呕吐，或吐出长虫，急宜白虎加黄连，虽严寒之令勿避也。
前二证，一经帮助，不难分辨。复有火毒本甚，外感寒邪，外虽寒而中实热，又宜表里双解。古人有麻黄石
膏汤，余仿其法，全活甚多。又有火毒本甚，父母只知郁遏，医家只知表散，内外交炽，火极似水，反生厥逆
之象者，书谓热深厥亦深是也，宜白虎汤加黄连。若作寒治，殆矣。
治痧疹有三法∶一升散，一降火，一养阴。善用者，升散之中，即寓清凉之意；养阴之剂，不离生发之机。
痧点隐隐未透，发热咳嗽，有涕泪，宜升散；两颊不透，宜升散；发热肢冷，面不赤，唇不燥，宜升散；
喘促鼻煽，辨得是表邪，宜升散；泄泻日五六行，宜升散。
痧疹已出，壮热不退，宜降火；呕吐烦渴，吐出长虫，宜降火；不食宜降火；热盛烁金而喘，宜降火；鼻
衄宜降火；小便不利宜降火；喉痛腮肿，牙痛口疮，宜降火；牙疳臭烂，宜降火。
痧疹三四日后，大热不退，宜养阴；紫点不收，宜养阴；脉来数大，宜养阴；夜热心烦 齿，宜养阴；音
哑不清，宜养阴；目赤羞明，宜养阴；身痒便燥，宜养阴。
宜升散而不升散，重则顷成喘闭，轻则余毒淹缠。宜降火而不降火，则肺胃受伤，或音哑烦渴，或牙疳口
疮。宜养阴而不养阴，则午后潮热，肌肤瘦削，渐成疳证。
痧出总要表透，表一透，里热虽甚，清之可愈。表未透，毒陷于中，门户一关，发表不可，养阴又不可，多
致因循而死。
表透者，非皮毛之表，要从脏腑透。出没得从容，才得表透。亦有火毒甚，外见繁红，没后犹作牙疳肺痈
者，或鼻衄下痢者，脏腑之毒未透出也。
痧痘之毒由脏腑而出，虽已到表而根蒂在里。解字从表，化字从里。表虽解而里不化，其为后患实多。
肺主皮毛，痧疹虽出于六腑，必从皮毛而解，故不离乎肺。解之不透，久咳潮热，累成痧疳。此疳字非疳
积之疳，因其潮热肌瘦，有似乎疳耳。治宜润肺为主，辛燥药用不得。
解表之药从阳分从气分，其效速而易见。化毒之药从阴分从血分，其效缓而难成。《金镜录》养阴退阳四
字，治痧之要诀也。
养阴退阳，书用四物汤，余少时常习用之，多不获效，以归芎辛温之性为不合也。因制生
地、丹皮、麦冬、赤芍为痧疹四物汤，节节应手。古方不必尽泥，师其意可也。
痧后潮热，最为可嫌。发在午后，天明退凉。退时脉平静，发时脉数大。唇红舌赤而无苔，切牙揉鼻人渐
瘦，每多不治。间有能食者，大剂养阴，可救一二。
胃为受毒之壑，遗热甚多，其急莫如牙疳，牙疳是失清之证，必须大剂清里。若便闭者可下之，使热毒
内泄，与痘后同治，余有勒马饮方。甚者加大黄急下之。稍迟不但齿落腮穿，更
有唇鼻皆烂者，涂药不过帮扶而已。
痧后音哑者，多由火甚伤金，治宜甘、桔、牛蒡、山栀之属。痧后口疮治法同牙疳臭烂，与痘后同治。往
年痧疹多不损目，迩来有损目者。其来甚速，二三日间，翳膜遮透，即不能治。缘儿本有肝热，更加郁遏，或病家
不知是火，饮以芫荽酒，遂令热毒攻目。速宜清凉养阴退阳，不可再行疏散。
痧后咯吐脓血腥臭，有肺痈者，有胃痈者，皆肺胃遗毒为患。循经而出则为牙疳，着于脏腑则为痈也。治
当辨其在肺在胃，余用甘、桔、牛蒡、银花、料豆、枳壳、赤芍数味，在肺加山栀、贝母、桑皮，在胃加生地、
花粉、木通以佐之，身无大热者可治。
问∶牙疳、肺痈可治者何也？此毒已化而出也。毒化而脏腑不败者可治，脏腑败者不能治也。
大人出痧疹十中二三，多有房室经产之患，大概轻轻一散，即宜养阴。麻黄、升麻、羌活等味，俱当慎用。
霖按∶叶、许二君之论，审证定变，各有心传，真绿文赤字之书，读者当细心领会，作治疹圭臬，不可忽
也。若泥执不化，率尔操觚，又为二君之罪人矣。
吴鞠通曰∶若明六气为病，疹不难治。但疹之限期最迫，只有三日，一以辛凉解透为主，如俗所用防风、
广皮、升麻、柴胡之类，皆在所禁。世俗见疹必表，外道也。大约先用辛凉清解，后用甘凉收功。赤疹误用麻
黄、三春柳等辛温伤肺，以致喘嗽欲厥者，初用辛凉加苦桔梗、旋复花上提下降，甚则用白虎加旋复花、苦杏
仁，继用甘凉加旋复花以救之，咳大减者去之。凡小儿连咳数十声不能回转，半日方回，如水鸡声者，千金苇
茎汤合葶苈大枣泻肺汤主之。近世用大黄者，杀之也。盖葶苈走肺经气分，虽兼走大肠，然从上下降，而又有
大枣以载之缓之，使不急于趋下；大黄则纯走肠胃血分，下有形之滞，并不走肺，徒伤其
无过之地故也。若固执病在脏泻其腑之法，则误矣。
章虚谷曰∶每见治疹 ，起首必用升麻葛根汤，世俗相沿，牢不可破。虽升散其毒不为大害，但止见其标
不察其本，或证不应药则茫然莫知其故。是以有屡用升提表散而 不出，竟不知其脏气怯弱不能传送毒瓦斯，徒用
表药，耗散卫气，毒更难出。或本无寒邪外闭腠理，而妄用麻黄大泄肺气，至于鼻煽而喘，毒伏心肾，烦扰不
安而死。医者卒不悟其所以然，良由平日认定疹出于腑，及 毒在皮毛肌肉等说。既不究胎毒发源传化之由，
而见内毒不能外达者，反认作外毒内陷而谓无法可治。试思 毒如果本在肌肉，初治莫不先用升提表散其 ，
岂有不出之理？即或有外邪内食阻滞，亦必有证可辨，治之何难？其毒即非由脏而发，则脏气本和，又用升表
之药，岂有外毒内陷之事乎？殊不知脏气不能送毒传化，虽用升表无益；而非外毒内陷，实是内毒未出。乃
平素未明此理，亦可慨也。且起首必用升葛汤为定法，则不独未明疹 源流，并将斑疹混而不分矣。汪 庵
升葛汤歌曰∶斑疹已出慎勿使。可见将斑疹混治已久。世俗熟诵《汤头歌》，授受流传，以为定法，更无疑议。
而不思升麻葛根，阳明之药也，阳明主肌肉，邪热闭郁则成斑。斑者赤色成片，或如锦纹，扪之无形，不成颗
粒。若未发透而用表散，则宜升葛汤。已发透而清里，当用白虎汤。或兼内实积滞，宜承气汤。至于疹 ，虽
有外感风温，胎毒内发之殊，然皆由心肺两经从营出卫，为血络中病。因从毛窍而出，故有颗粒，与斑之由阳
明而发于肌肉者迥异，奈何不分脏腑经络，而以治斑之药治疹，已非对证，而更不明疹 之源流传化，欲求治
法之善以愈病，不亦难乎？因其脏气无亏，已经送毒外出，得升散之药，因势导之而成功者多，遂笃信初治
必用升提表散，终不自觉法之未善。或遇脏气怯弱，内毒
不能外达，皆认作外毒内陷，归于不治也。若知源流所自，辨其由外感由胎毒之殊，而按时透发者，原可不药
而愈。或不能透发，则必审其所因，或因外邪闭遏，或因内食阻滞，或因元气怯弱，或宜升散，或宜通利，或
宜补托，随证而施，则断不可拘执先用升散为定法也。岂可囿于前人之说，而不准之以理乎？明医者，倘不以
余言为河汉，或可备刍荛之采。有司命之责者，胡可忽哉。
霖按∶章氏此论，深明慎发表之义。其案中治禀气怯弱，不能送毒外达之证，于辛凉透发剂内重加玄参；
遇元阳不足者，则凉透中稍佐附子，皆有卓见。较冯楚瞻之全真一气汤，精当多矣。
先哲论治病须辨三因，察六气。愚意三因既辨，六气已包括于中。痧疹伏毒为时厉感召，若能详辨其内外
二因，可不致操刃杀人。所谓内因者，命门伏藏胎毒是矣。然禀赋不一，未可拘牵。或多实热，或本虚寒。或
脏气怯弱，表散太过，则火盛伤金；或腠理致密，失于宣托，则毒难外达。或贪房室，少阴不藏；或缘病后，
元阳未复。或为痰滞，或为食积。或因劳伤而蓄血，或因生冷而损脾。或苦寒过剂，可温补暂投；或辛燥劫津，
而养阴难缓。所谓外因者，风寒暑湿燥火是矣。然须先明大运之转移，后察当年司天在泉，及主客气运之偏
胜。惟是木火当旺，或多淫雨严寒；水土司权，常见飙风燥热。亢害承制，救弊补偏，要未可一概论也。人之
禀受不同，治法亦当各异。宜表宜清，宜攻宜补，辨明所因，庶免虚实寒热之误。张石顽曰∶古人成法，虽当
参详诊切，仍不能舍其绳墨。临证之机，活法在乎心手，而绳墨又不可拘也。此千古不易之论，岂独痧疹为然哉。
呕吐，或者吐出蛔虫，应当紧急使用白虎加黄连汤，即使是严寒季节也不应避忌。
前两种证候，一旦加以辨析帮助，就不难分辨。又有火毒原本就很严重，又外感寒邪，外表虽然寒冷而体内实则热盛，适宜表里双解的方法。古人有麻石膏汤（注：此处原文为“麻黄石膏汤”，疑为笔误或特定方名，依文意理解为具有发表清里作用的方剂），我仿照其法治疗，救活了很多病人。又有火毒原本就很严重，父母只知道郁遏病邪，医生只知道发散解表，导致内外邪气交相炽盛，火极似水，反而出现四肢厥逆的现象，医书称之为“热深厥亦深”，适宜用白虎汤加黄连。如果当作寒证治疗，那就危险了。
治疗痧疹有三种方法：一是升散透发，二是降火清热，三是滋养阴液。善于运用的人，在升散之中，就蕴含清凉之意；在养阴的药剂中，不离生发之机。
痧点隐隐约约尚未透出，伴有发热咳嗽，有鼻涕眼泪，适宜升散；两颊部位痧点不透，适宜升散；发热但四肢冰冷，面色不红，嘴唇不干，适宜升散；气喘急促、鼻翼扇动，辨别清楚是表邪所致，适宜升散；腹泻每天五六次，适宜升散。
痧疹已经发出，高热不退，适宜降火；呕吐烦躁口渴，吐出蛔虫，适宜降火；不能进食，适宜降火；热盛灼伤肺金导致气喘，适宜降火；鼻出血，适宜降火；小便不利，适宜降火；喉咙痛、腮部肿胀、牙痛、口疮，适宜降火；牙疳恶臭腐烂，适宜降火。
痧疹三四天后，大热仍不退，适宜养阴；紫红色痧点不收敛，适宜养阴；脉象来势数而大，适宜养阴；夜间发热心烦、牙齿不适，适宜养阴；声音嘶哑不清，适宜养阴；眼睛发红怕光，适宜养阴；身体瘙痒、大便干燥，适宜养阴。
应当升散而不升散，重的则顷刻间形成喘闭，轻的则余毒缠绵不去。应当降火而不降火，则肺胃受伤，或者声音嘶哑、烦躁口渴，或者牙疳、口疮。应当养阴而不养阴，则午后潮热，肌肤消瘦，逐渐形成疳证。
痧疹发出总要透达体表，表气一透，即使里热很盛，清热即可痊愈。表气未透，毒邪陷入体内，门户关闭，此时发表不可行，养阴也不可行，多导致因循延误而死。
所谓表透，并非指皮毛之表，而是要从脏腑透发。出疹和没疹从容有序，才算是表透。也有火毒很盛，外表呈现繁多的红疹，疹退后仍然发生牙疳、肺痈的，或者有鼻衄、下痢的，这是脏腑之毒未能透出的缘故。
痧痘的毒邪由脏腑而出，虽然已经到了体表，但根蒂仍在体内。解字侧重于从表解除，化字侧重于从内部化解。表虽已解而里毒未化，其后患实在很多。
肺主皮毛，痧疹虽然出于六腑，必须从皮毛而解，所以离不开肺。解表如果不透彻，久咳潮热，累积成痧疳。这个“疳”字不是疳积的疳，是因为潮热肌瘦，看起来像疳证罢了。治疗宜以润肺为主，辛燥的药物不能用。
解表的药物作用于阳分、气分，见效快且容易看到效果。化毒的药物作用于阴分、血分，见效慢且难以成功。《金镜录》中的“养阴退阳”四个字，是治疗痧疹的要诀。
养阴退阳，书中使用四物汤，我年轻时经常习用，大多不获效，因为当归、川芎辛温的性质不合适用于此。因此我配制生地、丹皮、麦冬、赤芍作为痧疹专用四物汤，节节应手，疗效显著。古方不必完全拘泥，学习其用意即可。
痧疹后的潮热，最为令人厌恶。发作在午后，天亮后退去变凉。退去时脉象平静，发作时脉象数大。嘴唇红、舌赤而无苔，磨牙揉鼻，人逐渐消瘦，大多难以治愈。间或有能吃饭的，用大剂量养阴药，可以挽救一二。
胃是受毒的壅滞之处，遗留的热邪很多，其中最急迫的是牙疳。牙疳是失于清热的证候，必须用大剂量清里热的药物。如果大便闭塞的可以攻下，使热毒内泄，与痘疹后的治疗方法相同，我有勒马饮方。严重的加大黄急下之。稍晚一点不仅会导致牙齿脱落、腮部穿孔，更有嘴唇鼻子都腐烂的情况，涂药不过是辅助扶持而已。
痧疹后声音嘶哑的，多由火盛伤肺金所致，治疗宜用甘草、桔梗、牛蒡子、山栀等药物。痧疹后口疮的治疗方法同牙疳臭烂，与痘疹后治疗方法相同。往年痧疹多不损伤眼睛，近来有损伤眼睛的。发病很快，两三天间，翳膜遮盖瞳孔，就不能治愈了。这是因为孩子本来就有肝热，再加上郁遏，或者家属不知道是火邪，饮用芫荽酒，致使热毒攻目。速宜用清凉养阴退阳的方法，不可再行疏散。
痧疹后咯吐脓血腥臭，有肺痈的，有胃痈的，都是肺胃遗留的毒邪为患。顺着经络而出则为牙疳，附着于脏腑则为痈。治疗应当辨别是在肺还是在胃，我用甘草、桔梗、牛蒡子、金银花、料豆、枳壳、赤芍几味药，在肺的加山栀、贝母、桑白皮，在胃的加生地、花粉、木通来佐助，身体没有大热的可以治愈。
问：牙疳、肺痈可治的原因是什么？这是因为毒邪已经化解并排出体外。毒邪化解而脏腑未败坏的可治，脏腑败坏者不能治。
成年人出痧疹的十中二三，多有房事、经期、产后的病患，大概轻轻一散，就应立即养阴。麻黄、升麻、羌活等药物，都应当慎用。
叶霖按语：叶、许两位君子的论述，审察证候确定变化，各有心得传承，真是珍贵的书籍，读者应当细心领会，作为治疗疹病的准则，不可忽视。如果固执不知变通，轻率用药，又是这两位君子的罪人了。
吴鞠通说：如果明了六气致病，疹不难治。但疹的限期最紧迫，只有三天，一以辛凉解透为主，如世俗所用的防风、广陈皮、升麻、柴胡之类，都在禁忌之列。世俗见到疹必用表法，这是外道。大约先用辛凉清解，后用甘凉收功。赤疹误用麻黄、三春柳等辛温药物伤肺，以致气喘咳嗽欲昏厥的，初用辛凉加苦桔梗、旋覆花上提下降，严重时用白虎汤加旋覆花、苦杏仁，继用甘凉加旋覆花来救治，咳嗽大减的去除旋覆花。凡是小儿连咳数十声不能回转，半日才回，像水鸡叫声的，用千金苇茎汤合葶苈大枣泻肺汤主治。近世用大黄的，是杀之也。因为葶苈走肺经气分，虽然兼走大肠，但是从上下降，而且有大枣承载缓和它，使其不急于趋下；大黄则纯走肠胃血分，下有形之滞浊，并不走肺，徒然伤害无辜的地方罢了。如果固执病在脏泻其腑的方法，那就错了。
章虚谷说：每见治疗疹病，起首必用升麻葛根汤，世俗相沿成习，牢不可破。虽然升散其毒不为大害，但只看到表象不考察根本，或者证候不应药则茫然不知其原因。因此有用屡次升提表散而疹出不出的，竟不知其脏气怯弱不能传送毒瓦斯，徒用表药，耗散卫气，毒更难出。或者本无寒邪外闭腠理，而妄用麻黄大泄肺气，至于鼻煽而喘，毒伏心肾，烦扰不安而死。医者最终不明白其中的原因，良由平日认定疹出于腑，以及毒在皮毛肌肉等说法。既不探究胎毒发源传化的由来，而见内毒不能外达者，反认作外毒内陷而谓无法可治。试思考，毒如果本在肌肉，初治莫不先用升提表散其毒，岂有不出之理？即使或有外邪内食阻滞，也必有证候可辨，治之何难？其毒即非由脏而发，则脏气本和，又用升表之药，岂有外毒内陷之事乎？殊不知脏气不能送毒传化，虽用升表无益；而非外毒内陷，实是内毒未出。乃平素未明此理，亦可慨叹。且起首必用升麻葛根汤为定法，则不独未明疹之源流，并将斑疹混而不分矣。汪昂《升葛汤歌》说：“斑疹已出慎勿使。”可见将斑疹混治已久。世俗熟诵《汤头歌》，授受流传，以为定法，更无疑议。而不思升麻葛根，阳明之药也，阳明主肌肉，邪热闭郁则成斑。斑者赤色成片，或如锦纹，扪之无形，不成颗粒。若未发透而用表散，则宜升葛汤。已发透而清里，当用白虎汤。或兼内实积滞，宜承气汤。至于疹，虽有外感风温、胎毒内发之殊，然皆由心肺两经从营出卫，为血络中病。因从毛窍而出，故有颗粒，与斑之由阳明而发于肌肉者迥异，奈何不分脏腑经络，而以治斑之药治疹，已非对证，而更不明疹之源流传化，欲求治法之善以愈病，不亦难乎？因其脏气无亏，已经送毒外出，得升散之药，因势导之而成功者多，遂笃信初治必用升提表散，终不自觉法之未善。或遇脏气怯弱，内毒不能外达，皆认作外毒内陷，归于不治也。若知源流所自，辨其由外感由胎毒之殊，而按时透发者，原可不药而愈。或不能透发，则必审其所因，或因外邪闭遏，或因内食阻滞，或因元气怯弱，或宜升散，或宜通利，或宜补托，随证而施，则断不可拘执先用升散为定法也。岂可囿于前人之说，而不准之以理乎？明医者，倘不以余言为河汉，或可备刍荛之采。有司命之责者，胡可忽哉。
叶霖按语：章氏此论，深明慎发表之义。其案中治禀气怯弱，不能送毒外达之证，于辛凉透发剂内重加玄参；遇元阳不足者，则凉透中稍佐附子，皆有卓见。较冯楚瞻之全真一气汤，精当多矣。
先哲论述治病须辨三因，察六气。我的意思是三因既已辨明，六气已包括在其中。痧疹伏毒为时厉感召，若能详辨其内外二因，可不致操刃杀人。所谓内因者，命门伏藏胎毒是矣。然而禀赋不一，不可拘牵。或多实热，或本虚寒。或脏气怯弱，表散太过，则火盛伤金；或腠理致密，失于宣托，则毒难外达。或贪房室，少阴不藏；或缘病后，元阳未复。或为痰滞，或为食积。或因劳伤而蓄血，或因生冷而损脾。或苦寒过剂，可温补暂投；或辛燥劫津，而养阴难缓。所谓外因者，风寒暑湿燥火是矣。然而须先明大运之转移，后察当年司天在泉，及主客气运之偏胜。惟是木火当旺，或多淫雨严寒；水土司权，常见飙风燥热。亢害承制，救弊补偏，要未可一概论也。人之禀受不同，治法亦当各异。宜表宜清，宜攻宜补，辨明所因，庶免虚实寒热之误。张石顽说：古人成法，虽当参详诊切，仍不能舍其绳墨。临证之机，活法在乎心手，而绳墨又不可拘也。此千古不易之论，岂独痧疹为然哉。
Vomiting, or expelling long roundworms (Ascaris), requires the urgent use of Baihu Tang with Coptis Rhizome (Baihu Jia Huanglian Tang). This should not be avoided even in severe cold weather.
Regarding the previous two conditions, once differentiated and assisted, they are not difficult to distinguish. There are cases where fire-toxin is originally severe, combined with an external contraction of cold pathogen; although the exterior appears cold, the interior is actually heat-excess. In such cases, a method that releases both the exterior and interior is appropriate. The ancients had a formula called Mahuang Shigao Tang (Ephedra Decoction with Gypsum), and I have imitated this method, saving many lives. There are also cases where fire-toxin is originally severe, but parents only know how to suppress it, and physicians only know how to disperse it via sweating, causing internal and external pathogens to blaze together. Extreme heat may mimic water (cold), presenting with reversal cold limbs (Jue Ni). Medical texts refer to this as "the deeper the heat, the deeper the reversal" (Re Shen Jue Yi Shen). In such cases, Baihu Tang with Coptis Rhizome is indicated. If treated as a cold syndrome, it would be disastrous.
There are three methods for treating Sha Zhen (Scarlet Fever-like rash): one is ascending and dispersing, one is descending and clearing fire, and one is nourishing Yin. Those who master these methods incorporate cooling intentions within ascending and dispersing techniques, and maintain the mechanism of vitalization within nourishing Yin prescriptions.
If the rash spots are faint and not yet fully erupted, accompanied by fever, cough, runny nose, and tearing, ascending and dispersing is indicated. If the rash does not appear on both cheeks, ascending and dispersing is indicated. If there is fever with cold limbs, a non-red face, and dry-free lips, ascending and dispersing is indicated. If there is panting and nasal flaring, provided it is identified as caused by exterior pathogens, ascending and dispersing is indicated. If there is diarrhea occurring five or six times a day, ascending and dispersing is indicated.
Once the Sha Zhen has erupted, if high fever persists, descending and clearing fire is indicated. If there is vomiting, irritability, thirst, and expulsion of roundworms, descending and clearing fire is indicated. If there is loss of appetite, descending and clearing fire is indicated. If excessive heat scorches Metal (Lungs) causing panting, descending and clearing fire is indicated. If there is epistaxis (nosebleed), descending and clearing fire is indicated. If urination is difficult, descending and clearing fire is indicated. If there is sore throat, mumps, toothache, or mouth ulcers, descending and clearing fire is indicated. If there is noma (gangrenous stomatitis) with foul odor and rotting, descending and clearing fire is indicated.
Three to four days after the eruption of Sha Zhen, if high fever persists, nourishing Yin is indicated. If purple spots do not retract, nourishing Yin is indicated. If the pulse is rapid and large, nourishing Yin is indicated. If there is night fever, irritability, and dental discomfort, nourishing Yin is indicated. If hoarseness occurs, nourishing Yin is indicated. If eyes are red and photophobic, nourishing Yin is indicated. If there is body itching and dry stool, nourishing Yin is indicated.
Failing to ascend and disperse when indicated can lead to severe cases of sudden panting and closure, or mild cases lingering with residual toxin. Failing to descend and clear fire when indicated damages the Lungs and Stomach, leading to hoarseness, irritability, thirst, noma, or mouth ulcers. Failing to nourish Yin when indicated leads to afternoon tidal fever, emaciation, and gradual development of Gan Syndrome (malnutrition syndrome).
The eruption of Sha Zhen must always be fully released through the exterior. Once the exterior is resolved, even if interior heat is severe, clearing it will cure the disease. If the exterior is not resolved, the toxin sinks inward. With the "doors" closed, neither releasing the exterior nor nourishing Yin is effective, often leading to death due to delay.
"Exterior resolution" here does not merely mean resolving the skin and hair level, but rather allowing the toxin to emerge from the Zang-Fu organs. Only when the emergence and disappearance of the rash are calm and orderly can it be considered truly resolved at the exterior. In some cases, fire-toxin is very severe, presenting with abundant redness externally, but after the rash subsides, noma or lung abscess still develop, or epistaxis and dysentery occur. This indicates that the toxin within the Zang-Fu has not been fully expelled.
The toxin of Sha Zhen and smallpox originates from the Zang-Fu organs. Although it reaches the exterior, its root remains inside. "Jie" (resolve) refers to action from the exterior, while "Hua" (transform/dissolve) refers to action from the interior. Even if the exterior is resolved but the interior toxin is not transformed, there will be many subsequent complications.
The Lungs govern the skin and hair. Although Sha Zhen emerges from the Six Fu organs, it must be resolved through the skin and hair; thus, treatment cannot depart from the Lungs. If exterior resolution is incomplete, chronic cough and tidal fever may accumulate into Sha Gan (rash-induced malnutrition). This "Gan" character does not refer to intestinal parasitic accumulation (Gan Ji), but implies a condition resembling Gan syndrome due to tidal fever and emaciation. Treatment should focus primarily on moistening the Lungs; acrid-drying herbs must not be used.
Herbs that release the exterior act on the Yang aspect and Qi level, producing fast and visible effects. Herbs that transform toxin act on the Yin aspect and Blood level, producing slow and difficult-to-achieve effects. The four characters "Nourish Yin and Retreat Yang" (Yang Yin Tui Yang) from the *Jin Jing Lu* (Record of Golden Mirrors) are the key secret to treating Sha Zhen.
For "Nourish Yin and Retreat Yang," the text prescribes Siwu Tang (Four Substances Decoction). I frequently used it in my youth but rarely achieved success because the acrid-warm nature of Dang Gui (Angelicae Sinensis Radix) and Chuan Xiong (Chuanxiong Rhizoma) was unsuitable. Therefore, I formulated a "Sha Zhen Siwu Tang" using Sheng Di Huang (Rehmanniae Radix), Mu Dan Pi (Moutan Cortex), Mai Dong (Ophiopogonis Radix), and Chi Shao (Paeoniae Radix Rubra), which yielded consistent results. One need not rigidly adhere to ancient formulas; understanding their intent is sufficient.
After-rash tidal fever is particularly objectionable. It occurs in the afternoon and subsides with coolness at dawn. During subsidence, the pulse is calm; during onset, the pulse is rapid and large. Red lips, red tongue without coating, teeth grinding, nose rubbing, and progressive emaciation indicate a prognosis of poor curability. Occasionally, patients who can eat may be saved with large doses of Yin-nourishing herbs.
The Stomach is the reservoir receiving the toxin, retaining much residual heat. The most urgent manifestation is noma. Noma is a syndrome resulting from failure to clear heat, requiring large doses of interior-clearing herbs. If constipation is present, purgation may be used to drain heat and toxin internally, similar to post-smallpox treatment. I have a formula called Le Ma Yin (Horse-Leashing Drink). In severe cases, Da Huang (Rhei Radix et Rhizoma) is added for urgent purgation. Delaying treatment not only leads to tooth loss and perforated cheeks but also rotting of the lips and nose. Topical application only serves as auxiliary support.
Hoarseness after Sha Zhen is mostly caused by excessive fire damaging Metal (Lungs). Treatment should involve Gan Cao (Licorice Root), Jie Geng (Platycodon Root), Niu Bang Zi (Arctii Fructus), and Shan Zhi (Gardeniae Fructus). The treatment for mouth ulcers after Sha Zhen is the same as for noma and foul rot, following post-smallpox protocols. In past years, Sha Zhen rarely damaged the eyes, but recently there have been cases. Onset is rapid; within two to three days, nebulae cover the pupil, rendering it incurable. This is because the child already had Liver heat, compounded by suppression, or family members, unaware it was fire-toxin, administered Yan Sui Jiu (Coriander Wine), causing heat-toxin to attack the eyes. Immediate treatment with cooling, Yin-nourishing, and Yang-retreating methods is required; dispersing methods must not be used again.
Coughing up purulent, bloody, foul-smelling sputum after Sha Zhen indicates Lung Abscess (Fei Yong) or Stomach Abscess (Wei Yong), both caused by residual toxin in the Lungs and Stomach. When following the meridians outward, it becomes noma; when settling in the Zang-Fu, it becomes an abscess. Treatment must differentiate whether the pathology is in the Lungs or the Stomach. I use Gan Cao, Jie Geng, Niu Bang Zi, Jin Yin Hua (Lonicerae Japonicae Flos), Dou Chi (Prepared Soybean), Zhi Ke (Aurantii Fructus), and Chi Shao. For Lung involvement, add Shan Zhi, Bei Mu (Fritillariae Bulbus), and Sang Bai Pi (Mori Cortex). For Stomach involvement, add Sheng Di Huang, Hua Fen (Trichosanthis Radix), and Mu Tong (Akebiae Caulis) as assistants. Cases without high fever are treatable.
Question: Why are noma and lung abscess treatable? Because the toxin has transformed and exited. If the toxin transforms and the Zang-Fu remain intact, it is treatable; if the Zang-Fu are ruined, it is untreatable.
Adults contracting Sha Zhen constitute two or three out of ten cases, often complicated by sexual activity, menstruation, or childbirth. Generally, a light dispersing approach should be followed immediately by Yin nourishment. Herbs like Ma Huang (Ephedrae Herba), Sheng Ma (Cimicifugae Rhizoma), and Qiang Huo (Notopterygii Rhizoma et Radix) should be used with caution.
Ye Lin's Note: The discussions of Masters Ye and Xu carefully examine syndromes to determine variations, each possessing unique insights. They are truly precious texts. Readers should study them meticulously and use them as standards for treating rashes; they must not be ignored. Rigid adherence without flexibility and hasty prescribing make one a sinner against these masters.
Wu Ju-tong said: If one understands diseases caused by the Six Qi, treating rashes is not difficult. However, the timeframe for rashes is extremely tight, lasting only three days. The primary approach should be acrid-cool release and penetration. Commonly used herbs like Fang Feng (Saposhnikoviae Radix), Guang Pi (Citri Reticulatae Pericarpium), Sheng Ma, and Chai Hu (Bupleuri Radix) are prohibited. The common practice of always using exterior-releasing methods for rashes is heterodox. Generally, start with acrid-cool clearing and resolving, then conclude with sweet-cool methods. For red rashes, misusing acrid-warm herbs like Ma Huang or San Chun Liu causes Lung damage, leading to panting, coughing, and impending syncope. Initially, use acrid-cool herbs plus Ku Jie Geng and Xuan Fu Hua (Inulae Flos) to lift and descend. In severe cases, use Baihu Tang with Xuan Fu Hua and Ku Xing Ren (Prunus Armeniaca Semen Amarum), followed by sweet-cool herbs with Xuan Fu Hua to rescue. Remove Xuan Fu Hua when cough significantly decreases. For children coughing continuously for dozens of times without relief, taking half an hour to recover, making a sound like a waterfowl, treat with Qianjin Wei Jing Tang (Thousand-Gold Coix Seed Decoction) combined with Ting Li Da Zao Xie Fei Tang (Descurainia Seed and Jujube Decoction to Drain the Lungs). Using Da Huang in recent times is lethal. Ting Li (Descurainiae Semen seu Lepidii Semen) travels through the Qi level of the Lung meridian; although it also affects the Large Intestine, it descends from above, and Da Zao (Zizyphi Fructus) moderates it, preventing rapid downward movement. Da Huang, however, acts purely on the Blood level of the intestines and stomach, purging有形 (solid) stagnation, does not affect the Lungs, and merely injures innocent areas. Adhering rigidly to the method of "draining the Fu organs for Zang organ diseases" is erroneous.
Zhang Xu-gu said: I often see rashes treated starting with Sheng Ma Ge Gen Tang (Kudzu Root and Cimicifuga Decoction). This secular custom is unbreakable. Although ascending and dispersing the toxin is not greatly harmful, it only addresses the branch (symptoms) without investigating the root (cause). If the syndrome does not respond to medication, physicians are baffled. Thus, there are cases where repeated ascending and dispersing fails to bring out the rash, not realizing that weak Zang Qi cannot transport the toxin. Merely using exterior herbs dissipates Wei Qi, making toxin expulsion even harder. Or, in cases without external cold closing the pores, reckless use of Ma Huang excessively depletes Lung Qi, leading to nasal flaring, panting, toxin hiding in the Heart and Kidneys, restlessness, and death. Physicians fail to understand why, largely due to the preconceived notion that rashes originate from the Fu organs and reside in the skin and muscles. Failing to investigate the origin and transformation of fetal toxin, they mistake internal toxin failing to reach the exterior as external toxin sinking inward, declaring it untreatable. Consider: if the toxin were originally in the muscles, initial treatment would surely use ascending and dispersing methods. How could it fail to erupt? Even if blocked by external pathogens or internal food stagnation, there must be differentiating signs, making treatment feasible. If the toxin did not originate from the Zang organs, the Zang Qi would be harmonious, and using ascending/exterior herbs would not cause external toxin to sink inward. The truth is that if Zang Qi cannot send out and transform toxin, ascending and dispersing is useless; it is not external toxin sinking inward, but internal toxin failing to exit. This lack of understanding is lamentable. Furthermore, insisting on Sheng Ma Ge Gen Tang as a fixed rule at the outset confuses the source and flow of rashes and conflates Ban (macules) and Zhen (papules/rashes). Wang Ang's song for Sheng Ma Ge Gen Tang says: "When macules and rashes have appeared, beware of using [this formula]." This shows that conflating macules and rashes has been long-standing. Secular practitioners memorize the *Tang Tou Ge* (Song of Formulas) and pass it down as fixed rules without question. They fail to realize that Sheng Ma Ge Gen Tang is a Yangming channel herb; Yangming governs muscles, and evil heat closure郁 leads to macules. Macules are red patches, sometimes like brocade patterns, flat to touch, not granular. If not fully erupted and exterior dispersal is needed, Sheng Ma Ge Gen Tang is appropriate. If fully erupted and interior clearing is needed, Baihu Tang is appropriate. If accompanied by interior excess and stagnation, Chengqi Tang is appropriate. As for rashes, although they differ in origin (external wind-heat vs. internal fetal toxin), they all arise from the Heart and Lung channels moving from Ying (Nutrient) to Wei (Defensive) levels, affecting blood collaterals. Because they emerge from hair follicles, they form granules, distinct from macules arising from Yangming in the muscles. How can one treat rashes with macule-treating herbs without distinguishing Zang-Fu and meridians? This is inappropriate. Moreover, ignoring the source and transformation of rashes makes finding good treatments difficult. Since Zang Qi is usually intact and sends toxin outward, successful cases using ascending/dispersing herbs reinforce the belief that initial treatment must use ascending/dispersing methods, unaware of the flaw. When encountering weak Zang Qi where internal toxin cannot reach the exterior, it is mistaken for external toxin sinking inward and deemed untreatable. If one understands the source, distinguishes between external contraction and fetal toxin, and allows timely eruption, the disease might heal without medicine. If eruption fails, one must examine the cause: external cold closure, internal food stagnation, or Yuan Qi weakness. Depending on the case, one may use ascending/dispersing, promoting drainage, or tonifying/supporting. Treatment must follow the syndrome; one must not rigidly stick to initial ascending/dispersing as a fixed rule. How can one be confined to predecessors' words without applying reason? Enlightened physicians, if you do not dismiss my words as nonsense, they may serve as humble suggestions. Those responsible for life and death, how can they ignore this?
Ye Lin's Note: Master Zhang's discussion deeply clarifies the principle of cautiously using exterior-releasing methods. In his cases, for patients with weak constitution unable to send toxin outward, he heavily adds Xuan Shen (Scrophulariae Radix) to acrid-cool penetrating agents. For those with insufficient Yuan Yang, he slightly adds Fu Zi (Aconiti Lateralis Radix Praeparata) to cooling-penetrating formulas. These show profound insight, far surpassing Feng Chu-zhan's Quan Zhen Yi Qi Tang (Complete True Vital Energy Decoction) in precision.
Ancient sages stated that treating disease requires distinguishing the Three Causes and observing the Six Qi. My view is that once the Three Causes are distinguished, the Six Qi are included therein. The latent toxin of Sha Zhen is influenced by epidemic qi. If one carefully distinguishes internal and external causes, one avoids killing patients with the scalpel. The so-called Internal Cause is the fetal toxin hidden in the Ming Men (Gate of Life). However, constitutions vary, so one cannot be dogmatic. Some have excess heat, others deficiency-cold. If Zang Qi is weak and exterior dispersal is excessive, fire flourishes and damages Metal. If pores are dense and ventilation/support is lost, toxin is hard to reach the exterior. Excessive sexual activity causes Shao Yin (Kidney) to fail to store essence. Post-illness, Yuan Yang may not have recovered. Phlegm stagnation or food accumulation may occur. Labor injury may cause blood stasis; raw/cold foods may damage the Spleen. Overuse of bitter-cold herbs may require temporary warm-tonifying; acrid-drying herbs consuming fluids make Yin-nourishing urgent. The so-called External Cause is Wind, Cold, Summer-heat, Dampness, Dryness, and Fire. One must first understand the shift of the Great Movement (Da Yun), then observe the ruling Qi of the year (Si Tian/Zai Quan) and the bias of Host/Guest Qi. When Wood and Fire are prosperous, there may be excessive rain and severe cold; when Water and Earth rule, fierce winds and dry heat are common. To counteract harm and restore balance, remedies cannot be generalized. Human constitutions differ, so treatments must vary. Whether to release exterior, clear heat, purge, or tonify depends on distinguishing the cause, avoiding errors of deficiency/excess and cold/heat. Zhang Shi-wen said: Ancient established methods should be studied and palpated, but one cannot abandon principles. Clinical flexibility lies in the mind and hands, but principles cannot be disregarded. This is an eternal truth, applicable not only to Sha Zhen.