论曰。发斑一证。缘仲景书遗逸不详见。故诸家之说无所统。大
抵斑有数种。惟热毒入胃者当下之。非下斑也。下其胃中之毒也。而
胃中之毒。由斑而后见也。若皮间暴作瘾疹。无他里热证者。不可
下。当服平凉去风解肌药。及以摩膏治之。若在春末及夏。不宜火灸
及重覆。随其浅深略分内外。不可一切用药。亦表虚不可发汗也。
千金方载华元化之言曰。伤寒热毒之气。五日在腹。六日入胃。
乃可下也。若热毒在外。未入于胃。而先下之者。其热乘虚入胃。则
烂胃也。然热入胃。要须下去之。不可留于胃中。胃若实。其热为病。
三死一生。胃虚热入。烂胃也。其热微者。赤斑出。此候五死一生。剧
者黑斑出。此候十死一生。
千金又曰。病者过日。不以时下。则热不
得泄。亦烂胃斑出。雍曰。发斑有下之太早者。有失下者。故王仲弓
谓下早热入胃者斑出。下之迟失下之亦斑出。
活人书曰。发斑有两证。温毒热病。皆有斑也。温毒发斑者。冬
时触冒寒毒。至春始发。病初在表。或已发汗吐下。而表证未罢。毒
气未散。故发斑。黑膏主之。又冬月温暖。人感乖戾之气。冬未即病。
至春或被积寒所折。毒瓦斯不得泄。至天气暄热。温毒始发。则肌肉斑
烂。瘾疹如锦文。内攻心闷。但呕清汁。葛根橘皮汤主之。雍详发斑。
有阳毒温毒热病。热病。即今之伤寒也。温毒发斑于三日之内。毒瓦斯
在表时即出。以此验其温毒。非热病也。盖其毒久郁而发。病不在
里。故不可下。必随表证治之。当用药解肌热。麻黄桂枝皆不可用
也。如三日毒不解。其病入里。则同伤寒治之。
又曰。热病发斑。与时气同。或未发汗。或已经汗下而热毒不
散。表虚里实。热毒乘虚出于皮肤。所以发斑。雍曰。此证是温毒发
斑也。与伤寒发斑不同。盖温毒之毒本在里。久为积寒所折。腠理闭
塞不得出。及天气暄热。腠理开疏。乃因表虚郁发为斑。是时在里之
毒发在表。故可解肌而不可下也。伤寒之毒。初亦在里。久不能出。
及春再感温气。腠理方开。随虚而出于表。遂见表证。而未成斑也。
医者昧于表里之证。下之太早。时内无毒瓦斯可下。所损皆胃之真气。
真气既损。则胃为之虚矣。邪毒者。乘虚而出。乘虚而入者。以先损
之虚胃。而当复入之今毒。力必不胜。而胃将烂。是以其华见于表而
为斑。则伤寒之毒。初蕴于里出而之表耳。既见于里。又见于表。是
毒瓦斯往来者再矣。诸经者。血脉之道路也。今邪毒往来于道路。而营
卫气血不通。其人可久乎。此其所以不通也。然温毒之斑。惟感于动
而发。从而散之。则去矣。伤寒之毒。已发而复遏之。又虚而复客之。
即入于胃。如升堂入室。不复可逐。必使下泄于肠胃则可出。故必下
之。所以救胃烂也。元化曰。要须下去之。不可留于胃中是也。故温
毒之斑。郁发之毒也。伤寒之斑。烂胃之证也。发则可去。烂则不可
生。是以言五死一生。十死一生也。其烂如何。曰。毒热焚于内。则胃
为疮烂矣。
又曰。大抵发斑。不可用发表药。盖表虚里实。若发汗重令开
泄。更增斑烂也。元参升麻汤、大青四物汤、猪胆鸡子汤。可选用之。
雍曰。温毒发斑。感在表。惟可解肌。不可发汗。伤寒发斑。毒瓦斯在
胃。当下不当汗也。故皆腹痛。眼睛疼。身体倦怠。四肢逆冷。额上手
背冷汗不止。或多烦渴。精神恍惚。如有所失。二三日间。或可起行。
不甚觉重。诊之则六脉沉细而疾。尺部短小。寸口脉或大。若误服
凉药。则渴转甚。烦躁急。有此病证者。便须急服辛热之药。一日或
二日便安。
又曰。若阴毒渐深。其候沉重。四肢逆冷。脘腹转甚。或咽喉不
利。心下胀满。结硬躁渴。虚汗出不止。或时郑声。指甲面青色黑。六
脉细沉而疾。一息七至以上。有此证者。速于气海及关元二穴灸二
三百壮。以手足和暖为效。仍兼服诸丹散。内外逼逐。令阳气复而大
汗解矣。若阴毒盛而阳气暴绝。则为阴毒。阳毒盛而阴暴绝。则为阳
毒。大抵离绝阴阳。非大汗不能复其正气也。
又曰。若阴毒已深。疾势困重。六脉附骨。取之方有。按之则无。
一息十至以上。或不可数。至此则药饵难为功。但于脐中用葱熨法。
或灼艾三五百壮。如手足不温。不可治也。如手足温。更服药以助
之。若阴气散。阳气来。则渐减热药调治之。阳气乍复。往往却烦躁。
切不可投凉药。烦躁甚者。再与返阴丹则定也。
又曰。六脉俱浮大。或沉取之而不甚疾者。非阴证也。大抵阳毒
伤寒。其脉多弦而洪数。阴毒伤寒。其脉沉细而弦疾。
又曰。阳盛则身热而无汗。阴盛则身冷而有汗。岐伯曰。阳盛则
身热。腠理闭。喘粗为之俯仰。汗不出而热。阴盛则身寒汗出。身常
清。数 而寒。寒而厥。不可用发表药。雍曰。发斑一证。以仲景不
言。故诸书少至当之论。既不分温毒伤寒在表在里不同。又不别发
斑瘾疹诸疮之异。虽朱氏亦然。活人书曰。斑疮瘾疹如锦文。俗名麸
疮。素问谓之疹。此亦发斑、瘾疹、麸疮三病为一证也。雍详发斑。未
尝成疮也。伤寒之斑。初如朱砂细点。又如狗蚤啮痕。初甚稀有。渐
加稠密是也。瘾疹略如风尸。亦有赤白二种。赤者如锦文也。不如风
尸之高起。渐隐而起相连续。初多起臂腿。次满腹背。皆成锦花者是
也。温毒之斑。略类赤色瘾疹。又不与伤寒斑同。至俗名麸疮者。乃
是阳毒诸疮之类。与斑疹二者不同。古有阳毒疮者。即本俗名豆疮、
麻子疮、水铃、麸疮。皆是也。皆因形名之。每有轻重。惟豆疮为至
重。其他若误服凉药。亦皆能杀人。又有暴发锦文瘾疹者。初无伤寒
证。但前一日二日减食。情思不佳。次必臂腿瘙痒。搔之随手锦文
出。丹毒治之。涂赤小豆鸡子清甚佳。胸中余毒不去。则胸中烦闷。
不入食。二三日。服解毒药。去毒尽乃安。石南汤、元参升麻汤。正解
此毒。诸家论斑毒疮疹皆为一类。故此略辨之。其详自有阳毒斑疮
论。并在小儿伤寒部中。
问曰。仲景不言斑者。何也。庞氏曰。古方虽有治方。而法不详
备。疑当时热毒未甚。鲜有死者。雍曰。非也。其论亡逸也。如阴阳二
毒。本论皆无。考之千金。则知尝有而今亡矣。亦犹是也。又仲景自
治伤寒。必不至出斑。盖伤寒之斑非本证。皆医者之所为。仲景不可
下则不下。可下则下。必不至于下之早。亦必不至于失下。何缘有斑
出。阳明证中多言急下之者是也。亦恐伤寒为庸医所误。则斑出。故
不得不论耳。医者苟能工于汗下证。则结胸。痞气。发斑。发黄。皆不
应有。可不审哉。
问曰。诸证发斑。何药以解之。孙真人曰。凡除热解毒。无过苦
酢之物。故多用苦参、青葙、艾、栀子、葶苈、苦酒、乌梅之属。是其要
也。热盛非苦酢之物不解。热在身中。既不时治。治之又不用苦酢之
药。如此。救火不以水也。今诸疗治。多用甘、辛。姜、桂、人参之类。
此皆贵价不常有。比行求之。转以失时。而苦参、青葙、葶苈、艾之
属。所在尽有。除热解毒最良。得病内热者。不必按药决也。便以青
葙、苦参、艾、苦酒疗之。但稍与。促其间。无不解也。雍曰。此论不暇
寻求。所在可得之药。其他则如千金活人书庞氏论中。药与证相对
者皆可用。前已载之矣。
问曰。斑出必欲下。何药为宜。雍曰。三者之病。阳毒最为重。其
斑为证自有之。治从本方。温毒内外热盛。不能偏表偏里。须两解之
以去内外热。宜白虎加人参汤、化斑汤。若内外热太甚者。根据阳毒治
之。常时伤寒误下失下致斑出者。其毒已入胃。审其无表证。有下
证。宜用调胃承气汤以除胃中热。盖此斑非独表证也。
雍论曰。仲景本论不见斑证。惟千金方载华佗之说。最为至当。
而近时医家多不见取。故其论不分毒在表里。仍并疮疹混为一说。
设误汗下。宁不害人。惟庞氏朱氏善究根源。持论亦如此。若不用华
言。则无用调胃承气之理。雍曰。睹其效验。故主其说。然已经孙真
人手。复何疑哉。
论述说：发斑这一病症，由于张仲景的著作中遗缺失传、记载不详，所以各家学说缺乏统一的标准。大体上，斑疹有几种类型，只有热毒侵入胃腑的才应当使用下法，这并非直接攻下斑疹，而是攻下胃中的热毒。而胃中的热毒，是由斑疹显现后才被发现的。如果皮肤间突然发作瘾疹（一种类似荨麻疹的皮肤瘙痒症），没有其他里热证候的，不可使用下法，应当服用平和凉润、祛风解肌的药物，并配合外用摩膏治疗。如果在春末及夏季，不宜用火灸及厚衣重覆保暖的方法，应根据病邪深浅略分内外，不能一概用药，同时也因为表虚不可发汗。
《千金方》记载华元化（华佗）的话说：伤寒热毒之气，第五天在腹部，第六天进入胃腑，这时才可以攻下。如果热毒还在体表，未进入胃腑，就先用下法，那么热毒就会乘虚进入胃腑，导致胃腑腐烂。然而热毒一旦入胃，必须将其攻下排出，不可留在胃中。如果胃气充实，热毒致病，十人中有九个死亡，一人可生；如果胃气虚弱，热毒侵入，会导致胃腑腐烂。热毒轻微的，出现赤色斑疹，这种证候十人中有五个死亡，一人可生；病情严重的，出现黑色斑疹，这种证候十人中有九个死亡，一人可生。
《千金方》又说：病人过了发病日期，不及时攻下，热毒就无法宣泄，也会导致胃腑腐烂而发斑。郭雍说：发斑有的因为攻下太早，有的因为该下而未下（失下）。所以王仲弓说，攻下过早导致热毒入胃而发斑，攻下过迟或失下也会发斑。
《活人书》说：发斑有两种证候，温毒和热病都会出现斑疹。温毒发斑，是冬季感受寒毒，到春季才发作。病初在表，或者已经经过发汗、吐、下治疗，但表证未罢，毒气未散，所以发斑，用黑膏主治。另外，冬季气候温暖，人感受了乖戾不正之气，冬天并未立即发病，到了春天又被积寒所遏制，毒气不得宣泄，等到天气变暖炎热时，温毒才发作，则肌肉斑烂，瘾疹如锦纹般美丽，内攻导致心闷，只呕吐清汁，用葛根橘皮汤主治。郭雍详细分析发斑，有阳毒、温毒、热病之分。热病，就是现在的伤寒。温毒发斑在发病三日之内，毒气在表时就发出，以此验证其属于温毒，而非热病。大概是因为毒气久郁而发，病不在里，所以不可攻下，必须随表证治疗，应当用药解肌热，麻黄、桂枝都不可用。如果三天后毒气不解，病邪入里，则同伤寒治疗。
《活人书》又说：热病发斑，与时行疫病相同，或者尚未发汗，或者已经发汗、攻下但热毒不散，表虚里实，热毒乘虚出于皮肤，所以发斑。郭雍说：此证是温毒发斑，与伤寒发斑不同。大概温毒之毒本在里，长久被积寒所遏制，腠理闭塞不得外出，等到天气变暖炎热，腠理开疏，于是因表虚郁结而发为斑。此时在里的毒发于表，所以可以解肌而不可攻下。伤寒之毒，起初也在里，长久不能外出，到了春天再次感受温气，腠理才开，随虚而出于表，于是见到表证，但尚未形成斑疹。医生不明白表里证候的区别，攻下太早，此时内无毒气可下，所损伤的都是胃的真气。真气既已受损，胃就变虚了。邪毒乘虚而出，又乘虚而入，以先损之虚胃，来容纳复入之新毒，力量必定不胜任，胃将腐烂。因此其荣华见于表而为斑，这是伤寒之毒，起初蕴藏在里，出而至于表罢了。既见于里，又见于表，这是毒气往来两次了。诸经，是血脉的道路。现在邪毒在道路中往来，导致营卫气血不通，这个人能长久吗？这就是不通的原因。然而温毒之斑，只在感动时发作，从而疏散它，就能去除。伤寒之毒，已经发作又被遏制，又因虚而复受客邪，即进入胃腑，如同升堂入室，不再可驱逐，必须使其从肠胃下泄才可排出，所以必须攻下，以此来挽救胃腐烂。华元化说：“必须攻下排出，不可留在胃中”，是正确的。所以温毒之斑，是郁结而发的毒；伤寒之斑，是胃腐烂的证候。发出来则可以去除，腐烂了则不可再生，所以说五死一生，十死一生。那腐烂是怎么回事呢？回答说：毒热焚烧于内，则胃成为疮烂。
《活人书》又说：大体上发斑，不可用发表药。因为表虚里实，如果发汗令其更加开泄，更会增加斑烂。玄参升麻汤、大青四物汤、猪胆鸡子汤，可以选择使用。郭雍说：温毒发斑，感邪在表，只可解肌，不可发汗。伤寒发斑，毒气在胃，应当攻下而不应当发汗。所以都有腹痛、眼睛疼、身体倦怠、四肢逆冷、额头手背冷汗不止、或多烦渴、精神恍惚如有所失等症状。二三天之间，或许还可以起身行走，不觉得特别沉重。诊脉则六脉沉细而疾速，尺部短小，寸口脉或大。如果误服凉药，则口渴转甚，烦躁急迫。有此病证的，就必须急服辛热药物，一日或二日便安。
《活人书》又说：如果阴毒逐渐加深，证候沉重，四肢逆冷，脘腹疼痛加剧，或咽喉不利，心下胀满，结硬躁渴，虚汗出不止，或有时郑声（神志不清，语言重复），指甲面色青黑，六脉细沉而疾速，一息七至以上。有此证者，速在气海及关元二穴灸二三百壮，以手足和暖为有效。仍兼服各种丹散，内外逼迫逐邪，使阳气恢复而大汗解。如果阴毒盛而阳气暴绝，则为阴毒；阳毒盛而阴暴绝，则为阳毒。大体上阴阳离绝，非大汗不能恢复正气。
《活人书》又说：如果阴毒已深，病势困重，六脉附骨，按之才有，轻按则无，一息十至以上，或无法计数。到了这种地步，药物难以奏效，只能在脐中用葱熨法，或灼艾三五百壮。如果手足不温，则不可治。如果手足温，再服药以助之。如果阴气散，阳气来，则逐渐减少热药调治。阳气乍复，往往反而烦躁，切不可投凉药。烦躁严重的，再给予返阴丹则可安定。
《活人书》又说：六脉俱浮大，或沉取之而不甚疾速的，不是阴证。大体阳毒伤寒，其脉多弦而洪数；阴毒伤寒，其脉沉细而弦疾。
《活人书》又说：阳盛则身热而无汗，阴盛则身冷而有汗。岐伯说：阳盛则身热，腠理闭，喘粗为之俯仰，汗不出而热；阴盛则身寒汗出，身常清，数栗而寒，寒而厥。不可用发表药。郭雍说：发斑这一证，因为张仲景没有论述，所以各书少有确当之论。既然不分温毒伤寒在表在里的不同，又不辨别发斑、瘾疹、诸疮的差异，即使是朱氏也是如此。《活人书》说：斑疮瘾疹如锦纹，俗名麸疮，《素问》称之为疹。这也是把发斑、瘾疹、麸疮三种病当作一证。郭雍详细分析发斑，未曾成疮。伤寒之斑，初如朱砂细点，又如狗蚤咬痕，初时很稀少，逐渐变得稠密。瘾疹略如风尸，也有赤白两种，赤色的如锦纹，不如风尸之高起，逐渐隐退又起相连续，初多起于臂腿，次满腹背，皆成锦花状。温毒之斑，略类赤色瘾疹，又不与伤寒斑相同。至于俗名麸疮的，乃是阳毒诸疮之类，与斑疹二者不同。古时有阳毒疮的，即本俗名豆疮、麻子疮、水铃、麸疮等，都是如此，皆因形状命名。每有轻重，惟豆疮最为严重，其他如误服凉药，也都能杀人。又有暴发锦文瘾疹的，初无伤寒证，只是前一两日减食，情思不佳，随后必臂腿瘙痒，搔之随手锦文出，用丹毒法治之，涂赤小豆鸡子清甚佳。胸中余毒不去，则胸中烦闷，不入食，二三日，服解毒药，去毒尽乃安。石南汤、玄参升麻汤，正解此毒。诸家论斑毒疮疹皆为一类，故此略加辨析。其详情自有阳毒斑疮论，并在小儿伤寒部中。
问：张仲景不言斑，为什么呢？庞氏说：古方虽有治方，而法不详备，疑当时热毒未甚，鲜有死者。郭雍说：不对。那是论述亡逸了。如阴阳二毒，本论皆无，考证《千金方》，则知曾经有而今亡佚了，也是同样的情况。又张仲景自己治疗伤寒，必不至于出斑。大概伤寒之斑非本证，皆是医者所为。张仲景不可下则不下，可下则下，必不至于下之早，也必不至于失下，何缘有斑出？阳明证中多言急下之者是也。也恐怕伤寒被庸医所误，则斑出，故不得不论罢了。医者如果能精通汗下证，则结胸、痞气、发斑、发黄，都不应有，可不审慎吗？
问：诸证发斑，什么药可以解除？孙真人说：凡除热解毒，无过于苦酢之物，故多用苦参、青葙、艾、栀子、葶苈、苦酒、乌梅之类，是其要也。热盛非苦酢之物不解。热在身中，如果不及时治，治之又不用苦酢之药，如此，救火不以水也。今诸疗治，多用甘、辛，姜、桂、人参之类，此皆贵价不常有，比行求之，转以失时，而苦参、青葙、葶苈、艾之类，所在尽有，除热解毒最良。得病内热者，不必按药决也，便以青葙、苦参、艾、苦酒疗之，但稍与，促其间，无不解也。郭雍说：此论不暇寻求，所在可得之药，其他则如《千金》、《活人书》、庞氏论中，药与证相对者皆可用，前已载之矣。
问：斑出必欲下，什么药为宜？郭雍说：三者之病，阳毒最为重，其斑为证自有之，治从本方。温毒内外热盛，不能偏表偏里，须两解之以去内外热，宜白虎加人参汤、化斑汤。若内外热太甚者，根据阳毒治之。常时伤寒误下失下致斑出者，其毒已入胃，审其无表证，有下证，宜用调胃承气汤以除胃中热。盖此斑非独表证也。
郭雍论述说：张仲景本论不见斑证，惟《千金方》载华佗之说，最为至当，而近时医家多不见取，故其论不分毒在表里，仍并疮疹混为一说，设误汗下，宁不害人。惟庞氏、朱氏善究根源，持论亦如此。若不用华言，则无用调胃承气之理。郭雍说：睹其效验，故主其说，然已经孙真人手，复何疑哉。
Commentary states: The syndrome of macules (skin eruptions) is not detailed in Zhang Zhongjing's writings, leading to a lack of unified theories among various schools. Generally, there are several types of macules. Only when heat-toxin enters the Stomach should purgation be used; this does not mean purging the macules themselves, but rather purging the heat-toxin within the Stomach. The heat-toxin in the Stomach becomes apparent only after the macules manifest. If urticaria (urticaria-like skin eruptions with itching) suddenly appears on the skin without other interior heat symptoms, purgation is contraindicated. One should take mild, cooling herbs that dispel wind and release the muscle layer, along with external massage ointments. In late spring and summer, moxibustion and heavy covering for warmth are inappropriate. Treatment should be slightly differentiated based on the depth of the pathogen (superficial vs. deep), and one must not apply medication indiscriminately, nor induce sweating due to exterior deficiency.
The *Qianjin Fang* records Hua Yuanhua's (Hua Tuo's) words: "In cold damage, the qi of heat-toxin resides in the abdomen on the fifth day and enters the Stomach on the sixth day; only then can it be purged. If the heat-toxin is still on the exterior and has not entered the Stomach, but purgation is applied first, the heat will enter the Stomach through the deficiency, causing the Stomach to rot. However, once heat enters the Stomach, it must be purged out and cannot remain in the Stomach. If the Stomach is full/excess, and heat causes disease, nine out of ten die, and one survives. If the Stomach is deficient and heat enters, the Stomach rots. If the heat is mild, red macules appear; in this prognosis, five out of ten die, and one survives. If severe, black macules appear; in this prognosis, nine out of ten die, and one survives."
The *Qianjin Fang* also says: "If a patient passes the appropriate time for treatment without purging, the heat cannot be vented, leading to Stomach rot and the appearance of macules." Guo Yong states: Macules may result from purging too early or from failing to purge when necessary. Thus, Wang Zhonggong said that purging too early causes heat to enter the Stomach and produce macules, while purging too late or missing the opportunity to purge also produces macules.
The *Huoren Shu* (Book of Vitality) states: There are two types of macule syndromes; both warm toxin and heat diseases can present with macules. Warm toxin macules occur when cold toxin is contracted in winter and manifests in spring. Initially, the pathogen is at the exterior. Even if sweating, vomiting, or purging have been performed, if the exterior syndrome persists and the toxic qi has not dispersed, macules will appear, treated primarily with Hei Gao. Additionally, if the winter is unusually warm, people contract aberrant qi. They do not fall ill immediately in winter, but in spring, they may be constrained by accumulated cold, preventing the toxic qi from venting. When the weather becomes hot, the warm toxin erupts, causing muscle maceration and macules like brocade patterns. Internally, this attacks the heart causing oppression, with only clear fluid vomited; Ge Gen Ju Pi Tang is indicated. Guo Yong analyzes macules in detail, distinguishing between Yang Toxin, Warm Toxin, and Heat Disease. Heat disease refers to what is now called Cold Damage. Warm toxin macules appear within three days of onset, while the toxic qi is still at the exterior, identifying it as warm toxin rather than heat disease. This is because the toxin has been stagnant and long-suppressed before erupting; the disease is not in the interior, so purgation is contraindicated. One must treat according to the exterior syndrome, using herbs to release the muscle layer heat. Ma Huang and Gui Zhi are contraindicated. If the toxin does not resolve after three days and enters the interior, it is treated as Cold Damage.
The *Huoren Shu* further states: Heat disease macules are similar to epidemic diseases. Whether sweating has not yet been induced, or sweating and purging have already been performed but heat-toxin remains undispersed, resulting in exterior deficiency and interior excess, the heat-toxin escapes through the skin due to deficiency, causing macules. Guo Yong states: This syndrome is warm toxin macules, different from Cold Damage macules. The toxin of warm toxin originates in the interior, suppressed for a long time by accumulated cold, closing the pores so it cannot exit. When the weather warms, the pores open, and due to exterior deficiency, the stagnated toxin erupts as macules. At this time, the interior toxin erupts to the exterior, so muscle-releasing is appropriate, but purgation is not. For Cold Damage, the toxin initially resides in the interior and cannot exit for a long time. In spring, upon contracting warm qi again, the pores open, and the toxin exits through the deficiency to the exterior, presenting as an exterior syndrome but not yet forming macules. Physicians ignorant of exterior-interior distinctions purge too early. At this point, there is no toxic qi in the interior to purge, so only the true qi of the Stomach is damaged. Once the true qi is damaged, the Stomach becomes deficient. The evil toxin takes advantage of this deficiency to exit and re-enter. Using the previously damaged deficient Stomach to accommodate the newly entering toxin, strength is insufficient, leading to Stomach rot. Thus, its brilliance manifests on the exterior as macules. This means the Cold Damage toxin, initially stored in the interior, moves to the exterior. It appears in the interior and then in the exterior, meaning the toxic qi has traveled twice. The meridians are the pathways of blood vessels. Now, evil toxin travels back and forth on these pathways, blocking Ying and Wei Qi and Blood. How long can such a person survive? This is why blockage occurs. However, warm toxin macules only erupt when moved; dispersing them removes them. Cold Damage toxin, once erupted and then suppressed, and re-infected due to deficiency, enters the Stomach like entering a hall or room, making it impossible to drive out. It must be discharged through the intestines and stomach to exit, hence purgation is necessary to save the Stomach from rotting. Hua Yuanhua said, "It must be purged out and cannot remain in the Stomach," which is correct. Therefore, warm toxin macules are toxins erupting from stagnation; Cold Damage macules are signs of Stomach rotting. Eruption allows removal; rotting makes regeneration impossible. Hence, the sayings "five deaths, one life" and "ten deaths, one life." How does the rotting occur? Answer: Heat-toxin burns internally, causing the Stomach to become ulcerated and rotten.
The *Huoren Shu* also states: Generally, for macules, exterior-releasing herbs should not be used. Because there is exterior deficiency and interior excess, inducing sweating to increase opening and draining will worsen the maculation. Xuan Shen Sheng Ma Tang, Da Qing Si Wu Tang, and Zhu Dan Ji Zi Tang can be selected for use. Guo Yong states: For warm toxin macules, the pathogen is at the exterior; only muscle-releasing is suitable, not sweating. For Cold Damage macules, the toxic qi is in the Stomach; purgation is indicated, not sweating. Symptoms include abdominal pain, eye pain, body fatigue, cold limbs, continuous cold sweat on the forehead and back of hands, excessive thirst and irritability, mental confusion as if losing something. Within two to three days, the patient might still walk, feeling not overly heavy. Pulse diagnosis reveals six pulses sinking, fine, and rapid; the Chi position is short/small; the Cun position pulse may be large. If cool herbs are mistakenly taken, thirst intensifies, and irritability becomes urgent. For such patients, pungent-hot medicines must be administered urgently. Relief comes within one or two days.
The *Huoren Shu* further states: If Yin Toxin deepens, the condition becomes heavy, with cold limbs, worsening epigastric/abdominal pain, throat obstruction, chest fullness, hardness, irritability, and thirst, continuous spontaneous sweating, occasional Zheng Sheng (repetitive speech), blue-black nails and face, six pulses fine, sinking, and rapid, exceeding seven beats per breath. For such cases, moxibustion of 200-300 moxa cones should be quickly applied to Qihai and Guanyuan acupoints until hands and feet warm up. Concurrently, various Dan San preparations should be taken to force the pathogen out from inside and outside, restoring Yang Qi and resolving through profuse sweating. If Yin Toxin is excessive and Yang Qi abruptly fails, it is Yin Toxin; if Yang Toxin is excessive and Yin Qi abruptly fails, it is Yang Toxin. Generally, when Yin and Yang separate, only profuse sweating can restore the righteous Qi.
The *Huoren Shu* also states: If Yin Toxin is deeply entrenched, the disease is critical, with six pulses requiring deep pressure to feel, disappearing upon light pressure, exceeding ten beats per breath, or uncountable. At this stage, herbal medicine is ineffective. One should use the scallion warming method on the navel or apply 300-500 moxa cones. If hands and feet remain cold, it is incurable. If hands and feet warm, administer medicine to assist. If Yin Qi dissipates and Yang Qi returns, gradually reduce hot medicines for regulation. When Yang Qi temporarily returns, irritability often occurs; cool herbs must absolutely not be given. For severe irritability, Fan Yin Dan can stabilize the condition.
The *Huoren Shu* further states: If all six pulses are floating and large, or sinking but not excessively rapid, it is not a Yin syndrome. Generally, Yang Toxin Cold Damage presents with wiry, surging, and rapid pulses; Yin Toxin Cold Damage presents with sinking, fine, wiry, and rapid pulses.
The *Huoren Shu* also states: Yang excess leads to body heat without sweat; Yin excess leads to body cold with sweat. Qibo said: Yang excess causes body heat, closed pores, rough breathing, difficulty lying flat, no sweat, and heat. Yin excess causes body cold, sweating, constant chills, frequent shivering, coldness, and cold extremities. Exterior-releasing herbs are contraindicated. Guo Yong states: Regarding macules, since Zhang Zhongjing did not discuss them, few books offer definitive theories. They fail to distinguish whether warm toxin Cold Damage is at the exterior or interior, and do not differentiate between macules, urticaria, and other sores. Even Zhu Shi did this. The *Huoren Shu* states: Macules, sores, and urticaria resembling brocade patterns are commonly known as bran sores. The *Su Wen* calls them zhen. This conflates macules, urticaria, and bran sores into one syndrome. Guo Yong analyzes macules carefully; they never form sores. Cold Damage macules initially resemble fine cinnabar dots or flea bites, sparse at first, becoming dense later. Urticaria resembles Feng Shi, existing in red and white forms. Red ones look like brocade patterns, not raised like Feng Shi, fading and recurring continuously, starting on arms and legs, then filling the abdomen and back, forming brocade flower patterns. Warm toxin macules resemble red urticaria but differ from Cold Damage macules. The common name "bran sore" refers to Yang Toxin sores, distinct from macules and rashes. Ancient texts mention Yang Toxin sores, including bean sores, smallpox, water bells, and bran sores, named by shape. Severity varies, with bean sores being the most severe. Mistakenly taking cool herbs can also be fatal. There are also sudden outbreaks of brocade-pattern urticaria without Cold Damage symptoms, preceded by reduced appetite and low mood for one or two days, followed by arm and leg itching, scratching releases brocade patterns. Treat with Dan Du methods; applying red adzuki bean and egg white is excellent. If residual toxin in the chest remains, chest oppression and loss of appetite occur. After two or three days, take detoxifying herbs until the toxin is cleared for relief. Shi Nan Tang and Xuan Shen Sheng Ma Tang correctly resolve this toxin. Various schools classify macule toxins and sores/rashes together, so a brief distinction is made here. Details are found in the Yang Toxin Macule Sore treatise, located in the Pediatric Cold Damage section.
Question: Why does Zhang Zhongjing not mention macules? Pang Shi said: Although ancient formulas existed, the methods were not detailed. Perhaps the heat-toxin was not severe at the time, and few died. Guo Yong said: Incorrect. The discussion was lost. For example, Yin and Yang Two Toxins are absent from the original text. Checking the *Qianjin Fang* shows they existed but are now lost, similarly. Also, Zhang Zhongjing himself treated Cold Damage and would not have produced macules. Macules in Cold Damage are not the primary syndrome but result from physician error. Zhang Zhongjing would not purge when inappropriate, nor fail to purge when indicated, avoiding premature purging or missed opportunities. Thus, how could macules appear? The Yang Ming chapter mentions urgent purging, which is correct. It is feared that lay physicians mistreat Cold Damage, causing macules, hence the necessity to discuss it. If physicians master sweating and purging indications, Jie Xiong (chest binding), Pi Qi (stagnation), macules, and jaundice should not occur. Must one not be careful?
Question: For macules arising from various syndromes, what herbs resolve them? Sun Simiao said: For clearing heat and detoxifying, nothing surpasses bitter and sour substances. Thus, Ku Shen, Qing Xiang, Ai, Zhi Zi, Ting Li, Ku Jiu, and Wu Mei are frequently used, which are key. Severe heat cannot be resolved without bitter and sour substances. If heat is in the body and not treated promptly, or treated without bitter and sour herbs, it is like trying to extinguish fire without water. Current treatments often use sweet and pungent herbs like Jiang, Gui, and Ren Shen, which are expensive and hard to obtain, leading to delays. However, Ku Shen, Qing Xiang, Ting Li, and Ai are readily available everywhere and are best for clearing heat and detoxifying. For internal heat illness, one need not strictly follow specific prescriptions; simply using Qing Xiang, Ku Shen, Ai, and Ku Jiu, administered frequently in small doses, will resolve it. Guo Yong said: This theory does not require extensive searching; any available herb can be used. Others, as discussed in *Qianjin*, *Huoren Shu*, and Pang Shi's treatises, where herbs match syndromes, are all usable, as previously recorded.
Question: Since macules require purging, what herbs are suitable? Guo Yong said: Among the three diseases, Yang Toxin is the most severe, and its macules arise naturally from the syndrome; treat according to the primary formula. Warm Toxin has severe internal and external heat, unable to focus solely on exterior or interior; both must be resolved to remove internal and external heat. Bai Hu Jia Ren Shen Tang and Hua Ban Tang are suitable. If internal and external heat are extremely severe, treat according to Yang Toxin. For ordinary Cold Damage where mistaken or missed purging caused macules, the toxin has entered the Stomach. Confirm no exterior syndrome and presence of purgation indications; use Tiao Wei Cheng Qi Tang to remove Stomach heat. These macules are not solely an exterior syndrome.
Guo Yong comments: Zhang Zhongjing's original text does not show macule syndromes. Only the *Qianjin Fang* records Hua Tuo's theory, which is most appropriate, but recent physicians rarely accept it. Thus, their discussions fail to distinguish toxin location (exterior vs. interior) and confuse sores and rashes into one explanation. Mistaken sweating and purging would surely harm people. Only Pang Shi and Zhu Shi investigate the root cause well, holding similar views. Without Hua's words, there would be no rationale for using Tiao Wei Cheng Qi Tang. Guo Yong states: Observing its efficacy, I support this theory. Moreover, it has been handled by Sun Simiao; what doubt remains?