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Sun Dongsu said: The condition of sha-zhen (scarlet fever-like rash) seems lighter than smallpox, but if the treatment and care are improper, disaster strikes immediately. If the toxic qi cannot be excreted, it turns purple-black, leading to death. If the patient is extremely thirsty and desires water, only a small amount of scallion white decoction should be given to moisten the thirst. It is essential that the skin pores maintain a slight perspiration and moisture. One must also avoid plums, peaches, fish, honey, and other fragrant/fresh foods, as these may provoke "gan" parasites to ascend.

Nie Jiuwu said: Sha-zhen has major taboos. If the family violates them, death results; if the physician violates them, death also results. Although the specific taboos differ, they all concern blocking the toxic qi and preventing its eruption.

1. Taboo against meat, raw/cold foods, wind, and cold. When sha-zhen is erupting, it is strictly forbidden to eat meat, consume raw or cold foods, or be exposed to wind and cold. These factors cause the skin to close up, depressing the toxic qi and forcing it inward.

2. Taboo against sudden use of cold/cooling medicines. At the initial stage of fever, it is most taboo to suddenly use cold/cooling medicines to "freeze" the toxin. This suppresses the toxic qi, preventing its release and causing internal attack. Ancients stated that in hot weather, one should use acrid-cool medicines to disperse, such as Huanglian Jiedu Tang (Coptis Decoction for Detoxification). They failed to realize that seasonal summer-heat qi cannot be resolved by cold medicines. Sudden use of cold medicines now may fail to resolve external heat and instead obstruct internal heat, preventing its exit. I once saw an official's son, aged one year, who developed sha-zhen with fever and convulsions before the rash appeared. The physician misdiagnosed it as acute jing-feng (wind-stroke/seizure) and used cooling medicines to attack it. Consequently, the sha-toxin remained hidden under the skin. A subsequent physician treated with yin-nourishing herbs like Siwu Tang (Four Substances Decoction), which also failed. The patient suffered from irritability, hoarseness, and died after ten days. This illustrates the harm of using cold medicines to freeze toxins. Using cold medicines suddenly due to hot weather is unreasonable.

3. Taboo against mistaken use of acrid-hot medicines. At the initial fever stage, it is most taboo to mistakenly use acrid-hot medicines to assist the toxin, such as Guizhi Twig (Guizhi), Ephedra Herb (Mahuang), Notopterygium Rhizome (Qianghuo), Atractodes Rhizome (Cangzhu), Clove (Dingxiang), Cinnamon Bark (Rougui), and Amomum Fruit (Sharen). These cause toxin congestion and blockage, leading to internal attack. Even if limbs are cold at the onset of sha-zhen, this is due to extreme heat resembling cold (fire extremity mimicking water); one must not recklessly administer hot medicines. Once the rash appears, the condition will naturally harmonize. Ancients claimed that in severe cold, acrid-hot medicines like Guizhi Tang (Cinnamon Twig Decoction) should be used. They did not understand that in severe cold, one should simply stay in a warm room and avoid wind/cold. Moreover, even if the weather is cold, the body's heat-toxin does not necessarily decrease; using many acrid-hot medicines is unreasonable.

4. Taboo against mistaken use of tonifying and astringent medicines. During the eruption of sha-zhen, there is often unceasing diarrhea, which allows the toxin to dissipate through the stool; this is generally harmless. If diarrhea is excessive, Jiawei Siling San (Modified Four-Ling Powder) can be given. One must strictly avoid using tonifying/astringent herbs like Ginseng Root (Renshen), Astragalus Root (Baizhu), Chebula Fruit (Hezi), and Cardamom Seed (Doukou) to stop diarrhea quickly. Severe cases lead to abdominal distension and wheezing, which are incurable; mild cases become chronic dysentery (xiuxi li), lingering indefinitely. If yellow-red stool occurs after sha-zhen, it indicates latent heat inside; adding Thrustraw Stem (Mutong), Plantago Seed (Cheqianzi), and Scutellaria Root (Huangqin) is appropriate.

Furthermore, children with smallpox/sha-zhen should avoid foul odors: axillary狐臭 (fox odor), sexual fluids, sweat from long travel, fecal miasma from ditches, menstrual blood odor, pus/odor from sores, arsenic/sulfur/mosquito smoke, burnt hair smoke, extinguished candle smoke, wood smoke/fish bone smell, garlic/chive/allium odor, frying oil smoke, drunk/meat fumes, and musk/foul smells.

One must observe behavioral taboos: avoid visitors, shouting/scolding, combing hair nearby, scratching nearby; do not sweep the floor, do not face absurd talk, do not allow monks/Daoists/wizards into the room, do not engage in eating/singing/music during these times. Adhering to these taboos can turn serious illness mild; neglecting them can turn mild illness serious.

At the onset of pediatric sha-zhen, many people now administer bamboo shoot soup to promote eruption. However, it should only be used in small amounts to guide the toxin out through the skin. Overuse damages yuan qi (primordial qi) and spleen qi, impairing the digestion of toxins, leading to dry heaving, diarrhea, sweating, irritability, and complications like ulceration, itching, and mouth ulcers during the pustule stage. Using bamboo shoot tips in herbal formulas is particularly taboo. This is highlighted to warn against the habitual abuse of bamboo shoot soup.

Ye Lin commented: Sha-zhen is a yang-toxin; eruption is auspicious. Acrid-dry and sour-astringent flavors must not be mistakenly administered. Bamboo shoots are sweet and cool, promoting phlegm resolution and having a dispersing nature; their use is acceptable, except for those with weak spleen qi who should be cautious.

Zhang Shiwan said: Ancient formulas for sha-zhen eruption often use Cimicifuga Rhizome (Shengma). However, Shengma is ascending and moves yang qi, often causing pathogenic heat to float upward, resulting in wheezing. Zi Su Ye (Perilla Leaf) and scallion white should be used instead. Not only must Shengma be used cautiously, but Platycodon Root (Jiegeng) should also be used judiciously at the onset, as it may carry turbid qi upward. Sha-zhen requires cooling and moistening; all acrid-dry substances are contraindicated. Medication strategy must be handled with great caution.

Meng Jieshi said: Sha-zhen belongs to lung fire. The lung is the canopy of the five zang organs, clear and empty above. Thus, the rash appears and disappears quickly without leaving marks on the skin, unlike smallpox which forms pustules and scabs. Therefore, medication should not focus heavily on exterior-releasing methods, lest it stir up zang-fu heat, steaming the lungs, closing lung orifices, preventing rash eruption, and increasing wheezing/distension. Modern quacks and ignorant women see sha-zhen and indiscriminately use drying/dispersing medicines regardless of heat severity. Families happily administer them, unaware of the harm. Generally, at the onset, light and clear exterior-dispersing methods followed by cooling to resolve lung heat are the major principles.

For pediatric post-sha-zhen mouth ulcers and gum rot, topical preparations must not contain large amounts of Borneol (Bingpian) or Musk (Shexiang). These two have strong aromas reaching the heart and lungs directly, severely damaging true qi, causing restlessness and poor appetite. Robust individuals may escape harm, but those with green-yellow complexion, emaciation, and weak qi face life-threatening risks. Moreover, efficacy does not depend solely on these two; users must be cautious.

The *Zhen Quan Shu* states: Licorice Root (Gancao) is often overlooked. Improper use causes significant harm. It is sweet and warm, neutral and retaining. Sweetness generates heat, warmth assists yang, and retention causes stagnation. With limited disease duration and abundant yang-toxin, initial stagnation leads to later gan-heat complications. It must be used cautiously throughout the course.

Ephedra Herb (Mahuang) is effective when used correctly, capable of saving dying patients. However, in cases of nightly tidal fever, abdominal tidal fever, sweaty tidal fever, amenorrhea, or irregularities in pregnancy/postpartum, one must not rigidly adhere to the theory of "three tides a day." Mistaken use of Mahuang depletes exterior qi and collapses yang qi, leading to night sweats, jing-feng seizures, [missing text], and jue syndrome, which are incurable. Users must be cautious.

Ye Lin commented: Regarding sha-zhen taboos, avoiding wind/cold, regulating diet, abstaining from sex, and avoiding foul odors is correct. However, medication should not be rigidly applied. Although latent heat is triggered by seasonal pestilence, individual constitutions vary, leading to different etiologies. Some require direct treatment, others indirect treatment. Between cold, heat, warm, and cool therapies, one must avoid the error of "reinforcing excess and depleting deficiency," which is crucial. Nie Qingjiang’s emphasis on the character "zhou" (sudden/rash) holds deep meaning; readers should not overlook it.