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Mottles and Macules (Ban Zhen)

Mottles caused by Shanghan (Cold Damage), mottles caused by Shiqi (Seasonal Pathogenic Factors), mottles caused by Yangdu (Yang Toxin), and mottles caused by Wendu (Warm Toxin); among these four syndromes, Wendu is the most severe. All are due to heat pathogens in the exterior; if purgation is incorrectly used when not indicated, the pathogen enters the stomach via deficiency; or if heat pathogens are in the interior but cannot be vented, both situations can cause mottles. (San Yin Fang)

Epidemic diseases often present with mottles. Generally, if fever persists after sweating, accompanied by restlessness and a deep pulse, it indicates the onset of mottles. In mottle syndromes, vomiting and diarrhea are auspicious signs, indicating that toxins are being expelled through both upper and lower pathways. (Yixue Liuyao)

Those appearing in clusters like brocade patterns are called Ban (Mottles); those appearing as faint red spots are called Zhen (Macules). This is because gastric heat, left un-purgated, rushes into the Shaoyang channel, assisting the Ministerial Fire to form Ban; if it rushes into the Shaoyin channel, it assists the Sovereign Fire to form Zhen. ○ When Ban and Zhen are about to erupt but have not yet appeared, it is appropriate to administer Shengma Gegen Tang (Cinnamon Twig and Kudzu Root Decoction) to vent the toxin. One must not immediately use cold-natured drugs to attack the heat, nor use diaphoretic or purgative methods that would weaken the Qi of the exterior and interior. If internal heat is severe, add Huanglian (Coptis Rhizome), Xijiao (Rhinoceros Horn - *note: substitute with water buffalo horn in practice*), Qingdai (Indigo Naturalis), Zhimu (Anemarrhena Rhizome), Shigao (Gypsum Fibrosum), Huangqin (Scutellaria Root), Huangbai (Phellodendron Bark), and Xuanshen (Scrophularia Root). If the mottles subside slightly, but tidal fever, delirium, and constipation occur, Dai Chai Hu Tang (Major Bupleurum Decoction) or Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) may be used for purgation. (Wang An)

Ban syndromes range from mild, resembling macules, to severe, resembling brocade patterns. Although there are various causes, they all stem from unresolved pathogenic toxins. If sweating was indicated but not performed, exterior pathogens remain unresolved; if purgation was indicated but not performed, interior pathogens remain unresolved; if clearing heat was indicated but not performed, fire remains excessive; if tonification was indicated but not performed, righteous Qi is too weak to resolve the pathogen; if purgation is performed too early, pathogens sink inward; if Yang syndromes are mistakenly treated with warming and tonifying, Yang becomes hyperactive; if Yin syndromes are mistakenly treated with cold and cooling, Yin becomes stagnant. Whenever pathogenic toxins are unresolved, they penetrate directly into the Yin aspect, stagnate and generate heat, leading to exhaustion of fluids and blood, causing mottles to appear on the skin surface. ○ Cheng Wuji stated: Heat injures the Blood. If heat does not dissipate, the interior becomes full while the exterior becomes deficient; heat pathogens exit through the skin via this deficiency, forming mottles. Sweating should not be induced, as opening the pores further will only increase the severity of the mottles. I disagree. The pathogen of Shanghan originally enters from the exterior; if it penetrates deeply and remains unresolved, it naturally emerges from the interior. This mutual interaction between interior and exterior is inevitable and does not originally constitute an exterior deficiency syndrome. As long as interior and exterior communication is restored, the pathogen will surely resolve via the exterior. (Jingyue Quanshu)

When mottles and macules first appear, one must use a paper torch to illuminate the chest, back, and hypochondrium. Spots that are large and on the skin surface are Ban; those that are cloud-like and faint, or small and granular, are Zhen. Medical texts state that red mottles belong to gastric heat, purple to extreme heat, and black to "rotten stomach." However, external symptoms must also be considered for diagnosis. During spring and summer, dampness diseases often present with mottles and macules; their color must be distinguished. If the color is pale, limbs are cool, thirst is slight, and the pulse is not surging and rapid, it is either a Deficiency Mottle or a Yin Mottle. If only a few spots appear on the chest and abdomen, with a red face and cold feet, or diarrhea with undigested food, this indicates Yin excess repelling Yang upward; warming treatment is required. If mottles are purple and small, it is Heart Protector heat; if large and purple, it is Stomach heat; if black and shiny, it is heat exceeding toxin. Although considered untreatable, if the patient's Qi and Blood are robust, rescue may be possible; if black and dull, death is certain; if black and faint with red surroundings, it is Fire stagnation hidden inside; vigorous cooling and venting may occasionally turn them red and save the patient. Ban belongs to Blood, Zhen belongs to Qi; both are manifestations of pathogens manifesting externally. If the spirit is clear after eruption, it indicates external resolution and internal harmony. If the spirit becomes confused after eruption, it indicates righteous Qi failing to overcome the pathogen with internal sinking, or exhaustion of Stomach fluids. ○ Ban caused by failure to release the exterior requires diaphoresis; Ban caused by failure to purge requires purgation. Excessive fire is cleared; excessive toxin is transformed. If Ying Qi is deficient, tonify and support it. The concept of Yin Mottles is rarely discussed. "Sha" is a general term for macules, having granules like millet seeds; "Yin" refers to a type of macule that is swollen and itchy. Eruption should be uniform, and fading should be gradual. Causes involve primarily the Taiyin and Yangming channels; thus, Master Mou specialized in treating from the Spleen and Stomach, which is precise and pertinent. Treatments include acrid-cool, sweet-cold, bitter-cold, salty-cold, and bland-draining methods. (Ye Tianshi)

Internal injury causing mottles resembles mosquito bites, mostly on hands and feet, without initial headache or fever. This results from overexertion causing extreme Stomach Qi deficiency, allowing fire to wander externally, or from post-sweat/purge deficiency where pathogens scatter on the skin surface. Treatment requires Dajian Zhong Tang (Greatly Establish the Middle Decoction); do not recklessly use cooling drugs. ○ Yin syndrome mottles are sparse and pale, resembling mosquito bites, unlike the bright red of Yang mottles. This is due to Kidney Qi deficiency and cold, with Yin excess below forcing rootless fire to float upward. Mistaking this for heat and using cooling drugs leads to immediate danger. Treatment requires Bawei Tang (Eight-Ingredient Pill) to store the Yin fire, causing mottles to recede. (Mingyi Zhizhang)

Mosquito-bite-like lesions mistaken for mottles kill quickly. Differentiation: Red then yellow indicates mosquito bites; pale then red indicates mottles; mosquito bites are common on hands/feet; mottles are common on chest/abdomen. (Zhu Danxi)

Ban has no granules, resembling mosquito bites or flea marks, severe cases like brocade; Zhen has granules, appearing and disappearing. Ban originates in the Yangming channel; Zhen originates in the Taiyin channel. Zhen is caused by Lung heat scorching, resulting in red spots on skin/hair, differing from eczema which is white without red spots. Zhen is a contagious seasonal disease, where irregular seasonal Qi combines with latent fire in the diaphragm to scorch the Lung. It may be caused by Sovereign or Ministerial Fire, or by Cold, Warmth, Summerheat, or Dampness. Symptoms include chills, fever, vomiting, aversion to nausea, excessive eye discharge, cold ears and buttocks; pulses may be deep and rapid, or hidden and unrising, becoming surging and rapid only after eruption. Regarding treatment: Ban indicates Stomach excess, so lifting agents are contraindicated upon appearance; urgent cooling and toxin transformation are needed. Fear of "Stomach rot," which turns purple/black and is critical. Zhen is Heart Protector latent heat steaming the Lung; throughout, cooling and resolving/supporting are suitable. Liangge San (Cooling the Diaphragm Powder) minus Mangxiao and Dahuang is the main formula. Add Jingjie, Fangfeng, Qianhu for exterior symptoms. Do not use Qianghuo unless Taiyang symptoms exist; add only if joint pain is present. For surging pulse, profuse sweat, and Yangming symptoms, add Gegen. For alternating chills/fever and Shaoyang symptoms, add Chaihu. In summerheat, combine with Yiyuan San; in cold, combine with Xiangsu Yin. Clear fire with Huanglian and Shigao, always combined with Gancao and Jiegeng. Later, nourish Yin, keeping Gancao and Jiegeng. Crucially, any chest tightness indicates unvented toxin; lack of sweating throughout requires inducing generalized blistering to clear diaphragmatic heat; for deficiency, avoid Baizhu and Cangzhu, add Renshen. This is the method for Zhen; methods for Ban are detailed elsewhere. (Wang Xiezhi)

Ban is rootless fire of the Sanjiao; Zhen is damp-heat fire of the Heart and Spleen; both invade the Lung similarly. ○ Red macules dissipate with slight cooling; white macules dissipate with slight warming. Pale-red/yellow spots hidden in muscles with heavy limbs indicate Wind-Heat with Dampness in the Spleen channel, often from bathing followed by wind exposure and removing clothes while sweating. (Yixue Rumen)

Zhen has granules, like millet or mosquito bites, appearing/disappearing rapidly. Red spots hidden under skin are Yin Zhen; prominent granules are Sha Zhen. Syndromes differ, but initially accompany nasal congestion, runny nose, hoarse cough, headache, chest tightness, fever, and spontaneous sweating. Severe cases involve Wind obstructing the Lung, causing shortness of breath, flaring nostrils, and inability to lie down due to cough. First use moistening Lung and eliminating pathogen formulas. Later, if tidal fever appears without headache and chest discomfort improves, but cough/shortness of breath persist, it is due to constitutional deficiency. Although Lung pathogens are resolved, Yin deficiency with Hyperactive Fire and rapid/large pulse require nourishing Yin and clearing Lung heat; do not mistakenly use Renshen or sour/astringent herbs. (Zhengzhi Huibu)

Dan Sha (Scarlet Fever-like Rash)

Medical texts rarely discuss Dan Sha in detail. My research shows its origin lies in Wind, Cold, Warmth, Heat, or Epidemic Qi. Thus, releasing the exterior and clearing heat are appropriate depending on the stage. Proper treatment cures quickly; improper treatment brings disaster. There are essentially two paths: dispersing and clearing. Initially, there is aversion to cold, slight fever, or high fever with chills. Even with sore throat and thirst, the priority is releasing the exterior and venting. Dispersing is key, following the principle "Vent Fire Stagnation." Indiscriminate use of cold drugs closes exterior pathogens and intensifies internal fire, worsening throat ulceration. Misunderstanding this, some blame cooling drugs for persistent fire, failing to see the error of neglecting dispersal, continuing to cool until internal sinking and death occur. Others argue for exclusive dispersal, which is biased. Initially, during chills/fever, dispersal is urgent to induce sweating and vent Dan Sha. If chills cease, exterior Wind-Cold is resolved, and internal pathogenic fire flares; then cooling and draining heat is appropriate until the disease resolves. Persisting with acrid-dispersants when fire is dominant exacerbates swelling and ulceration. Those advocating cooling criticize dispersal as causing stagnation. Both views have merit depending on timing. Post-recovery, limb pain/stiffness may occur due to Yin injury from fire; treat by nourishing Yin, not as Bi Syndrome. (Wu Yi Huijiang)

Bai Fei (White Vesicles)

Ancient texts lack specific sections on Bai Fei, mentioning it briefly under mottles/macules. In warm-heat syndromes, white, pointed, rice-like vesicles appear. Some resolve immediately, some are critical, some appear late after tonification/purgation. Laypeople call it "seasonal qi," but etiology and treatment differ from mottles/macules. Shanghan transmitting heat with incomplete sweating shifts to Yangming; heat steams, injuring Ying and Blood, causing interior fullness/exterior deficiency; heat exits skin as mottles (sparse like mosquito bites, dense like brocade). Seasonal Wind-Heat invading a Lung-deficient/Blood-heat body, lacking clearing/venting, injures Hand Taiyin Blood; heat exits skin as red, granular macules. If Fire Luck year plus epidemic toxin, sore throat leads to Dan Sha/Rotten Throat Sha (most severe). Bai Fei usually involves Dampness in Warmth/Summerheat diseases. Latent Qi emerges internally but requires external contraction and inherent Dampness evaporating together, generating heat. Initial treatment must clear/vent and drain; otherwise, Lung is injured, Qi fails, heat sinks to Ying. Switching to clearing Ying/nourishing transforms slows heat and restores Lung Qi; residual Dampness exits from Upper Jiao Qi level, forming Bai Fei. Since Lung governs Qi, it appears on shoulders/back/chest. White is Lung color; moisture is residual Dampness; here pathogens fully exit. If constitution is weak, it may lead to collapse. Auspicious: vibrant, moist, spirited; Inauspicious: dry, white, hollow, sparse. Judge Qi/fluid status by texture/color. Common in late spring/early summer dampness; rare in autumn/winter. Disease affects Hand meridians, exits via Hand meridians, unlike Foot meridians which can be drained downward. Lung governs Qi; strong Qi resolves pathogens externally/upward; weak Qi leads to exhaustion/death. Neijing links Summerheat/Dampness; Zhang Zhongjing links Spasm/Dampness/Heatstroke; confirming Dampness in Warmth/Summerheat. Small crystal-like Bai Fei indicates Damp-Heat injuring Lung, Qi/fluids exhausted; needs sweet tonics. If not prolonged, due to Dampness stagnating in Wei level/incomplete sweating, regulate Qi level pathogens. White like dead bone is inauspicious, Qi/fluid exhaustion. (Wu Yi Huijiang)

Pulse Signs

After mottles erupt, a surging, rapid, forceful pulse with warm body and feet indicates treatability; a small pulse with cold feet and weak Yuan Qi indicates difficulty. (Zhou Yuzaï)

Selected Cases

A patient with internal cold/external heat, deep/fine pulses, scattered mottles on shoulder/back/chest that appeared and disappeared, with delirious speech. Yang was forced by Yin, entering Lung and skin. Skin felt hot but turned ice-cold to touch. Given Jiangfu (Ginger and Aconite) medicines, cured with profuse sweating. (Xu Shumi)

A patient with deficient pulse and spontaneous sweating was mistakenly given Zhenwu Tang, leading to coma, hidden pulse, and burning skin heat. This was Ying heat causing mottles, not comparable to Yang disease with Yin pulse. First given Baitao Jia Renshen Tang (White Tiger Decoction with Ginseng) to resolve mottles, then Taoren Chengqi Tang (Peach Kernel Decoction to Order the Qi) for purgation; cured. (Lu Cangzhou)

Hu Huchen had chronic Yuan Qi deficiency and frequent colds; cured with Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). One day, widespread mottles with blackened centers appeared. Physicians said Yang syndrome mistreated with warmth was incurable. I said: No, this is extreme Stomach Qi deficiency with fire wandering externally. Given Renshen (5 qian), Huangqi and Maidong (2 qian each), Wuweizi, Huafen, Danpi, Mutong, Xuanshen, Beimu, Jingjie (0.7 qian each); cured. (Cheng Huazhong)