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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.