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Feeling at a loss, some people even instructed patients to first consume a cup of ginger juice; others used large doses of warming and tonifying medicines as the main treatment. These prescriptions were printed and posted all over public thoroughfares. Believing in them, patients' families resulted in thousands of deaths daily, with corpses lying along the roadsides. Wu Ju from Qiantang, a scholar named Tan Maocai, told me that he witnessed a person die from bleeding out of all seven orifices. Hearing this, he felt deeply sorrowful, wondering if this was merely the result of a calamitous fate.

*Yu Heng* states: Cases presenting with vomiting and diarrhea preceding heart and abdominal pain are mostly caused by foul qi (pathogenic noxious factors); cases presenting with heart and abdominal pain preceding vomiting and diarrhea are mostly caused by summer-heat qi. However, cholera-like syndromes characterized primarily by vomiting and diarrhea result from summer-heat and dampness-noxieties injuring the Qi level (Qi Fen). It is appropriate to scrape the skin with salt and oil so that Sha toxins do not penetrate inward. If there is chest and epigastric distension and oppression, abdominal pain, feeling as hard as a board, as tight as being bound by a rope, as if tendons are pulling, or as if pierced by awns and knives, despite extreme pain but without vomiting or diarrhea, it is named Dry Cholera (Gan Huoluan). This indicates that the pathogen has entered the Ying (Nutritive) level. It is appropriate to prick the skin to release blood, allowing the toxin to be discharged. Thereafter, one should re-examine the etiology and prescribe medication accordingly. If Sha distension is extremely severe, making scraping and pricking difficult, one must first use medicine to revive the patient before life can be saved. Understanding these three methods allows for near-perfect efficacy.

Wang Jin San stated: Sha syndromes can be caused by cold, heat, or dampness. It may be cold-dampness of the four seasons stagnating in the collaterals; or damp-heat of summer obstructing the meridians; or inhaling foul odors blocking the flow of meridian Qi; or internal accumulation obstructing Fu organ Qi. All these can cause rebellious Qi in the stomach and epigastrium, leading to distension and pain, even to the point of fainting and desire to die. People in the northwest whip their abdomen with willow branches dipped in hot water, calling it "Beating Cold Sha." People in the southeast scrape their chests, backs, and arms with oil bowls or oil threads, calling it "Scraping Hand Sha." They then take Yushu Dan to treat the interior. These methods all open external and internal orifices to vent Qi, allowing blood and Qi to circulate normally, resolving distension. This is essentially Cholera, not a separate "Sha pathogen."

My Case Note: Medical texts never mention the name "Sha Syndrome." Only Dry Cholera has the vulgar name "Intestine-Twisting Sha." Thus, the secular concept of "Sha" has an unknown origin. *Zhi Yi Shuo* first recorded Ye Tianshi's method of using silkworm pupal casings to treat Sha. Since silkworms have properties to resolve phlegm, dispel wind, and open orifices, and the paper is salted, it descends rapidly. Jiang Minying mistakenly interpreted this as treating exterior syndromes, though ridiculed by Hang Jinping, it shows that Sha syndromes were rare previously, hence ancient texts omitted detailed descriptions. By the early Qing dynasty, the disease became prevalent, spreading from north to south, leading to names like "Manchu Disease" and "Foreign Sha." Guo Shi, influenced by Gong Yunlin's theory of green veins, wrote *Sha Zhang Yu Heng*, attributing it to foul pathogens. Wang Jin San further clarified that "Sha" refers to sudden invasion of exogenous pathogens blocking the flow of healthy Qi, clarifying the pathology of Sha. For individuals with emotional depression, slight exposure to cold or heat can induce Sha, which recurs frequently due to impaired circulation of Qi and Blood. Although You Tao had formulas to stop Sha, the medication... [Text fragment]

Long Qingfei of Changzhou, in *Mai Xue Lian Zhu*, stated: Sha distension syndromes mostly involve the Extraordinary Vessels. The Extraordinary Vessels are tributaries of the Twelve Regular Meridians. When clear Qi of the Zang organs fails to ascend and turbid Qi of the Fu organs fails to descend, it is like lakes and rivers overflowing, mixing clear and turbid waters, causing mud and silt to churn, blocking channels. Hence the name "Sha Distension." "Sha" resembles sand rising. It results from the failure of the Twelve Meridians to distinguish clear from turbid, leading to overflow into the Extraordinary Vessels, manifesting as Sha syndromes. Pathogens stagnate in the meridians, unrelated to the Zang-Fu organs directly. One should not merely attack the organs with herbs. Instead, use lifting and scraping methods, and needling, to unblock the meridians first, then administer medication for effective results.

My Case Note: This theory seems novel yet accurate. Once meridians are unblocked, recovery may occur without medicine. However, one must worry that pathogens may gradually affect the Zang-Fu organs, rendering scraping and pricking insufficient. It is like a strategic pass occupied by bandits; mere defense is inadequate.

*Yi Zhen Yi De* states: In the initial stage, if the six pulses are fine, rapid, deep, and hidden, the complexion is dark blue and grim, the patient is confused and dazed, limbs are cold, head sweats profusely, pain feels like splitting, abdominal pain is churning, with inability to vomit or defecate, this is called "Stifling Plague" (Men Yi). Death occurs within half a day.

"Stifling" means heat-toxin is deeply concealed internally and cannot vent outward. As it sinks deeper, entering the Zang organs, death ensues quickly, often within a day. Regarding treatment, it is appropriate to needle Qu Chi (LI11) and Wei Zhong (BL40) to vent toxins from the Ying level; then administer Zi Xue (Purple Snow) to clear and penetrate concealed pathogens, facilitating their outward release, which might save the patient.

(Excellent treatment method. Commented by Suyuan.)