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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?