moreover, the phrase "do not stay away from heat" does not refer only to medicines and food. For instance, laboring in long-distance fields allows summer-heat pathogens to enter from the exterior. As the saying goes, "hot ground like a furnace, harming people most rapidly," it is appropriate to use sweet-cold herbs like Baihu Tang (White Tiger Decoction) or Liu Yi San (Six-to-One Powder) to clear heat. Or, enjoying rich wine and fatty foods.

If summer-heat enters and damages the Yuan Qi, Ginseng can be added to Baihu Tang. If Qi deficiency attracts pathogens, Ren Shen (Ginseng Root) and Bai Zhu (Atractylodis Rhizoma) must be assisted by herbs that clear pathogens. The established methods of past sages can naturally be applied by analogy.

However, ignorant people rashly believe that diseases of fatigue and injury should be treated with tonification, and bodies accustomed to rich food are necessarily deficient. Knowing one aspect but not the other, they casually administer warming and tonifying treatments, often causing death, which is truly pitiable.

The *Suwen: Zhizhen Yao Dalun* states: "All heat conditions causing mental confusion and convulsions, all rebellious upward rushing of Qi, all restlessness, mania, and deviation from normal conduct, belong to Fire."

"Mao" refers to mental confusion; "yuan" refers to convulsive twitching. Heat damaging the Spirit causes confusion; Fire forcing blood causes convulsions. Fire nature is flaming upward, so Qi rebels and rushes upward. "Zao" is restlessness and unease. "Kuang" is mania. "Yue" is deviation from normal conduct. Heat excess in the exterior causes limb restlessness; heat excess in the interior causes mental disturbance. Generally, Fire nature is active; any disease with movement belongs to Fire. When cholera presents with these symptoms, it is definitive evidence of internal excess of heat pathogens.

It also states: "All cases of turning, twisting, and rigidity with turbid fluids; all vomiting of sour fluid, sudden violent diarrhea with tenesmus, belong to Heat."

"Turning, twisting, and rigidity" refers to muscle cramps and spasms. Heat drying and scorching the sinews leads to spasms and pain; Fire governs burning and scorching, hence restlessness. "Fluids" refer to urine. Heat excess forces Qi to rebel and rush upward. Earth's nature is planting and harvesting, but when the taste becomes sour, it is because Liver Heat is burning internally, transforming accordingly. "Bao zhu" is sudden violent diarrhea. Intestinal and gastric heat excess disrupts transmission and transformation; Fire nature is rapid, hence this condition. "Xia po" is tenesmus and urgent abdominal pain. Fire nature is rapid and desiccating, hence this.

These are colloquial names for Ma Sha (Plague Sha), yet people rashly administer drying and heating drugs, hastening death, which is extremely thoughtless!

*Qianjin Yaofang* states: "For Heat Cholera with severe diarrhea, mental irritability, rapid pulse, and desire for cold water, drink one sheng of newly drawn well water at once."

Guo Baiyun said: "Among methods for treating cholera, *Qianjin Yaofang* is the most comprehensive."

*Zhishu Quan Shu* states: "When summer-heat Qi enters the abdomen, causing nausea, abdominal pain, upper vomiting, and lower diarrhea with watery stools..."

After Spring Equinox and before Autumn Equinox, Shaoyang Ministerial Fire, Shaoyin Sovereign Fire, and Taiyin Damp Earth jointly exercise their functions. Thus, Heaven's heat descends, and Earth's moisture ascends. Humans exist in the intersection of these Qi, receiving its steaming and overflowing influence, entering via mouth and nose to disturb the center, causing loss of ascending and descending control, and failure to distinguish clear and turbid. The expelled substances are the Jin-Ye (body fluids) of the five Zang organs; stopping them urgently is necessary, but this does not mean blocking due to free-flowing symptoms (opposite of Tong Yin Yong Tong). For severe dampness, Weiling Tang (Stomach Calming Decoction) separates Yin and Yang, and summer-heat naturally dissipates; for severe heat, Guiling Ganlu Yin (Cassia Seed and Lingzhi Sweet Dew Drink) clears summer-heat fire, and dampness quietly消 (dissipates). For those with Fire-excess constitutions who have no internal dampness but merely inhale summer-heat pathogens, Baihu Tang (White Tiger Decoction) is suitable. Furthermore, Zang organs differ in Yin and Yang natures. Those with Yin deficiency have Fire hyperactivity; even if cold/raw food is consumed during onset, Chen Pi (Citri Reticulatae Pericarpium) and Hou Po (Magnoliae Officinalis Cortex) should only be used temporarily. Those with Yang deficiency have Damp excess; even cold/moistening items are unsuitable, making Weiling Tang appropriate. Even if the body is extremely emaciated, one should only combine Qi tonification with pathogen clearing. If one ignores the current summer-heat disease due to constitutional deficiency and administers Ding (Caryophylli Flos), Fu Zi (Aconiti Lateralis Radix Preparata), Jiang (Zingiberis Rhizoma), or Gui (Cinnamomi Cortex) formulas, it kills people in the blink of an eye. For summer-heat cholera presenting with fever, irritability, thirst, coarse breathing, panting, and accompanied by cold limbs and restlessness, do not mistake it for a Yin syndrome. Observe that urine must be yellow-red, tongue coating sticky, or white and thick; Ran Zhao Tang (Illuminating the View Decoction) cooled is appropriate.

If the whole body turns blue-purple and death ensues. Even if hands and feet are cold, Qi is short, lips/face/nails are cyanotic, abdominal pain with spontaneous sweating, and six pulses are hidden, but vomit is sour/foul, stool is foul, urine is yellow/red/hot/short, or vomit/stool is clear water but stool burns like fire, or urine is scant/non-existent, these are all Heat hiding in the Jueyin channel. Extreme Heat mimics Yin; quickly prepare Di Jiang (Earth Slurry) and decoct Ye Zhu Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) to take. After vomiting/diarrhea, if the body is ice-cold, pulse deep/almost absent, unable to keep down medicine, or hiccups occur, this is also Heat hiding internally. If doctors fail to notice and administer slightly warm medicine, vomiting worsens. Check for thirst; giving cool water stops it. Then administer Jia Qing Tang (Light Riding Decoction); if pulses gradually emerge, survival is possible. However, summer-heat disease: acute injury causes sudden onset; gradual injury causes slow onset. Thus, in September, many cases of latent summer-heat cholera remain; doctors must know this.

*Jingui Yaolue* states: "Regarding the disease of muscle cramps, if arms and legs are straight, pulses run up and down, slightly wiry, and cramps extend to the abdomen, Ji Shi Bai San (Chicken Droppings White Powder) is the main treatment."

Liu Shouzhen said: "Turning and twisting is caused by heat scorching sinews, leading to spasms and pain. To attribute it to cold invading sinews is wrong. Cold governs contraction and pulling, causing cold limbs and stiffness, limiting flexion and extension, but how can it cause 'turning'? Turning implies movement. Yang moves, Yin is still; this proves Heat. Muscle cramps are mostly caused by severe Heat from cholera vomiting/diarrhea. Because Spleen/Stomach Earth declines, Liver Wood overacts, and heat scorches sinews, causing cramps. Thirst indicates Heat; there has never been a case of cholera cramps without thirst."

You Zhuowu said: "Liver governs sinews, corresponding to Wind-Wood. Liver disease generates Wind, causing cramps. Arms/legs straight, pulses running up/down, slightly wiry. The Classic says: 'All sudden strong rigidity belongs to Wind.' Cramps extending to the abdomen indicate Spleen Earth deficiency allowing Liver Wood to invade. Chicken is a Wood animal; its droppings are slightly cold and can dispel wind-damp to benefit Spleen Qi, hence used for this disease."

Zhang Shiweng said: "Vomiting and diarrhea are changes of Damp Earth; cramps are changes of Wind Wood."

When Damp Earth is overcome by Wind Wood, it becomes cholera with cramps; Pingwei San (Peace the Stomach Powder) plus Mu Gua (Chaenomelis Fructus) is the main treatment. Any hint of thirst indicates latent Heat. All drying-hot drugs like Bai Zhu, Fu Zi, Jiang, Gui, if taken by mistake, cause death. Even Gui (Cinnamon Twig) in Wuling San should be used cautiously. Wang Shixiong's Note: Zhang's words hit the nail on the head. Although Zhang Zhongjing established the rule "Heat predominance with desire to drink water, Wuling San governs," the preceding text mentions headache and aversion to cold (exterior signs), indicating it is still Typhoid Cholera, thus using a dual-release method. For those with exterior signs but not Wind-Cold pathogens, or no exterior signs but severe heat/thirst, how can one rigidly stick to established methods without flexibility, merely using the Sage as an excuse? (Thorough understanding of ancient usage is true scholar talk. Dingzhou, Yang Zhaoli notes.)

Xue Yipiao said: "Wind is born from Fire; Fire follows Wind. Entering Yangming causes vomiting; attacking Taiyin causes diarrhea; this is named Cholera. Penetrating sinews causes spasms; flowing into collaterals causes opisthotonos; this is named Spasm (Jing). Therefore, I say Spasm and Cholera share the same source, but Spasm often involves Jue (collapse), while Cholera rarely does. Spasm involves Wind-Fire closure/depression; depression makes rebellion more rampant, disturbing the Spirit, hence often Jue. Cholera involves Wind-Fire external release; release spreads evil outward, preventing meridian invasion, hence less Jue. This distinguishes Spasm and Cholera. However, Spasm evil stagnates in Sanjiao (Fire transformation); Wind gets fanned by Fire, pressing into Danzhong causing sudden Jue. Cholera evil travels through Spleen/Stomach (Damp transformation); evil stays due to Damp, spreading to meridians causing cramps. Fire depression causes Jue; Fire wandering causes cramps, further consequences of Spasm and Jue. Spasm cramps are Damp-Heat generating Wind; Cholera cramps are Wind overcoming Damp (Wood overacting on Earth). Spasm goes from Meridian to Zang then Jue; Cholera goes from Zang to Meridian then cramps. Ultimately due to Damp-Heat and Wind..."

Jue without return is death. Dryness of Stomach fluids indicates Fire evil entrenchment. Cramps extending to abdomen is death. Internal depletion of Stomach fluids, Wind evil alone is vigorous. Thus, the role of Stomach Jin-Ye is indeed significant! Jue syndrome uses Acrid-Opening to drain formless evil in Chest. Gan Cholera uses induced vomiting to drain有形 (form-solid) stagnation in Stomach. However, draining evil without rising Stomach fluids intensifies Heat. Induced vomiting without distributing Stomach fluids exacerbates Wind. Both lead to death; this must be known.

Wang Shixiong's Note: Cholera usually has more Damp than Heat; this is the norm. But cramps indicate Wind born from Fire, with momentum to overcome Damp and seize fluids. Since my childhood... must be severe. Starting late summer/early autumn, lasting until after Start of Winter. How can Damp come from lingering summer heat? Only because modern people retain much Damp, allowing summer-heat pathogens to lie deep. When suddenly erupting, it spreads house-to-house/village-to-village like plague. Doctors, unaware of the origin, randomly prescribe Lizhong Tang (Regulate the Middle Decoction) or Sini Tang (Reverse the Extremity Decoction), truly lamentable! Whenever I cure this, I ask: "Were you completely healthy before illness?" Some say: "Days before illness, palms/soles felt like burning irons." Others: "Before illness, everything looked red like fire." Alas! Isn't this latent summer-heat revealing itself before eruption? If wise men could plan early (curtail chimney/remove firewood), how would it reach uncontrollable prairie fire? Judging life/death by Stomach fluid survival is profound insight; ignorants recklessly use drying-hot drugs, assisting cruelty in scorching fluids, reading father's books in vain—worth weeping! (Daoguang Year 1, this disease raged across provinces; awareness of cramps meant immediate death. Capital ran out of coffins, bodies wrapped in mats buried. No one knew the disease; folk rumor said eating watermelon caused death, so watermelon was cheap. I was eleven, ate watermelon daily with classmates, remained safe. Reading this now, medical ignorance isn't just today's problem. Suyuan Yang Zhaoli notes.)

(Yang's argument is very correct. I also ate watermelon daily that year, and my family didn't get sick, proving his point. However, some cholera patients that year died after mistakenly eating watermelon, witnessed by friend Dong Zhufan. These were cases suitable for Xiangru, but misled by spirit-writing, causing death by cold suppression. This too must be known. Thus, prescription and treatment require differentiation. In Part 2 of this treatise, 'Frequent Sweating' in treatment/watermelon juice sections is most accurate. Wucheng Wang Yazhen Xie Cheng.)

Wang Qingren said: "In Daoguang Year 1, vomiting/diarrhea/cramps affected several provinces, especially the capital, killing many. The poor couldn't afford burials; state funds provided coffins, costing hundreds of thousands of taels in a month. Doctors then claimed either Yin-Cold or Fire-Toxin. I said: Regardless of gender/age, everyone having the same disease is Plague (Epidemic) (Profound insight). Some asked: If it's plague, why did Huang Qin (Scutellariae Radix), Lian (Scutellariae Baicalensis Radix), Jiang, Fu work? Look at the blood flow—it's purple-black. Isn't this Plague Fire-Toxin penetrating Ying (Nutrient) level? Plague pathogens enter via mouth/nose, travel through air tubes to... named Jinmen (Gate of Fluids). On Jinmen is a tube named Jinguan (Tube of Fluids), the path for Stomach essence/fluids.) Water cannot exit, hence upper vomiting/lower diarrhea. At onset, prick Chize (LU-5) acupoint immediately to bleed purple-black blood, releasing toxin gas. Human air tubes connect throughout body; blood vessels also connect throughout. Pricking 4-5 vessels around Chize bleeding all cures. Pricking above/below Chize also cures. Simultaneously needle and treat with detoxifying/blood-invigorating herbs."

Wang Shixiong's Note: Mr. Wang saw viscera personally and excelled in acupuncture; his theories are credible, not speculative. Though medication wasn't his strength, using "Detoxify and Invigorate Blood" as the guideline shows profound vision.

*Buwang Lun* states: "Of the Five Confusions in *Lingshu*, only confusion in intestines/stomach is named Cholera, causing vomiting/diarrhea. The other four don't cause vomiting/diarrhea, just called Confused Qi. The ailment of Liu Zongyuan was likely Confused Qi affecting Heart, not Cholera."

Calling it Gan Cholera is wrong, but it remains one of the Five Confusions; today, no one knows the name Confused Qi.

*Zhifa Hui* states: "Gan Cholera, colloquially Jiao Chang Sha (Intestine-Twisting Sha). Symptoms: desire to vomit but can't, desire to defecate but can't, chaotic turmoil. Urgently induce vomiting; survival depends on vomiting, otherwise death. The Classic says: What enters must exit. Now it enters but can't exit, causing blockage, mostly fatal. After vomiting, regulate Qi and harmonize middle, treating according to syndrome. *YiTong* states: Gan Cholera is Earth stagnation failing to vent, internal blazing fire, Yin/Yang not interacting."

Question: Formulas say old food fights cold Qi, why single out Fire? Answer: Mental confusion/restlessness belongs to Fire's restlessness/manic deviation? Often causing sudden death, belonging to Fire's acute/sudden death? Over-attacking hurts Spleen Qi; over-warming ignites Fire; over-cooling...

This disease has various causes. Sudden dietary injury: induce vomiting. Old food stagnation: resolve/digest. Qi stagnation/pathogen invasion: vent/open. Summer-fire direct invasion: clear/resolve. Methods listed below; users examine carefully.

(Considering rejection, use counter-agent therapy—true refined words. Guiling Ganlu Yin treats Heat but uses Gui; Tongmai Sini Tang treats Cold but uses Pig Bile, both follow this principle. *Mengying* treating Granny Chen: Gypsum, Qin, Lian plus少许 (a little) Xi Xin; Ran Zhao Tang using Dou Kou Ren (Cardamomi Fructus), also this principle. If Cold uses Qin/Lian, Heat uses Jiang/Fu, it opposes the disease, not counter-agent principle. Xie Cheng.)

Also states: Spleen/Stomach likes aromatic-dry, dislikes foul-damp. If prone to Damp-stagnation and encounters foul Qi, Righteous Qi is depressed, abdominal pain arises. Pain may connect to head/forehead or lower back/legs. Some die of pain unconscious, then recover; some have constant upper-rushing abdominal pain, unable to eat/drink, lasting days. Even desire to vomit/defecate but can't, or cold limbs, cyanotic face, hidden pulse, or full-body high fever, purple face, firm pulse—all if chewing raw soybean tastes sweet, it is Foul Toxicity (Chou Du). Urgently induce vomiting with burnt salt, or use Child's Urine processed Xiang Fu (Cyperi Rhizoma) 4-5 qian powder, taken with stopped soup—most effective. Worldly methods include water draping shoulders/back/arms, ramie water scraping, porcelain bowl oil scraping, porcelain needle pricking Weizhong (BL-40) bleeding—all intend to open pores. Pulses mostly hidden, or fine/small/tight/astringent, or firm/beating finger, with intermittent/interrupted beats—all images of Yin rebellion/Yang hiding. Do not mistake for Yin-Cold and give Heat drugs; even Sha Ren (Amomi Fructus) Acrid-Warm-Aromatic should not be lightly used. If face cyanotic, lips black, pulse firm/beating, Jue/panting, mostly incurable.

Also states: Touching foul smell, abdominal pain/vomiting, scraping back reveals red spots, colloquially Sha. Severe cases: desire to vomit/defecate but can't, dry retching/pain, called Jiao Chang Sha. More severely, sensing toxic strange Qi suddenly causes Black Sha, colloquially Fan Sha. Sudden collapse, abdominal pain, face... sweating, or faint spots appear, this is Toxic Evil emerging on Exterior. Also emergence with diarrhea/Jue, abdominal distension/no pulse, this is Toxic Evil hiding internally, unable to emerge externally. Most sufferers die before spots appear. Classic says: Large Qi enters Zang-Fu, sudden death without prior illness. Upon first feeling, dip paper twist in head/forehead, then roast buckwheat, remove husk, take 3 qian powder, mix with cool boiled water; severe cases repeat shortly for relief. Buckwheat refines intestinal waste, descends Qi, widens chest, treats turbid stagnation, specific drug for Sha toxin. Severe toxicity/black face: urgently prick Weizhong (BL-40) behind knees, bleed black blood to drain toxin. For sudden diseases, don't worry about deficiency; without this urgent draining, hands tied waiting for death. Originally this disease resembles Foul Toxicity, similar to Cholera, being the most severe Epidemic. Onset: coma/unconscious, pulses mostly deep/hidden/unclear. Don't give Warm drugs for abdominal pain/cold feet... Prioritize regulating Qi, e.g., Xiang Su San plus Bo He (Menthae Haplocalycis Herba), Jing Jie (Schizonepetae Spica), Acrid-Cool releasing Exterior; next, dispel evil is key, e.g., Zhi Zi Chi Tang plus Niu Bang Zi (Arctii Fructus), Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma), detoxify/harmonize middle. Strong Exterior Heat urgently clear Heat, e.g., Huang Qin Tang plus Lian Qiao (Forsythiae Fructus), Mu Tong (Akebiae Caulis), separate Yin/Yang. If irritability/abdominal distension, rapid pulse, urgently give Liang Ge San, replace Sheng Jiang (Zingiberis Rhizoma) with Zhu Ye (Phyllostachdis Folium), toxin drains downward. Severe Heat/coma, even San Huang (Three Yellows) mostly incurable. Irritable/thirsty drinking, enuresis, quickly clear Yangming, Baihu Tang plus Cong Chi (Scallion and Soybean Decoction), toxin transforms via Exterior. Deep red spots, toxin in Blood level: decoct Yi Mu Cao (Leonuri Herba) thick, add少许 (a little) raw honey, warm freely, fastest effect. Specifically removes bad blood; or add half cup raw Lu Bo (Raphani Semen) juice, total goal is dispersing blood. Above methods, if no mistaken drugs, maybe save one or two. Saw a merchant, new to Wu-Huai, drank/sang, suddenly uneasy at table, asked for Ginger Soup, drank and died. Another northern traveler, went to Feng for bath, suddenly dizzy/vomited, died on boat (Those sensing summer-heat/foul plague evils strictly avoid hot baths). More mistaking Typhoid, giving Fa Han (Releasing Exterior)... (Also mistaking Cold for Heat, nose/mouth bleeding to death). Changes happen in flip of hand, unlike seasonal流行的 (epidemic), which can linger days.

Shanghai is merely a coastal town. Twenty years, frequent wars, sea changing to mulberry fields, foreign management expanding, Jiangsu becoming metropolis. But dense population, hotter earth Qi, dense houses, stronger foul Qi, rivers near city hide filth, water foul/unbearable. This summer, I fled here,恰逢 (coincidentally) Cholera/Foul Toxicity/Fan Sha prevalent, and "Foul Toxicity" hits this location's cause precisely. Alas, doctors...