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[General Principle] Zhang Zhongjing said: In the disease of Yang Du (Yang Toxin), the face is red, with mottled spots like brocade patterns; there is sore throat and expectoration of pus and blood. It can be treated within five days after onset, but becomes incurable after seven days.

Shen Jin'ao's commentary: Zhang Zhongjing's *Treatise on Cold Damage* (*Shanghan Lun*) does not explicitly discuss the manifestation of macules/purpura (Fa Ban). However, in cold damage diseases, symptoms of macule/purpura manifestation are very common. Famous doctors through generations, when discussing macule/purpura symptoms, have all based their explanations on the *Jin Gui Yao Lue*'s description of Yang Du ("face red, mottled spots like brocade") and Yin Du ("face and eyes blue-black"). However, although the blue-black complexion of Yin Du belongs to the category of macular patterns, cold damage macule/purpura manifestation is essentially a condition of excessive Yang heat. Therefore, it should primarily focus on red patterns like brocade. If Zhao Sizhen considers this condition as heat-toxin injuring both Yin and Yang, his view has merit (his detailed theory is recorded later), but it can only be taken as a reference. Here, we merely record the article on Yang Du from *Jin Gui Yao Lue* as the general principle.

[Detailed Discussion] Li Gao said: In Yang syndrome macule/purpura manifestation, some cases arise from purgation performed too early, some from failure to purge when indicated, and some from stomach heat and gastric ulceration. Although the causes differ, generally speaking, they all involve pathogenic factors borrowing the fire of the Hand-Shaoyin Heart meridian to invade the Hand-Taiyin Lung meridian. Thus, red spots appear like macules between the skin and hair follicles. Baihu Tang (White Tiger Decoction) and Chengqi Tang (Descending Qi Decoction) should be used according to indications, with differentiation of the Lung pulse being key.

Zhao Sizhen said: The *Huoren Shu* states that there are two types of macule/purpura manifestation: one is Warm Toxicity (Wen Du), and the other is Heat Disease (Re Bing). It also states that exterior deficiency with interior excess allows heat-toxin to exploit the deficiency and emerge onto the skin, causing macules, sores, and urticaria-like rashes resembling brocade patterns. The *Suwen* calls this "Zhen" (Rash). Upon detailed examination of Zhang Zhongjing's treatise, there is no treatment recorded for this specific symptom. However, Hua Tuo stated that if purgation is performed before heat-toxin enters the stomach, it leads to stomach deficiency and heat invasion, corroding the stomach lining; or if heat-toxin has entered the stomach but purgation is delayed, heat cannot vent, also corroding the stomach. The macules are the size of a chicken head, slightly raised, and tend to appear on both hypochondriac regions. Wang Zhonggong said that purging too early allows heat qi to enter the stomach due to deficiency; purging too late leaves heat in the stomach, also causing macule manifestation. Improper use or excessive dosage of hot medicines can also cause macule manifestation. Mild cases with red color have a mortality rate of 9 out of 10; severe cases with black color have a mortality rate of 9 out of 10. Both are treated with Huaban Tang (Resolve Macules Decoction) and Ejiao Daqing Tang (Donkey-Hide Gelatin and Isatis Root Decoction). Furthermore, the *Suo Shi Xin Shu* states that patients with Yang Du toxin manifesting macules have lesions resembling burn marks, the size of a finger nail, dark green-black in color, and invariably die. This confirms the ancient saying about "gastric ulceration." Some people today claim that those who survive did not have macules but rather rashes. These rashes look like mosquito bites, small red dots. Hence, survivors often had rashes. What is described here as urticaria-like rash resembling brocade is actually a rash, not a macule. Equating macules with rashes is incorrect. The statement regarding "exterior deficiency and interior excess" is also incorrect. As mentioned above, how can there be only these two conditions?

Wu Shou said: There are six types of macule/purpura manifestation. One is Cold Damage (Shang Han); two is Seasonal Qi (Shi Qi); three is Warm Toxicity (Wen Du); four is Yang Du (Yang Toxin); five is Internal Cold Damage (Nei Shang Han); six is Yin Syndrome (Yin Zheng).
One, Cold Damage macule manifestation: This occurs because sweating was not induced when it should have been, or purgation was not performed when indicated, leading to heat-toxin accumulation in the stomach, which then manifests as macules. The *Qianjin Fang* states that red and bright indicates stomach heat; purple-red indicates severe heat; purple-black indicates gastric ulceration. Thus, red macules have a 9/10 mortality rate, and black macules also have a 9/10 mortality rate. Generally, fresh red eruption is auspicious, even if extensive, provided it is not dense and confluent. Purple-red is difficult to treat, and mixed black is even more difficult. Once macules have erupted, the pulse must be surging, rapid, and forceful; the body warm and feet warm indicate easy treatment. If the pulse is deep, small, and weak, with cold feet and weak Yuan Qi, treatment is difficult. When macules are about to erupt but have not yet done so, temporarily administer Siwei Shengma Tang (Four-Ingredient Ephedra Stem Decoction) to first vent the toxin. If the pulse is weak, double the dose of Renshen (Ginseng); if appetite is poor and stool is loose, double the dose of Baizhu (Atractylodes Macrocephala Rhizome). Once macules have erupted, further venting methods should not be used. Sweating should not be induced, as it will worsen the macule erosion. Purgation should not be performed early, as it will cause the macule toxin to sink inward. If the pulse is red and rapid, with severe heat, vexation, and thirst, use Renshen Huaban Tang (Ginseng Resolve Macules Decoction). To eliminate macule toxin, use Xijiao Yuanshen Tang (Rhino Horn and Scrophularia Decoction) or Daqing Siwu Tang (Isatis Root Four Substances Decoction). If internal macule toxin is severe, with vexation, insomnia, delirium, and groaning, use Huanglian Jiedu Tang (Coptis Detoxification Decoction), adding Yuanshen (Scrophularia Root), Shengma (Cimicifuga Rhizome), Daqing (Isatis Leaf/Root), and Xijiao (Rhino Horn). If heat is very severe, with vexation, thirst, wheezing, and cough, combine Jiedu Tang with Huaban Tang. If the macule trend subsides slightly, but there is interior excess, constipation, delirium, and tidal fever, use Daxiehu Tang (Major Bupleurum Decoction) plus Mangxiao (Mirabilite), or Tiaowei Chengqi Tang (Regulate Stomach and Descend Qi Decoction). If purgation is not yet appropriate, but there is tidal fever, vexation, and thirst, temporarily use Xiaochaihu Tang (Minor Bupleurum Decoction) without Banxia (Pinellia Tuber), adding Zhizi (Gardenia Fruit), Huanglian (Coptis Rhizome), Huangbai (Phellodendron Bark), and Huafen (Trichosanthes Root). Or add Daqing. If Daqing is unavailable, substitute with Qingdai (Indigo Naturalis). Generally, to resolve stomach heat and gastric ulceration toxins, one must use Huanglian (Coptis Rhizome), Daqing (Isatis Leaf/Root), Xijiao (Rhino Horn), Yuanshen (Scrophularia Root), Shengma (Cimicifuga Rhizome), Shigao (Gypsum Fibrosum), Zhimu (Anemarrhena Rhizome), Huangqin (Scutellaria Root), Zhizi (Gardenia Fruit), and Huangbai (Phellodendron Bark). The key lies in assessing the condition and using them appropriately.

Two, Seasonal Qi macule manifestation: This is caused by epidemic atmospheric pathogens. After infection, there is aversion to cold with high fever, body stiffness, possibly vomiting and regurgitation, wheezing and cough, chest oppression, restlessness, irritability, inability to sit or lie comfortably, headache, dry nose, groaning, and insomnia. These are all prodromal signs of macule manifestation. First, examine the patient's face, chest, limbs, and back with a lit paper lamp to see if there are red spots rising. If so, it is macule manifestation. Yi Lao (Li Gao) said: Large red spots appearing on the surface of the skin are called "Ban" (Macules/Purpura); small red spots moving within the skin without rising are called "Zhen" (Rashes). Rashes are mild, while macules are severe. Generally, if the eruption is fresh red and sparse, it is auspicious. If the eruption is dense, needle-head sized, purple-black, it is ominous; mixed black is untreatable. Cases with rapid onset may show macules one or two days after fever begins; cases with slow onset may take four or five days. Treatment must primarily assess the patient's Yuan Qi deficiency or excess and whether the pulse is forceful or weak. If the pulse is weak and Yuan Qi is deficient, first use Sanbai Tang (Three Whites Decoction) added with Renshen (Ginseng) to assist true Qi. Next, if macules are about to erupt but not fully transparent, use Shengma Gegen Tang (Cimicifuga and Kudzu Root Decoction). For those with weak stomach and deficiency, combine Shengma Jiedu Tang (Cimicifuga Detoxification Decoction) and Sijunzi Tang (Four Gentlemen Decoction), named Shengjun Tang. If macules do not become transparent, add Zicao Rong (Arnebia Root) from the *Zhizhi Fang*. If rash/macule initially appears with exterior symptoms such as aversion to cold with high fever, headache, bone pain, limb stiffness, and chest fullness, use Sanyin Jiayi Qianghuo San (Three Causes Modified Notopterygium Powder) or add Zicao (Arnebia Root). If macules are dense and throat is obstructed, use Xijiao Xiaodu Yin (Rhino Horn Detoxification Drink) or Yuanshen Shengma Tang (Scrophularia and Cimicifuga Decoction). Whenever macules erupt with a rapid, large pulse, vexation, and thirst, use Renshen Huaban Tang (Ginseng Resolve Macules Decoction). For fever or unresolved tidal fever, modify Xiaochaihu Tang (Minor Bupleurum Decoction) according to symptoms, or use Renshen Baidu San (Ginseng Overcome Toxin Powder); either can be adapted. For vomiting and regurgitation after macule eruption, use Chenpi (Citrus Peel), Banxia (Pinellia Tuber), Shengjiang (Fresh Ginger), and Huanglian (Coptis Rhizome). For persistent wheezing and cough, use Ermu (Fritillaria and Anemarrhena), Gualou (Trichosanthes Fruit), Huangqin (Scutellaria Root), and Shigao (Gypsum Fibrosum). For sore throat, use Lianqiao (Forsythia Fruit), Niuxi (Burdock Fruit), Yuanshen (Scrophularia Root), Shengma (Cimicifuga Rhizome), Jiegeng (Platycodon Root), and Gancao (Licorice Root). For severe toxin after macule eruption, use Xijiao (Rhino Horn), Daqing (Isatis Leaf/Root), Yuanshen (Scrophularia Root), Zhizi (Gardenia Fruit), Shigao (Gypsum Fibrosum), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root), Huangbai (Phellodendron Bark), and Zhimu (Anemarrhena Rhizome). In the north, this is called Hongyan'er Chuang Qi (Red Eye Child Sore Qi). Avoid fragrant and foul odors to prevent triggering it. Whether macules have erupted or not, absolutely do not immediately administer cold-cooling agents to attack heat, nor drink cold water, as this may damage Stomach Qi and cause vomiting. Do not induce sweating or perform purgation, as this depletes exterior and interior Qi, causing greater harm. If the pulse is weak, inquire carefully about prior sexual activity. If there is "Jia Yin" (Concealed Yin/Cold), assisting True Qi is paramount.

Three, Warm Toxicity macule manifestation: The *Huoren Shu* says: In early spring, patients develop muscle macules, urticaria-like rashes resembling brocade, accompanied by cough, chest oppression, and vomiting clear fluid. This results from contracting cold toxicity in winter, which manifests in spring. Initially the pathology is in the exterior; even if sweating, vomiting, or purgation has been used, if exterior symptoms persist and toxin vapors remain dispersed, macules may erupt. Hei Gao (Black Plaster) is suitable. Alternatively, if winter is unusually warm and people contract aberrant Qi, illness may begin at the end of winter or be suppressed by accumulated cold in spring, preventing toxin release. When weather warms, Warm Toxicity erupts as macules/rashes resembling brocade, with cough, chest oppression, and vomiting of clear juice. Gegen Ju Pi Tang (Kudzu Root and Tangerine Peel Decoction) is suitable. Generally, if winter should be cold but is instead warm, and people fall ill from this improper Qi, it is named Dong Wen (Winter Warmth). If macules erupt, it is named Wen Du (Warm Toxicity). Treatment principles are the same as for Seasonal Qi macule manifestation, but Warm Toxicity is more severe. Select from Hei Gao, Yuanshen Shengma Tang, Xijiao Daqing Tang, or Renshen Huaban Tang. Generally, Warm Diseases occur in spring, Heat Diseases in summer. If macules erupt, treatment is the same as for Cold Damage. This arises from stifled heat emanating from within to the exterior, and is not a light condition.

Four, Yang Du macule manifestation: Symptoms include delirious speech, diarrhea, sore throat, and face red with macules like brocade patterns. Select from Yangdu Shengma Tang (Yang Du Cimicifuga Decoction), Daqing Siwu Tang, Renshen Huaban Tang, or Zhizi Ren Tang (Gardenia Seed Decoction).

Five, Internal Cold Damage: Acquired during summer months. Initially suffering from Summerheat, then consuming cold foods and lying in cold places, resulting in interior and exterior cold. This forces Summerfire to float to the exterior and manifest as macules. Haizhang (Zhang Yuansu) treated General Wanyan for alternating chills and fever with three or five macule spots, slight epistaxis, deep and choppy pulses in both hands, and no significant heat upon pressing the skin. This was Internal Cold Damage. He administered Tiaozhong Tang (Regulate Middle Decoction) several times until cured. For cases complicated by Summerheat, add Xiangru (Elsholtzia Herb) and Bian Dou (Lablab Bean).

Six, Yin Disease macule manifestation: The *Luelie* states: Yin syndrome macule manifestation also appears on the chest, back, hands, and feet, but is sparse and pale red. This person has constitutionally weak Yuan Qi, or previously damaged Kidney Qi through sexual activity, or excessively used cooling medicines, resulting in Yin syndrome. Cold hides below, forcing rootless and unanchored Fire to gather in the chest, burning upward solely to the Lung, transmitting to the skin to manifest spots. These resemble mosquito or louse bites, not large red spots. Use Tiaozhong Wentao (Regulate Middle and Warm Stomach) method, adding Baishao (White Peony Root) and Huixiang (Fennel Fruit). For severe cold with faint pulse, use Dajianzhong Tang (Great Build the Middle Decoction), so that True Yang returns naturally and Yin Fire descends, leading to cure. This treats the root, not the branch. Generally, for macule manifestation, warm body, warm feet, and rapid/large pulse indicate favorable prognosis (Shun); cool body, cold feet, and weak/faint pulse indicate unfavorable prognosis (Ni). Treating macules requires not focusing solely on the spots, but observing the pulse's floating/sinking nature and the disease's deficiency/excess status to treat effectively.

Zhang Jiebin said: Although macule manifestation has various causes, it ultimately stems from unresolved cold toxin. For example, if sweating is not induced when needed, exterior pathogen remains unresolved; if purgation is not performed when needed, interior pathogen remains unresolved; if clearing heat is not done when needed, fire pathogen remains unresolved; if tonifying is not done when needed, weakness prevents resolution. Or, purging too early causes pathogen to sink inward unresolved; or using warming/tonifying erroneously for Yang syndrome causes unchecked Yang; or using cold/cooling erroneously for Yin syndrome causes Yin coagulation. Whenever pathogen-toxin remains unresolved, it directly enters the Yin aspect, leading to exhaustion of fluids and depletion of blood, causing macules to appear on the skin surface. This is actually a severe condition where pathogen-toxin is consolidated and Ying and Wei are both severely affected. However, macules vary in severity, and conditions vary in lightness or heaviness. Light cases affect only the limbs; heavy cases appear on the chest and abdomen. Light cases have pale, hidden colors; heavy cases have bright red, obvious colors. If black macules appear, or there is spontaneous diarrhea, shortness of breath, or obstruction of both urine and stool, nine out of ten will die. For any cold damage case where sweating, purging, warming, and clearing fail to resolve the condition, accompanied by cold feet, deafness, vexation, cough, and vomiting, these are signs of impending macule manifestation.
The pathogen of cold damage originally enters from the exterior; if it penetrates deeply and remains unresolved, it emerges from the interior. This mutual interaction of interior and exterior is inevitable and is originally not an exterior deficiency syndrome. As long as interior and exterior communicate freely, resolution must occur via the exterior. Take Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) as an example; it is a key medicine for treating macules. People know this decoction cools blood and clears toxin, but do not know it excels at resolving the exterior and dispersing pathogen. If used appropriately, it induces profuse whole-body sweating, instantly resolving heat pathogen. How can one say sweating is impossible? From this perspective, whenever the pulse is rapid without sweat and exterior symptoms are present, one must still proceed with dispersing methods.
When treating macule manifestation, one must observe interior and exterior. If plague pathogens remain unresolved, heat enters the Blood Chamber, tongue is scorched, vexation and heat cause macule manifestation: use Xijiao Dihuang Tang. Interior and exterior both hot, Yangming mania, restlessness, extreme thirst causing macule manifestation: use Baihu Tang. Yang Du red macules, delirium and seeing ghosts: use Yangdu Shengma Tang. Epidemic macule manifestation, extreme heat and restlessness: use Sanhuang Shigao Tang (Three Yellows and Gypsum Decoction). Fire stifled in meridians, cold pathogen unresolved, pulse still slippery and rapid with macule manifestation: use Yichaihu Yin (First Bupleurum Drink). Yangming exterior pathogen, Yang Du unresolved: use Shengma Tang. Spleen and Kidney constitutionally deficient, exterior pathogen unresolved causing macule manifestation: use Wuchaihu Yin (Five Bupleurum Drinks). Yangming exterior pathogen unresolved, warm-heat causing macule manifestation: use Chaihu Baihu Jian (Bupleurum and White Tiger Decoction). Warm-heat toxin severe, sore throat and macule manifestation: use Yuanshen Shengma Tang. Yin deficiency with water depletion, blood heat causing macule manifestation: use Yvnu Jian (Jade Woman Decoction). Yin deficiency with blood dryness, extreme heat and thirst causing macule manifestation: use Guishao Yin (Angelica and Peony Drink). Interior deficiency with exterior heat, Yin excess repelling Yang causing macule manifestation: use Dawenzhong Yin (Great Warm the Middle Drink). Taiyang-Yangming aversion to heat, constipation, pathogen-toxin in the Fu organs causing macule manifestation: use Tiaowei Chengqi Tang. For cases originally not Yang syndrome, but mistakenly treated with cold/cooling, diarrhea often ensues, pathogen sinks and remains unresolved. I have used Dawenzhong Yin, Liyin Jian (Nourish Yin Decoction), etc., to resolve cold and support the interior to expel pathogen, eventually inducing profuse sweating. After sweating, pathogen resolves, and many cases show red macules and wind welts emerging and disappearing quickly, recovering in moments, saving many lives. This demonstrates how cold toxin causes macules. If interior support is weak, this toxin will never exit, becoming deeper and more severe day by day, making death unavoidable. This principle is subtle and must not be overlooked.

Tao Hua said: Macule manifestation involves great heat injuring blood; blood heat fails to disperse, interior excess with exterior deficiency allows heat to exploit the deficiency and emerge onto the skin as macules. Mild cases resemble rashes; severe cases resemble brocade patterns. This can result from Yang syndrome mistakenly treated with hot medicines, or failure to sweat/purge when indicated, or persistence of disease despite sweating/purgation.

Chen Shiduo said: Cold damage macule manifestation is a fatal condition. However, macules differ. Some cover the whole body; others are confined to the heart pit. Whole-body coverage seems severe but is actually mild, as internal heat has fully manifested externally. Confinement to the heart pit seems mild but is actually severe, as heat remains trapped in the heart without exiting. One must use macule-resolving medicines to clear internal heat-toxin. One formula is most effective, named Qiban Tang (Raise Macules Decoction): Yuanshen (Scrophularia Root) 3 liang, Danggui (Angelica Sinensis Root) 1 liang, Jingjie (Schizonepeta Spike) and Huafen (Trichosanthes Root) each 5 qian, Shengma (Cimicifuga Rhizome), Huanglian (Coptis Rhizome), Fushen (Poria with Hostwood) each 3 qian, Gancao (Licorice Root) 1 qian. Decoct and take. Fire-toxin knotted internally must be fully expelled. However, without blood to nourish the heart, the heart becomes hotter, fire-toxin intensifies, and cannot exit outward. Therefore, use Yuanshen and Danggui to nourish heart blood, Huanglian to cool heart fire, and Huafen to resolve heart phlegm. Yet, without opening the gate to disperse, fire remains hidden and cannot vent. Thus, use Shengma and Jingjie to disperse, and Gancao and Fushen to harmonize. Naturally, fire is guided outward and does not accumulate internally. Once fire exits outward, macules gradually subside, avoiding death.

Shen Jin'ao's commentary: Macule manifestation, whether due to Warm Toxicity or Heat Disease, arises from Yang pathogen internally harboring heat-toxin qi that cannot vent. By the fifth to seventh or eighth day of illness, there is typically high fever, anhidrosis, red face, vexation, thirst, and chest oppression (chest oppression is particularly critical). Then macules erupt. They usually start on the head, face, chest, and abdomen. Internally within the skin, they may be fine like mosquito traces or large like rice/millet beans, subtly hidden between the skin. Within half a day, they emerge outside the skin. Severe cases swell and connect, resembling cloud patches or brocade patterns. Red and bright colors are auspicious; purple indicates heavier heat-toxin; black indicates pathogen-toxin sinking inward, representing a near-fatal condition (nine deaths, one life). At the initial stage of skin eruption, urgently use Huaban Tang (Resolve Macules Decoction) to vent, detoxify, and clear heat. For pathogen-toxin sinking inward, select from Lingyangjiao San (Antelope Horn Powder), Daqing Tang (Isatis Root Decoction), Yuanshen Jiedu Tang (Scrophularia Detoxification Decoction), or Xijiao Jiedu Tang (Rhino Horn Detoxification Decoction). If the weather is warm, additionally use Fangfeng Jiedu Tang (Saposhnikovia Detoxification Decoction). If the weather is extremely hot, additionally use Huanglian Jiedu Tang (Coptis Detoxification Decoction). This is the general principle. Lugeng (Reed Rhizome) and Shigao (Gypsum Fibrosum) can also be added酌情 (as appropriate).
Generally, cold damage macule manifestation starts roughly on the head, face, and chest, but it is ideal if the hands, feet, back, and spine all reveal simultaneously. If any area fails to reveal, toxin will sink inward, leading to difficult-to-treat skin conditions. Therefore, although the preceding general principle cites Zhang Zhongjing's Yang Du article, that text only mentions "face red, mottled spots like brocade," and does not mention the entire body. It serves merely as an origin point, not the main text for cold damage macule manifestation. Referencing the discussions of previous sages yields precise and detailed understanding.