【因】凡伤寒当汗不汗。当下不下。热毒蕴于胃中。血热气盛。从肌透肤而外溃。
乃发 。即温毒、热病、发 者。亦由于血热毒盛而发。此皆谓之阳证发 。有 疹并
发者。甚有 疮并发者。鲜红者为胃热。紫红者为热甚。紫黑者为胃烂。先发于胸背两胁脘腹
。续发于头面项颈四肢。若先由房劳太过。内伤肾阴。及凉遏太过。（如多服凉药
恣食生冷等）内伤脾阳。一经新感寒气。逼其无根失守之火。上熏肺经。浮游于皮肤而
发点者。此皆谓之阴证发 。亦谓之虚 。其形如蚊蚤虱咬痕。稀少而色多淡红。或淡
白微红。亦有淡黑色而仅发于两腰小腹之间者。故发 必察其虚实寒热四端。为临病求源
之首要。
【证】阳证发 。新感伤寒为轻。伏气热病较重。时行温毒尤重。伤寒应汗失汗。其
当欲出未出之际。证尚头疼体痛。壮热无汗。微恶风寒。胸闷不舒。舌苔黄白相兼。
或白薄微燥。边尖已红。应下失下。其 当欲出未透之时。证必热壮脘闷。躁扰不安。
头疼鼻干。咽干口燥。呻吟不寐。便闭溺涩。舌苔由白转黄。轻则嫩黄薄腻。重则深黄
带灰。热病发 。急则发热一二日便出。缓亦发热四五日而出。浅则鲜红起发。松浮皮
面。深则紫赤稠密。坚束有根。证必胸膈烦闷。热壮神昏。呕恶不纳。咽痛喉肿。渴喜
冷冻饮料。口秽喷人。舌苔正黄。轻浅者。黄而糙涩。舌质鲜红。深重者。黄夹灰点。舌本
紫红。温毒发 。当 毒内伏之际。证反身热不扬。神识不清。糊言妄笑。甚或昏厥如
尸。舌苔灰黑。中心黑晕。在 毒暴出之时。每多 疹并发。或 夹 疮。剧则皮肤统
红。 如针头稠密。紫黑成片。或杂烂 黑烂。证必面红咽痛。喉疼赤肿。甚则起腐。
目赤唇焦。脘闷烦灼。大渴引饮。口开吹气。臭秽喷人。耳聋足冷。便闭溺赤。神昏谵
语。甚或不语如尸厥。舌紫苔黄。或黄腻带灰。甚则焦紫起瓣。或见黑晕。此皆发 浅
深轻重之阳证。有实无虚。若阴证发 。皆属内伤夹外感。内伤脾阳者。 点隐隐而稀
。色多淡红。或夹淡灰。或夹 白。多则六七点。少则三五点。形如蚊迹。只见于手足
。或略见于腹部。似 而实为细疹。证多四肢厥冷。神倦嗜卧。喜向里睡。神识似寐非
寐。乍清乍昧。声低息短。少气懒言。大便多溏。溺色清白。或淡黄。舌苔白而嫩滑。
或胖嫩而黑润。内伤肾阴者。 多淡黑而枯。或淡白而嫩。多者十余点。少者八九点。
多发于两腰及少腹部。证多头晕目眩。或头重难举。或目闭畏光。耳鸣似聋。两颧嫩红
。腰酸足冷。精神衰弱。五液干枯。甚则筋惕肉 。手足微微螈 。男多精滑梦遗。
女多带下腰重。舌形圆嫩胖大。苔色淡黑而少津。或舌红而苔如烟煤隐隐。或舌紫绛而
圆。虽干无刺。或紫而
鲜润。间有微白苔。此皆似 非 之阴证。多虚少实。总之发 形状。并无点粒高起。以
手摸之。皆平贴于皮肉之间。不拘或大或小。总无碍手之质。但有触目之形。红色成片
。稠如锦纹者。属胃热血毒。毒盛者色红而紫。毒重者色黑而青。色淡不鲜稀如蚊迹者。
属虚多邪少。气虚者色淡微红。阴虚者色淡微黑。必先辨其病状之寒热虚实。以定病势之
轻重吉凶。（荣斋按。后段的总结。是辨证要诀）。
【脉】左浮弦而急。右浮洪而滑者。此客寒包火。当汗不汗。热毒乘隙而发 也。
右洪盛滑数。数大过于左手者。此胃热大盛。当下不下。火毒外溃而发 也。右长大滑
数。左亦浮弦搏数者。此胃中血热大盛。毒邪传遍三焦而发 也。脉伏而 亦伏。 现
而脉亦现者。此胃中血毒壅结。瘀热凝塞营卫而伏 。 出必夹丹疹。甚则夹发豌豆疮
也。右浮濡而虚。左沉涩欲绝者。此阳为阴逼。不走即飞。故淡红 微发于四肢大腹。
陶节庵所谓内伤寒发 也。左细数而急。右浮大而空者。此阴被阳销。非枯则槁。故淡
黑点微发于两腰少腹。陈念义所谓肾阴虚发 也。总之凡 既出。脉洪滑有力。手足
温而神识清爽者。病势顺而多吉。脉沉弱无神。四肢厥而神识昏沉者。病势逆而多凶。
（荣斋按。后段总结是察脉辨证要诀。）
【治】伤寒应汗失汗者。宜与透 解毒汤（方载疫疟治法中）加生葛根（一钱至钱
半）、辛凉解肌以发表。速使 与汗并达。应下失下者。宜与柴芩清膈煎。去柴胡、加
生葛根（一钱）、炒牛蒡（三钱）、活水芦笋（二两）、鲜茅根（一两、上二味煎汤代
水）、开上达下以清中。务使 与便并出。热病发 。便通者。新加白虎汤。加青连翘、
炒牛蒡（各三钱）。辛凉透 以泄热。便闭者。白虎承气汤。加连翘牛蒡（各三钱）。
活水芦笋、
鲜野菰根尖（各二两、煎汤代水），表里双解以逐热。温毒发 。便通者。宜与犀羚竹
石汤。（方载赤膈治法中）加活水芦笋（二两）、大青叶（五钱）、清凉解毒以透 。
便闭者。解毒承气汤加紫雪。直攻三焦以逐毒。阴证发 。内伤脾阳。阳为阴逼者。缓
则参附三白汤。（老东参、生白术、白茯苓、炒白芍各钱半、黑附块一钱、清炙草八
分、生姜两片、大红枣二枚）。补中益气以扶阳。急则回阳急救汤。益气固脱以追阳。
陶氏引用调中汤。辛散之品太多。反速虚阳外越。未免方不对证。慎勿妄投。内伤肾阴
。阴被阳消者。龟柏地黄汤。滋肾益阴煎。酌用二方以清滋之。若因房劳及阴阳易。热
入精室者。则以陶氏逍遥汤加减之。此二者。皆虚 证。均不必见 治 。总而言之。
凡见 不可专以 治。必须察脉之浮大滑数。沉弱涩微。病患之气血虚实。病状之寒热
湿燥。而分别用药。随证制方。此治 之要诀也。
【秀按】伤寒证汗下适宜。温热病清解得法。邪不壅塞。并不发 。即有隐隐见点
者。亦惟疹子居多。孙络血热者多发红疹。膜留湿热者多发白疹。（白疹后人改曰白
、其实 是疹之俗称。）今世俗通称发 伤寒者。实因发疹误作发 耳。或有发 。大
率由温热兼寒。初起不敢用辛凉开达。仍拘守伤寒成法。恣用辛温燥烈之药。强逼邪热
走入营中而发。故凡伤寒发 。多由于汗下失当。温热发 。多由于应清失清。皆由邪
遏于胃而热蒸成 。如果初治不误。何致成 。惟温毒热疫两证。必发 疹。若已成
。当其将发未发之际。首必辨其症候。凡若汗若清若下后。邪仍不解。其人壮热无汗
。胸膈烦闷。喘嗽呕恶。起卧不安。呻吟不寐。耳聋足冷。两寸关脉躁盛。甚或沉伏。
便是 点欲出之候。及其既出。先将红纸蘸香油燃着。照看病患面部、背心、胸膛、四
肢。有大红点平铺于皮肤之上。谓之 。若小红点突起于皮肤之上。谓之疹。 大而疹
小。 平而疹突。 重而疹轻。 夹丹疹并发者重。 夹豌疮并发者尤重。黑 如果实
靥。蓝 如烂青果。极重而必死不
治。至其治法。总以凉血宣气。解毒透 为首要。凉血如犀角、羚角、大青叶、鲜生地
、鲜茅根、青蒿脑、紫草、丹皮、山栀、元参之类。宣气如葱白、豆豉、葛根、薄荷
、嫩桑芽、水芦笋、菰根尖、青箬叶、鲜竹叶卷心、鲜石菖蒲叶之类。解毒如净银花、
鲜菊叶、鲜蒲公英、紫花地丁、生绿豆汁、莹白金汁、人中黄、尿浸石膏。大黑木耳、
紫金锭片之类。透 如牛蒡、连翘、蝉衣、僵蚕、角刺、钩藤钩、刺蒺藜、鲜西河柳叶
之类。（蒺藜河柳二味、配入于清凉药中、善能循经速达、提 最捷、切勿嫌其性温透
、弃而不用。）如 伏而不出。嵌于肉里。非略佐以升麻细辛之升窜。 毒终不得速透
。若毒蕴便闭。又当以解毒承气、犀连承气等汤速下之。必里气通而伏 随出。如果内
伤脾阳。气虚下陷。脉虚大无力者。则以补中益气汤、人参三白汤等。升补中气以提透
之。内伤肾阳。阳被阴遏。脉沉细或沉微者。则以真武汤加高丽参、鹿角尖。通脉四逆
汤加人参、鹿茸。温化阴凝以补托之。二者必阳气通而虚 乃出。盖温毒证内邪壅结。
得凉泻药。疏通其里而 出。与虚寒证阴气寒凝。得温补药。鼓舞其阳而 出。其法虽
殊。其理则一。若脾肾阴虚。冲任阴虚。则以张氏补阴益气煎。陶氏逍遥汤二方为主。
随证加减。一则峻补其下。疏启其中。一则清补其阴。疏启其气。得屡次补托滋垫。而
虚始出。又与阴证发 。得温补以鼓舞而出。同一理也。故凡治 。必察病患元气虚
实。阴阳盛衰。先其所因。辨其现证。察其色脉。庶免草率误人之弊。俞君治 方法。
大致已备。学人由此而推展之。足以尽治 之精微矣。
【廉勘】前清光绪时名医陆九芝。着《丹痧 疹》辩。独操己见。爰节述其说曰。
丹痧 疹四者。丹与 类。痧与疹类。痧轻而丹重。疹轻而 重。丹与 皆出于肤。
平而成片。痧与疹皆高出于肤而成点。痧自痧。丹自丹也。浑言之则通曰痧。亦疹自疹
。自 也。浑言之则通曰疹。而痧之原出于肺。因先有痧邪而始发表热。治痧者当治
肺。以升达为主。而稍佐以清凉。疹之原出于胃。因表热不解。已成里热。而蕴为疹邪
。治疹者当治
胃。以清凉为主。而稍佐以升达。痧于当主表散时。不可早用寒泻。疹于当主苦泄时。不
可更从辛散。大旨升达、主升葛柴之属。清凉、主芩栀桑丹之属。惟宗仲景葛根芩连一
法。出入增减。（方用升、葛、翘、蒡、柴、芩、桅、草、银花、赤芍、元参、或加蚕
、蝉、河柳、升散清凉合法。）则于此际之细微层折。皆能曲中而无差忒。此治痧疹之
要道也。自来治此证者。主辛散则禁寒泄。主寒泄则禁辛散。故两失之。至不仅为痧
与疹而为丹为 。则皆里热之甚。惟大剂寒药。（须用石膏、切忌犀角）。乃克胜任。
非第痧疹之比矣。有是四者脘必闷。四者之齐与不齐。以脘闷之解与未解为辨。有是四
者热必壮。四者之解与不解。以汗出之透与未透为辨。故当正治痧疹时。必兼行升清两
法。表里交治。务使痧疹与汗并达。惟痧疹当发出之际。病患每闷极不可耐。稍一辗转
反侧。其点即隐。病邪反从内陷。此正不必有外来之风也。即袖端被角间略有疏忽。其
汗便缩。一缩之后。旋即周身皆干。此时厥有二弊。一则汗方出时。毛孔尽开。新风易
入。一则汗已大出。不可再汗。非特痧疹之隐。且津液既泄。热必益炽。后此变端。皆
从此起。病家只道未愈。医家亦但说变病。孰知皆汗不如法之故耶。凡病之宜从汗解者
。无不皆然。而兼痧疹者尤甚。故特于此发之。其言如此。窃思痧即麻疹之俗称。故邵
仙根前哲。谓疹即痧 一类。实时毒入肺经而发。邪盛者。点子稠密。肌肤微肿而稍痒
。有红白二种。邪入营者红疹。邪入卫者白疹。大忌冒风凉遏。犯则肺闭内陷。发喘而
死。治法不外辛凉清透。宣肺化邪。观此。则痧与疹二而一。均当横开以轻宣肺气。肺
气宣。则痧疹自从皮肤外出。且其证每兼咽喉肿痛。咳嗽气逆。岂可用升柴葛一意直
升。独不虑其肺痹气喘而死耶。方中宜去升、柴、黄芩、三味。加芦笋、通草、灯心。
斯合轻扬清透之法矣。至其所谓丹与 。皆由里热之甚。法当大剂寒泻。其说甚善。但
谓须用石膏。切忌犀角。将古来犀角大青汤（犀角二钱半、大青五钱、栀子十枚、香豉
一撮。）之治 毒热甚。心烦咽痛。犀角元参汤（犀角、元参、大青、升麻、射干、黄
芩、人参、生甘草、加连柏山栀、去射干人参、亦名犀角大青
汤。）之治发 毒盛。心烦狂言。消毒犀角饮（犀角、牛蒡、荆芥、防风、薄荷、大青
、连翘、桔梗、生甘、内热加芩连。）之治发 瘾疹。咽喉肿痛。一概抹煞。未免执
一偏之见矣。惟余师愚《疫疹一得》。详辩 疹。确有见地。足为近今猩红热疫之标准
。今特节述其说曰。古人言热未入胃。早下之。热乘虚入胃。故发 。热已入胃。不
即下之。胃热不得泄。亦发 。此指伤寒化热。误下失下而言。若疫证未经表下。不一
二日而即发 疹者。若迟至四五日而仍不透者。非胃虚受毒愈深。即发表攻里过当。至
论赤者胃热极。五死一生。紫黑者胃烂。九死一生。余断生死。则又不在 之大小紫黑
。总以其形之松浮紧束为凭。如 一出。松活浮于皮面。红如朱点纸。黑如墨涂肤。此
毒之松活外见者。虽紫黑成片可生。一出虽小如粟。紧束有根。如履透针。如矢贯的。
此毒之有根锢结者。纵不紫黑亦死。其色红而活。荣而润。或淡而润。皆 疹之佳境也
。若淡而不荣。或娇而艳。或干而滞。其血最热。若色深红。较淡红稍重。色紫艳如胭
脂。较深红更恶。色紫赤类鸡冠花。较艳红毒火更盛。色青紫如浮萍之背。多见于胸背
。乃胃热将烂之候。其治法。总宜大清胃热。兼凉血解毒。以清瘟败毒饮为主。（生石
膏、知母、犀角、鲜生地、赤芍、丹皮、栀子、黄芩、连翘、元参、桔梗、生甘、鲜竹
[Causes] Whenever a Shanghan (Cold Damage) patient requires sweating but does not sweat, or requires purgation but does not purge, heat-toxin accumulates in the Stomach. Blood-heat and Qi-heat surge, penetrating from the muscles to the skin and bursting outward, resulting in the eruption of macules and papules (maculae et papulae). Even eruptions caused by Warm-Toxin (Wendu) or Heat Disease (Re Bing) stem from excessive blood-heat and toxin. These are all classified as Yang-type eruptions. Some may have concurrent rashes, and even sores. Fresh red color indicates Stomach-heat; purple-red indicates extreme heat; purple-black indicates rotting of the Stomach tissue. Eruptions first appear on the chest, back, hypochondrium, epigastrium, and abdomen, then spread to the head, face, neck, and limbs. If caused by excessive sexual activity damaging Kidney-Yin internally, or by excessive use of cold medicines (such as taking too many cooling drugs or indulging in raw/cold foods) damaging Spleen-Yang internally, followed by a new contraction of cold pathogen, the rootless and unanchored fire is forced upward, steaming the Lung Meridian, and floating on the skin to form spots. These are all classified as Yin-type eruptions, also known as deficiency macules. Their shape resembles bites from mosquitoes, fleas, or lice: sparse and mostly pale red, or pale white with slight redness. Some may be pale black, appearing only between the two loins and lower abdomen. Therefore, when treating eruptions, one must examine the four aspects of deficiency/excess and cold/heat; this is the primary step in seeking the root cause during clinical practice.
[Symptoms] For Yang-type eruptions: Newly contracted Shanghan is mild; latent Qi Heat Disease is more severe; epidemic Warm-Toxin is especially severe. In Shanghan where sweating was indicated but missed, at the stage where eruptions are about to emerge but not fully transparent, symptoms include headache and body pain, high fever without sweat, slight aversion to wind and cold, chest stuffiness and discomfort, tongue coating yellow-white mixed, or thin white slightly dry, with red edges and tip. Where purgation was indicated but missed, at the stage where eruptions are about to penetrate but not yet out, symptoms must include high fever, epigastric stuffiness, restlessness, headache, dry nose, dry throat, dry mouth, groaning, insomnia, constipation, and dysuria. The tongue coating turns from white to yellow: lightly tender yellow and thin greasy, heavily deep yellow with gray. In Heat Disease eruptions, acute cases erupt after 1-2 days of fever, chronic cases after 4-5 days. Superficial eruptions are fresh red, raised, and loose on the skin surface; deep eruptions are purple-red, dense, firm, bound, and rooted. Symptoms must include chest oppression, high fever with coma, vomiting, inability to eat, sore throat, swollen throat, thirst preferring cold drinks, foul breath, tongue coating bright yellow (lightly rough and dry with bright red tongue body; heavily yellow with gray spots and purple-red tongue root). In Warm-Toxin eruptions, while the toxin is latent internally, symptoms may show low-grade fever not obvious to touch, unclear consciousness, delirious laughter, or even coma resembling death, with gray-black tongue coating and a black halo in the center. When eruptions burst out violently, they often accompany rashes or sores. Severe cases show uniform redness of the skin, eruptions dense like needle heads, purple-black patches, or mixed rotten black decay. Symptoms include red face, sore throat, swollen red throat possibly with necrosis, red eyes, scorched lips, epigastric stuffiness and burning, extreme thirst, open-mouth breathing with foul odor, deafness, cold feet, constipation, dark urine, coma with delirium or mutism resembling shock, purple tongue with yellow coating (or yellow-greasy with gray), even scorched purple with peeling or black halos. These are all Yang-type eruptions of varying depth and severity, characterized by excess rather than deficiency.
For Yin-type eruptions, they belong to internal injury complicated by external contraction. Those with damaged Spleen-Yang show faint, sparse eruptions, mostly pale red, or mixed with pale gray or white, ranging from 3-5 to 6-7 spots, shaped like mosquito bites, visible only on hands and feet or slightly on the abdomen; they resemble macules but are actually fine papules. Symptoms include cold extremities, mental fatigue and drowsiness, preference for sleeping curled up, consciousness fluctuating between clear and confused, low voice, short breath, reluctance to speak, loose stools, clear or pale yellow urine, white and tender-slippery tongue coating, or fat-tender black-moist coating. Those with damaged Kidney-Yin show spots that are mostly pale black and withered, or pale white and tender, ranging from 8-9 to over 10 spots, mostly appearing on the loins and lower abdomen. Symptoms include dizziness, heavy head difficult to lift, closed eyes with photophobia, tinnitus resembling deafness, tender red malar flush, sore waist, cold feet, mental depletion, dryness of the five fluids, muscle twitching and tremors, slight convulsions of hands and feet, frequent seminal emissions in men, leukorrhea and heavy waist in women, round-tender-fat tongue, pale black coating with little moisture, or red tongue with smoke-like hidden coating, or purple-crimson round tongue, dry but without prickles, or purple and fresh-moist, occasionally with slight white coating. These are Yin-type eruptions that resemble macules but are not true macules, characterized by deficiency rather than excess.
In summary, true macules do not have raised granules; touching them feels flat against the skin and flesh, regardless of size, lacking any rough texture, presenting only visual forms. Red patches dense like brocade patterns indicate Stomach-blood heat and toxin; intense toxin makes them red-purple, heavy toxin makes them black-blue. Pale, non-vivid, sparse spots like mosquito bites indicate deficiency predominating over pathogen. Qi-deficiency presents as pale-light red; Yin-deficiency presents as pale-light black. One must first distinguish the cold/heat and deficiency/excess of the disease state to determine the severity and prognosis. (Xu Rongzhai notes: The summary in the latter part is the key to syndrome differentiation.)
[Pulse] Left pulse floating, wiry, and rapid; right pulse floating, surging, and slippery: This indicates exterior cold trapping interior fire. Due to missed sweating, heat-toxin exploits the gap to cause eruptions. Right pulse surging, full, slippery, and rapid, exceeding the left hand in magnitude: This indicates excessive Stomach-heat. Due to missed purgation, fire-toxin bursts outward causing eruptions. Right pulse long, large, slippery, and rapid; left pulse also floating, wiry, and fighting-rapid: This indicates excessive blood-heat in the Stomach, with toxin spreading through the Triple Burner causing eruptions. Pulse is hidden/fu, and eruptions are also hidden/fu; eruptions appear, and pulse appears: This indicates Stomach blood-toxin congestion and stasis-heat blocking Ying and Wei, causing eruptions to hide. When eruptions appear, they will likely mix with Dan-rash (scarlet rash), or even pea-pox. Right pulse floating, soggy, and deficient; left pulse deep, choppy, nearly absent: This indicates Yang being forced by Yin, leading to dispersion or flight. Thus, pale-red eruptions appear slightly on limbs and large abdomen, known as Tao Jie'an's "Internal Cold Injury Macules." Left pulse fine, rapid, and urgent; right pulse floating, large, and empty: This indicates Yin being consumed by Yang, leading to withering or desiccation. Thus, pale-black spots appear slightly on loins and lower abdomen, known as Chen Nianyi's "Kidney Yin Deficiency Macules."
In general, once eruptions have appeared, if the pulse is surging, slippery, and forceful, hands and feet are warm, and consciousness is clear, the disease course is smooth and auspicious. If the pulse is deep, weak, and spiritless, extremities are cold, and consciousness is dim, the disease course is adverse and ominous. (Xu Rongzhai notes: The latter summary is the key to pulse diagnosis and syndrome differentiation.)
[Treatment] For Shanghan requiring sweating but missed: Use Tou Ban Jie Du Tang (Macule-Releasing Toxin-Detoxifying Decoction, see Epidemic Malaria treatment) plus Sheng Ge Gen (Radix Puerariae Lobatae, 1-1.5 qian). Use acrid-cool muscle-releasing methods to release the exterior, ensuring eruptions reach the surface simultaneously with sweat. For those requiring purgation but missed: Use Chai Qin Qing Ge Jian (Bupleurum and Scutellaria Clearing Diaphragm Decoction), remove Chai Hu, add Sheng Ge Gen (1 qian), Chao Niu Bang Zi (Fructus Arctii Lappae, 3 qian), Huo Shui Lu Sun (Shoots of Phragmites Communis, 2 liang), Xian Mao Gen (Rhizoma Imperatae Cylindricae, 1 liang; decoct these two to replace water). Open upper and descend lower to clear the middle, ensuring eruptions exit with stool.
For Heat Disease eruptions: If bowels are open, use Xin Jia Bai Hu Tang (Newly Modified White Tiger Decoction) plus Qing Lian Qiao (Flos Lonicerae Japonicae, 3 qian), Chao Niu Bang Zi (3 qian). Use acrid-cool macule-releasing to drain heat. If bowels are closed, use Bai Hu Cheng Qi Tang (White Tiger and Da Huang Purgative Decoction) plus Lian Qiao and Niu Bang Zi (3 qian each), Huo Shui Lu Sun, Xian Ye Gu Gen Jian (Tips of Rhizoma Ziziphi Spinosae? Note: Text says Ye Gu Gen, likely Ziziphus or similar root, 2 liang each; decoct to replace water). Resolve both exterior and interior to expel heat.
For Warm-Toxin eruptions: If bowels are open, use Xi Ling Zhu Shi Tang (Rhinoceros Horn, Antelope Horn, Bamboo Resin, and Gypsum Decoction, see Red Diaphragm treatment) plus Huo Shui Lu Sun (2 liang), Da Qing Ye (Folium Isatidis, 5 qian). Use cool-clearing detoxification to release macules. If bowels are closed, use Jie Du Cheng Qi Tang (Detoxifying Purgative Decoction) plus Zi Xue (Purple Snow). Attack the Triple Burner directly to expel toxin.
For Yin-type eruptions with damaged Spleen-Yang and Yang forced by Yin: Chronic cases use Shen Fu San Bai Tang (Ginseng, Aconite, and Three Whites Decoction: Lao Dong Shen, Sheng Bai Zhu, Bai Fu Ling, Chao Bai Shao each 1.5 qian, Hei Fu Kuai 1 qian, Qing Zhi Gan Cao 8 fen, Sheng Jiang 2 slices, Da Hong Zao 2 pieces). Tonify middle and boost Qi to support Yang. Acute cases use Hui Yang Ji Jiu Tang (Restore Yang Emergency Rescue Decoction). Boost Qi and secure collapse to retrieve Yang. Tao's Tiao Zhong Tang contains too many acrid-dispersing herbs, accelerating the escape of deficient Yang; it is mismatched and should not be used recklessly.
For damaged Kidney-Yin and Yin consumed by Yang: Use Gui Bai Di Huang Tang (Tortoise Shell, Phellodendron, and Rehmannia Decoction) or Zi Shen Yi Yin Jian (Nourish Kidney and Benefit Yin Decoction), choosing appropriately to clear and nourish. If due to sexual exhaustion or Yin-Yang exchange with heat entering the Essence Chamber, modify Tao's Xiao Yao Tang. Both are deficiency macule syndromes; do not treat merely by seeing macules. In summary, never treat macules solely based on their presence. Must examine pulse (floating-large-slippery-rapid vs. deep-weak-choppy-micro), patient's Qi/Blood deficiency/excess, and disease state cold/heat/damp/dry to prescribe individually. This is the essence of treating macules.
[Commentary by Xiu] In Shanghan, if sweating and purgation are appropriate, and in Warm diseases, if clearing and resolving are effective, pathogens do not stagnate, and no macules appear. Even if faint spots appear, they are mostly rashes. Sun-luo blood-heat causes red rashes; membrane-dwelling damp-heat causes white rashes (Bai Pi, later called Bai Fei, is actually a common name for rashes). Modern colloquialism calls macular Shanghan "Fa Ban Shanghan," mistakenly confusing rashes with macules. True macules usually arise from Warm-Heat combined with Cold. Initially fearing acrid-cool opening, practitioners stick to old Shanghan formulas, using excessive acrid-warm drying-hot drugs, forcing evil-heat into the Ying level to cause eruptions. Thus, Shanghan macules result from improper sweating/purgation; Warm disease macules result from missed clearing. All stem from pathogen stagnation in Stomach and heat steaming into macules. If initial treatment were correct, how would macules form? Only Warm-Toxin and Heat-Epidemic inevitably cause macules/rashes.
When macules are forming but not yet out, first differentiate symptoms. After sweating, clearing, or purging, if pathogen remains unresolved, and patient has high fever, no sweat, chest oppression, cough/vomiting, restlessness, insomnia, deafness, cold feet, and hyperactive Cun/Guan pulses (even hidden), this indicates impending eruption. Once erupted, use red paper dipped in sesame oil lit to illuminate face, back, chest, limbs. Large red spots flat on skin are Macules (Ban). Small red spots raised on skin are Rashes (Zhen). Ban is larger, Zhen smaller; Ban is flat, Zhen raised; Ban is severe, Zhen mild. Ban with Dan-rash is severe; Ban with Pea-pox is worse. Black Ban like fruit scabs, Blue Ban like rotten green fruit are extremely severe and fatal.
Treatment priority: Cool blood, promote Qi circulation, detoxify, and release macules. Cooling blood: Xi Jiao, Ling Jiao, Da Qing Ye, Xian Sheng Di, Xian Mao Gen, Qing Hao Nao, Zi Cao, Dan Pi, Shan Zhi, Yuan Shen. Promoting Qi: Cong Bai, Dou Chi, Ge Gen, Bo He, Nen Sang Ya, Shui Lu Sun, Gu Gen Jian, Qing Ruo Ye, Xian Zhu Ye Juan Xin, Xian Shi Chang Pu Ye. Detoxifying: Jing Yin Hua, Xian Ju Ye, Xian Pu Gong Ying, Zi Hua Di Ding, Sheng Lv Dou Zhi, Ying Bai Jin Zhi, Ren Zhong Huang, Niao Jin Shi Gao, Da Hei Mu Er, Zi Jin Ding Pian. Releasing macules: Niu Bang, Lian Qiao, Chan Yi, Jiang Can, Jiao Ci, Gou Teng Gou, Ci Ji Li, Xian Xi He Liu Ye. (Ji Li and Xi He Liu, when paired with cool-clearing herbs, rapidly reach meridians and extract macules efficiently; do not discard due to warmth). If macules hide embedded in flesh, add Sheng Ma and Xi Xin to ascend and disperse, otherwise toxin won't release quickly. If toxin stagnates with constipation, use Jie Du Cheng Qi or Xi Lian Cheng Qi to purge rapidly; interior must open for hidden macules to emerge.
If Spleen-Yang is injured with Qi sinking and pulse large/weak/powerless, use Bu Zhong Yi Qi Tang or Ren Shen San Bai Tang to raise and tonify middle Qi to lift macules. If Kidney-Yang is injured with Yang blocked by Yin and pulse deep/fine/micro, use Zhen Wu Tang + Gao Li Shen, Lu Jiao Jian; Tong Mai Si Ni Tang + Ren Shen, Lu Rong. Warm and transform Yin-stagnation to tonify and support. Yang must flow for deficiency macules to emerge. Warm-Toxin involves interior stagnation resolved by cool-purgatives; Deficiency-Cold involves Yin-stagnation resolved by warm-tonics. Methods differ, principle is same. For Spleen/Kidney Yin deficiency, use Zhang's Bu Yin Yi Qi Jian or Tao's Xiao Yao Tang. One tonifies lower and opens middle; one clears/nourishes Yin and opens Qi. Repeated tonification allows deficiency macules to emerge, similar to Yin-type eruptions responding to warm-tonics. Thus, treating macules requires assessing Yuan-Qi deficiency/excess, Yin/Yang prosperity/decline, identifying causes, differentiating current signs, and observing color/pulse to avoid hasty errors. Yu's methods are comprehensive; students expanding upon them can master the subtleties of macule treatment.
[Commentary by Lian] During the Guangxu era, famous physician Lu Jiuzhi wrote "Dan Sha Ban Zhen Bian," holding unique views. Excerpt: Dan, Sha, Ban, Zhen. Dan and Ban are similar (flat, patchy); Sha and Zhen are similar (raised, dotted). Sha is mild, Dan severe; Zhen is mild, Ban severe. Dan/Ban originate from skin, flat patches; Sha/Zhen rise from skin, dotted. Sha originates from Lung, treated by ascending/releasing with slight cooling. Zhen originates from Stomach, treated by cooling with slight ascending. Do not use cold-purgatives early for Sha; do not use acrid-dispersion late for Zhen. Base treatment on Ge Gen Qin Lian Tang principles, modifying ingredients (Sheng Ma, Ge Gen, Lian Qiao, Niu Bang, Chai Hu, Huang Qin, Shan Zhi, Gan Cao, Yin Hua, Chi Shao, Yuan Shen, optionally Can, Chan, Xi He Liu). This handles nuances accurately. Historically, treating with acrid-dispersion forbids cold-purgation, and vice versa, leading to failure. For Dan/Ban (severe interior heat), large doses of cold herbs (Shi Gao essential, Xi Jiao forbidden) are needed, beyond simple Sha/Zhen treatment. All four cause epigastric stuffiness; resolution depends on clearing stuffiness. All four cause high fever; resolution depends on sweat transparency. Treat Sha/Zhen by combining ascending/clearing and exterior/interior therapy, ensuring Sha/Zhen exit with sweat. Patients suffer unbearable stuffiness during eruption; moving hides spots, causing interior collapse. Negligence in covering/sleeves stops sweat, drying body. Two dangers: open pores invite wind; excessive sweating depletes fluids, increasing heat. Variations stem from improper sweating. This applies generally but critically to Sha/Zhen.
Sha is commonly known as Measles. Qianzhe Shao Xianggen stated Zhen and Sha are similar, entering Lung via seasonal toxins. Pathogen excess causes dense spots, slight swelling/itching, red/white types. Ying-level = Red Zhen; Wei-level = White Zhen. Avoid wind/cold constraint causing Lung closure, asthma, death. Treatment: Acrid-cool clear-release, diffuse Lung, resolve pathogen. Sha and Zhen are essentially one, requiring light dispersal to diffuse Lung Qi. Lung Qi diffusing allows exit via skin. Often accompanied by sore throat, cough, reverse Qi. Using only Sheng Ma/Chai Hu/Ge Gen to ascend blindly risks Lung obstruction and asthma death. Remove Sheng Ma, Chai Hu, Huang Qin; add Lu Sun, Tong Cao, Deng Xin for light-yang clear-release method.
Regarding Dan/Ban from severe interior heat, large cold-purgation is good. But forbidding Xi Jiao ignores ancient formulas: Xi Jiao Da Qing Tang (for severe toxin, irritability, sore throat); Xi Jiao Yuan Shen Tang (for severe toxin, mania); Xiao Du Xi Jiao Yin (for macules/rashes, sore throat). Dismissing these is biased. Yu Shiyu's "Yi Zhen Yi De" details Ban/Zhen differentiation well, serving as standard for Scarlet Fever/Epidemic. Excerpt: Ancient texts say premature purgation lets heat enter Stomach causing Ban; delayed purgation lets Stomach heat accumulate causing Ban. This refers to Shanghan transforming to heat with mis-purgation. For Epidemic diseases, eruption within 1-2 days without prior release/purge indicates deep toxin absorption; delay until 4-5 days indicates excessive release/purge. Red indicates extreme Stomach heat (5 deaths, 1 life); Purple-black indicates Stomach rot (9 deaths, 1 life). However, prognosis depends not on size/color but on looseness/tightness. Loose, floating eruptions (red like cinnabar on paper, black like ink on skin) indicate toxin releasing externally; even purple-black patches can survive. Tight, rooted eruptions (small like millet, tight like needle piercing target) indicate toxin anchored internally; even without purple-black, death ensues. Red, vibrant, moist, or pale-moist are favorable. Pale-non-vibrant, delicate-bright, or dry-stagnant indicate hottest blood. Deep red heavier than pale; Purple-bright like rouge worse than deep red; Purple-red like cockscomb flower stronger fire than bright red; Purple-blue like duckweed back (often on chest/back) indicates impending Stomach rot. Treatment: Clear Stomach heat massively, cool blood, detoxify. Main formula: Qing Wen Bai Du Yin (Shi Gao, Zhi Mu, Xi Jiao, Xian Sheng Di, Chi Shao, Dan Pi, Shan Zhi, Huang Qin, Lian Qiao, Yuan Shen, Jie Geng, Sheng Gan Cao, Xian Zhu...)