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Zhao Xianke stated that there are two types of macules (maculae): one is warm-toxin macules (wen du ban), and the other is heat-disease macules (re bing ban). He further explained that when the exterior is deficient and the interior is excess, heat-toxin exploits this deficiency to emerge from the skin, resulting in macules, sores, or nettle-rashes (yin zhen) with patterns resembling brocade. The *Su Wen* refers to this as "zhen" (rash). Upon detailed examination of Zhang Zhongjing's treatises, I found no mention of this syndrome or its treatment. However, Hua Tuo said: if heat-toxin has not yet entered the stomach and purgatives are used prematurely, it leads to stomach qi deficiency and inward penetration of heat, causing corruption of the stomach; conversely, if heat has entered the stomach but purgatives are not applied promptly, the heat cannot be discharged, also leading to stomach corruption. The resulting macules are about the size of a chicken head, slightly raised, and tend to appear on both hypochondriac regions. Wang Zhonggong said: purging too early allows heat to enter the stomach due to deficiency; purging too late leaves heat retained in the stomach, also causing macules. Alternatively, excessive consumption of hot-natured medicines can also induce macules. In mild cases, the macules are red, with a mortality rate of five deaths for every one survival; in severe cases, they are black, with ten deaths for every one survival. Both should be treated with Baihu Jia Renshen Tang (White Tiger plus Ginseng Decoction), also known as Huaban Tang (Macule-Transforming Decoction), as well as Ejiao Daqing Tang (Donkey-Hide Gelatin and Cyanophora Decoction). According to Su Shi's new book, patients with Yang Toxicity who develop macules have lesions resembling moxibustion marks, about the size of a fingertip, appearing dark cyan or black, and none survive. The ancients' statement that the stomach becomes corrupted is indeed credible. Some people today claim that some macules are viable, but these are actually rashes (zhen). Their appearance resembles small red points like mosquito bites, which is common. Thus, the current nettle-rash resembling brocade is a rash, not a macule. To equate macules with rashes is incorrect. Similarly, describing the condition merely as "exterior deficiency and interior excess" is inaccurate. As discussed above, how can there be only two types?

Haizang stated that Yang-syndrome macules fall into four categories: warm-toxin macules, heat-disease macules, seasonal-qi macules, and cold-injury macules. The macules resemble brocade patterns, appearing on the extremities, face, chest, back, etc. Reddish macules indicate stomach heat; purple-black macules indicate stomach corruption. This results from either premature or delayed purgation in exogenous heat diseases. Suitable treatments include Yuanshen Shengma Tang (Scrophularia and Cimicifuga Decoction) and Baihu Tang (White Tiger Decoction). (Wang Chaofeng noted: emergence of red macules implies five deaths per one survivor; black macules imply ten deaths per one survivor. Both are treated with Baihu Jia Renshen Tang and Ejiao Daqing Tang, combined with Zixue San (Purple Snow Powder), which is highly effective. If purgation is indicated, use Tiaowei Chengqi Tang.)

Wu Qian stated that macules generally arise from six causes: 1. Cold injury (Shanghan); 2. Seasonal qi (Shiqi); 3. Warm toxin (Wendu); 4. Yang toxicity (Yangdu); 5. Internal cold injury (Nei Shanghan); 6. Yin syndrome (Yin Zheng).

1. Cold Injury Macules: These occur when sweating or purgation was neglected, allowing heat-toxin to accumulate in the stomach. The *Qianjin Fang* states: red indicates stomach heat; purple-red indicates intense heat; purple-black indicates stomach corruption. Red macules carry a prognosis of five deaths per one survivor; black macules carry ten deaths per one survivor. Generally, bright red and elevated macules are auspicious, even if extensive, provided they are not densely confluent. Purple-red macules are difficult to treat; those mixed with black are especially refractory. Once macules erupt, a surging, rapid, and forceful pulse, along with warmth of the body and feet, indicates ease of treatment. Conversely, a deep, small pulse, cold feet, and deficient yuan qi indicate difficulty. During the phase where macules desire to erupt but have not yet done so, administer Siwei Shengma Tang (Four-Ingredient Cimicifuga Decoction) first to vent the toxin. If the pulse is weak, double the dose of Renshen (Ginseng); if appetite is poor and stools are loose, double the dose of Baizhu (Atractylodes Macrocephala). Once erupted, avoid further ascending/dispersing methods. Sweating should be avoided as it exacerbates macule corruption; premature purgation risks internal entrapment of the toxin. For surging/rapid pulses, intense heat, irritability, and thirst, use Ren Shen Hua Ban Tang (Ginseng Macule-Transforming Decoction). To resolve toxin, consider Xijiao Yuanshen Tang (Rhinoceros Horn and Scrophularia Decoction) or Daqing Siwu Tang (Cyanophora Four Substances Decoction). For severe internal heat-toxin causing insomnia, delirium, and groaning, use Huanglian Jiedu Tang (Coptis Detoxification Decoction) augmented with Yuanshen, Shengma, Daqing, and Xijiao. For intense heat with irritability, thirst, wheezing, and cough, combine Jiedu Tang with Huaban Tang. If macules recede slightly but internal excess persists with constipation, delirium, and tidal fever, use Dachaihu Tang (Major Bupleurum Decoction) with Mangxiao (Mirabilite) or Tiaowei Chengqi Tang. I once treated a patient with eight to nine days of cold injury, presenting with macules, rigid limbs, stupor, delirium, unconsciousness, and four to five days of constipation. One dose of Tiaowei Chengqi Tang resolved the condition. If purgation is not yet appropriate but tidal fever and thirst persist, use Xiaochaihu Tang (Minor Bupleurum Decoction) removing Banxia, adding Huanglian, Shanzhi, Huangbai, and Gualougen. Adding Daqing is also beneficial. If unavailable, substitute with Dalanye (Isatis Leaf) or Zhen Qingdai (True Indigo Powder). Resolving stomach heat/corruption toxins requires herbs such as Huanglian, Daqing, Xijiao, Yuanshen, Shengma, Qingdai, Shigao, Zhimu, Huangqin, Shanzhi, and Huangbai. Crucial is accurate pattern differentiation.

2. Seasonal Qi Macules: Caused by epidemic seasonal pathogens. Symptoms include aversion to cold with high fever, body stiffness, nausea/vomiting, cough, chest oppression, restlessness, headache, dry nose, groaning, and insomnia. These are prodromal signs of macules. Inspect the face, chest, limbs, and back under candlelight; raised red spots indicate eruption. Yi Lao stated: large red spots on the skin surface are "ban" (macules); small red spots within the skin without elevation are "zhen" (rashes). Rashes are lighter; macules are heavier. Fresh, sparse, red eruptions are auspicious; dense, needle-like, purple-red eruptions are ominous; mixed black is difficult. Rapid onset appears after one to two days of fever; slow onset after three to four days. Treatment depends on the strength of yuan qi and pulse. For weak pulse and deficient qi, start with Sanbai Tang (Three Whites Decoction) doubled with Renshen to support true qi. For macules not fully transparent, use Shengma Gegen Tang (Cimicifuga and Pueraria Decoction). For weak stomach and deficiency, combine Sijunzi Tang (Four Gentlemen Decoction) to form Shengjun Tang. If macules remain untransparent, add Zicao Rong (Arnebia Root) per *Zhizhi Fang*. If initial eruption presents with exterior symptoms (aversion to cold, high fever, headache, body ache, limb stiffness, chest fullness), use Sanyin Jiawei Qianghuo San (Three Causes Augmented Notopterygium Powder) or add Zicao. For dense macules or throat obstruction, use Xijiao Xiaodu Yin (Rhinoceros Horn Detoxification Drink) or Yuanshen Shengma Tang. For rapid/large pulse with irritability/thirst post-eruption, use Ren Shen Hua Ban Tang. For persistent fever/tidal fever, adjust Xiaochaihu Tang or use Renshen Baidu San (Ginseng Resisting Toxin Powder). For vomiting post-eruption, add Chenpi, Banxia, Shengjiang, Huanglian. For persistent cough/wheezing, add Zhimu, Beimu, Gualouren, Huangqin, Shigao. For sore throat, add Lianqiao, Niubangzi, Hei Yuanshen, Shengma, Kujiegeng, Gancao. For severe toxin, use Xijiao, Daqing, Yuanshen, Huanglian, Huangqin, Huangbai, Shanzhi, Shigao, Zhimu. Northern regions call this "Red Eye Child Plague." Avoid fragrant/unfragrant substances fearing contact. Do not use cold-cooling agents or drink cold water during pre/post-eruption phases to avoid damaging stomach qi and inducing vomiting. Avoid sweating or purgation to prevent weakening exterior/interior qi. If pulse is weak, inquire about sexual activity; if "Jia Yin" (concealed yin) is present, prioritize supporting true qi.

3. Warm Toxin Macules: Per *Huoren Shu*, in early spring, macules/nettle-rashes resembling brocade appear on muscles, accompanied by cough, chest oppression, and vomiting. Winter cold-toxin lingers until spring. If exterior syndrome persists after sweating/vomiting/purgation, or toxin remains dispersed, macules may erupt. Use Hei Gao (Black Paste). Alternatively, winter warmth allows pathogenic qi to invade; illness begins late winter, exacerbated by accumulated cold in spring, trapping toxin. When weather warms, warm-toxin erupts with fever, macules, vomiting, chest oppression, and clear vomitus. Treat with Gegen Jupi Tang (Pueraria and Tangerine Peel Decoction). Wu Qian added: Winter should be cold but is warm; contracting this aberrant qi causes "Winter Warmth." If macules erupt, it is "Warm Toxin." Treatment mirrors seasonal qi macules but is more severe. *Huoren Shu* recommends Hei Gao, Yuanshen Shengma Tang, Xijiao Daqing Tang, Ren Shen Hua Ban Tang, or Qingdai Yiwu Tang for brocade-like macules. Spring warm diseases and summer heat diseases with macules follow cold injury protocols. This arises from internal stagnation transforming into heat emerging outward; it is not a minor ailment.

4. Yang Toxicity Macules: Symptoms include delirium, diarrhea, sore throat, red face, and brocade-like macules. Select from Yangdu Shengma Tang, Daqing Siwu Tang, Ren Shen Hua Ban Tang, or Zhizi Ren Tang (see relevant section).

5. Internal Cold Injury: Occurs in summer. Initial summerheat injury followed by cold food/sleeping in cold places creates internal/external cold, forcing summerheat fire to float on the exterior, causing macules. Haizang treated General Wanyan with alternating chills/fever, 3-5 macules, slight epistaxis, deep/sluggish pulses, and non-hot skin upon pressure—diagnosed as internal cold injury. Cured with several doses of Tiaozhong Tang. Add Xiangru and Bian Dou for summerheat involvement.

6. Yin Syndrome Macules: *Lueli* states macules appear sparsely on chest/back/extremities, pale red. Due to chronic deficiency, sexual excess damaging kidney qi, or excessive cold-medicine use, yin syndrome develops. Cold hides below, forcing rootless/fire-floating qi to gather in the chest, steaming the lungs, and transmitting to skin as macules resembling insect bites, not large red spots. Treat with Tiaozhong Wenwei Tang (Regulate Middle Warm Stomach Decoction) adding Huixiang and Chao Baishao. For severe cold and faint pulse, use Dajianzhong Tang (Great Build the Center Decoction). True yang returns, yin fire descends, and disease resolves. This treats the root, not the branch. Generally, warm body/feet and surging/rapid pulse are favorable (Shun); cool body/feet and faint/fine pulse are unfavorable (Ni). Treating macules requires observing pulse depth and syndrome excess/deficiency, not just the macules themselves. Negligent generalization leads to error. Example: Hou Guohua, day 4-5 of cold injury, slight macules, thirst. Pulse deep/string-taut/almost absent (Jueyin). Days of warm medicine failed. Ginger/Aconite restored slight yang/pulse, but private water intake caused pulse regression. Head down, eyes closed, indicating violation of yang principles. Only using Shaosan would fail due to cold. Used Wuzhuyu Tang once, followed by Shaosan twice, inducing heavy sweat over two days, resolving the case.

Formulas for Yang-Syndrome Macules:

Shengma Gegen Tang: For macules desiring to erupt but not yet out. Contraindicated if already erupted.
Ingredients: Shengma (3 qian), Gegen, Baishao (2 qian each), Zhigancao (1 qian). Decoct in 2 zhong water to 1 zhong. Filter and take orally. *Zhizhi Fang* adds Zicao Rong (1.5 qian) for incomplete eruption. Double Renshen (2 qian) for weak pulse; add Baizhu (2 qian) for weak stomach/poor appetite. Double Chao Baishao for abdominal pain.

Sanyin Jiawei Qianghuo San: For initial macule/rash eruption with chills/high fever, headache/body ache, chest discomfort.
Ingredients: Qianghuo (Superior grade), Duhuo, Chaihu, Qianhu, Zhike, Jiegeng, Renshen, Fuling, Chuanxiong, Baishao (Medium grade), Shengma (Superior grade), Zhigancao (Inferior grade), Shengjiang (5 slices). Decoct similarly. Add Zicao Rong (1.5 qian) if untransparent. Double Renshen for deficient pulse; add Baizhu (2 qian) for weak stomach/poor appetite or loose stools (remove Zhike). For severe eruption, irritability, or sore throat, add Jingjie, Bohe, Fangfeng, Niubangzi, Lianqiao (1.5 qian each). For internal heat, bitter taste, irritability, add Huangqin, Huanglian (1.5 qian each). For intense heat, dry tongue, thirst, add Shigao (2 qian), Zhimu (1 qian). Also applicable for cough/phlegm-heat/chest oppression (add Gualouren 1.5 qian). For severe toxin, add Yuanshen, Xijiao (1 qian each).

Jiawei Xiaochaihu Tang: For macules with muscle heat, tidal fever, alternating chills/fever, bitter taste, dry throat, vertigo, tinnitus, hypochondriac pain, chest fullness, irritability, dry retching, thirst, wheezing, or persistent cough.
Ingredients: Chaihu (Superior), Renshen, Huangqin, Banxia, Zhigancao (Inferior), Huanglian, Shengma, Baishao, Yuanshen (Medium grade), Shengjiang (3 slices), Dazao (2 pieces). Decoct similarly. For dry mouth/thirst, remove Banxia, add Gualougen (1.5 qian). For sore throat, add Jiegeng (2 qian), double Zhigancao. For vomiting, retain Banxia, remove Gualougen, add Shengjiang, reduce Zhigancao. For severe toxin, add Xijiao xie (1 qian), fried/stud Niubangzi (1 qian); add Daqing (2 qian) for severe toxin. For chest oppression, add Gualouren (1.5 qian). For phlegm-fire wheezing, add Jiegeng (1 qian), Zhimu, Beimu (1.5 qian each), Gualouren (1 qian), Sangbaipi (1 qian). For wheezing with dry tongue/thirst/surging pulse, add Shigao (3 qian). For hypochondriac pain/fullness, add Zhike, Jiegeng (1.5 qian each). For epigastric hardness, add Zhishi (1.5 qian), double Huanglian.

Xiaodu Xijiao Yin: For macules/nettle-rashes, sore throat swelling, or toxic congestion.
Ingredients: Zhen Xijiao xie (Superior), fried/grinded Niubangzi, Jingjiesui, Fangfeng, Zhigancao (Medium grade). Decoct 2 zhong water to 1 qian. Strain and take warm. For sore throat, add Ku Jiegeng (2 qian), double Zhigancao, add Yuanshen (2 qian). Can add Lianqiao, Bohe. For internal heat, add Huangqin, Huanglian (1 qian each).

Jiedu Fangfeng Tang: For macules/nettle-rashes with itching/pain.
Ingredients: Fangfeng (Superior), Digupi, Huangqi, Chishaoyao, Jingjie, Zhike, fried Niubangzi (Medium grade). Decoct similarly. Alternative formula adds Danggui, Hei Yuanshen (1 qian each).

Xijiao Yuanshen Tang: For severe macule toxin, irritability, delirium, or sore throat.
Ingredients: Xijiao xie (Superior), Shengma, Shegan, Huangqin, Renshen, Hei Yuanshen (Superior), Zhigancao (Inferior). Decoct similarly.

Daqing Siwu Tang:
Daqing (1.5 qian, substitute Zhen Qingdai if unavailable), Ejiao, Zhigancao (1 qian each), Danshichu (100 grains). Decoct similarly.

Xijiao Daqing Tang: For severe macules, irritability, high fever, delirium, groaning, insomnia, or throat obstruction.
Ingredients: Xijiao xie, Daqing (Superior), Yuanshen, Zhigancao (Inferior), Shengma, Huanglian, Huangqin, Huangbai, Shanzhi (Medium grade). Decoct similarly.

Danggui Wan: For macules with internal excess and constipation.
Ingredients: Danggui (5 qian), Zhigancao, Huanglian, Dahuang (1.5 qian each). Simmer Danggui in 1 zhong water to thick paste. Mix with powdered other ingredients. Form pills like paulownia seeds. Take 50 pills with warm white rice broth until bowel movement occurs; repeat if necessary.

Hei Gao: For warm-toxin/seasonal qi macules resembling brocade.
Ingredients: Shengdihuang (4 liang), Danshichu (0.5 sheng). Simmer in 1 jin pork fat until concentrated. Add Xionghuang (0.5 fen), Muxiang (0.1 fen). Mix and form pills like quail eggs. Dissolve in white soup. Repeat if ineffective.

Gegen Jupi Tang: For winter warmth not immediately manifesting, suppressed by accumulated cold in spring, releasing in summer with heat. Symptoms: macules/sores/nettle-rashes resembling brocade, cough, chest oppression, vomiting clear fluid.
Ingredients: Gegen, Jupi, Xingren (skin removed, bran-fried), Zhimu, Huangqin, Mahuang (nodes removed, boiled), Zhigancao (roasted, 0.5 liang each). Chop. Take 5 qian, decoct in 1.5 sheng water to 1 sheng. Strain and take warm.

Loulu Lianqiao Tang: For heat-toxin macules without sweat and solid stool.
Ingredients: Loulu, Lianqiao, Huangqin, Mahuang, Bailian, Shengma, Zhigancao (1 qian each), Zhishi (2 qian), Dahuang (3 qian). For severe heat, add Mangxiao (2 qian). Decoct 2 zhong water to 1 zhong, add Mangxiao, boil briefly. Strain and take warm. If no effect after walking distance equivalent to 5 li, repeat. Stop when bowels move.

Zhudan Jizi Tang: For heat-toxin macules, sore throat, hoarseness, irritability, insomnia.
Ingredients: Zhudan, Mi Cu (3 he each), Jizi (1 egg). Simmer together 3-4 boils. Strong patients take all; weak patients simmer 6-7 boils, divide into 3 doses. Cure upon sweating.

Huanglian Yiwu Tang: For heat disease causing pea-pox.
Ingredients: Huanglian (1 liang). Decoct in 2 zhong water to 1 zhong. Strain and take orally.

Wuwu Muxiang Tang: For pea-pox with irritability/pain.
Ingredients: Qingmuxiang (2 qian), Xunluxiang, Dingxiang, Fanshi (1 qian each), Muxiang (0.5 fen). Decoct 2 zhong water to 1 zhong. Strain and take warm. For severe heat-toxin, add Xijiao xie (1 qian) or substitute Shengma (1.5 qian). For mild cases, remove Fanshi; highly effective.

Sun Zhao Shanzhi San: For intense heat-toxin causing widespread severe macules/pea-pox.
Ingredients: Mudanpi, Shanzhiren, Huangqin, Dahuang, Mahuang (2.5 qian each), Muxiang (0.5 fen). Decoct 2 zhong water to 1 zhong. Strain and take warm.

Topical Formula for Macules/Pea-Pox:
Grind Mangxiao to fine powder, mix with pig bile. Apply to sores; do not disturb. Wait for natural shedding without scarring. Sleep on loess powder. Prognosis: If urine is astringent/bloody, internal decay, black crusts, no pus—death.

Xijiao Daqing Tang: For severe macule toxin heat/pain.
Ingredients: Daqing (5 qian), Xijiao xie (2.5 qian), Zhizi (10 pods), Xiangchi (1 handful). Decoct/Take as before.

Huanglian Jiedu Tang: For severe heat macules, irritability, insomnia.
Ingredients: Huanglian (3 qian), Huangqin, Huangbai, Shanzhi (2 qian each). Decoct 2 zhong water to 1 zhong. Strain and take warm. For severe toxin, add Daqing (2 qian) or Zhen Qingdai (1 qian) mixed into decoction. For string-tapid/rapid pulse with internal/external heat and delirium, combine with Xiaochaihu Tang. For surging/rapid pulse with internal/external heat, dry tongue, thirst, combine with Huaban Tang.

Jiajian Sanhuang Shigao Tang: For heat-induced purple/red macules, thirst, surging/rapid pulse.
Ingredients: Huanglian (Superior), Huangqin, Huangbai, Shanzhi, Shigao, Zhimu, Shengma, Chishaoyao, Yuanshen (Medium grade), Zhigancao (Inferior), Jingsmi (2 scoops). Decoct similarly. For severe toxin, add Daqing (2 qian), Xijiao xie (1 qian) to clear heat/toxin/macules. For epidemic macules, apply good honey topically. Another method: apply honey-decocted Shengma.

Formulas for Internal Cold Injury and Yin Syndrome Macules:

Tongmai Sini Tang (see Diarrhea), Yindu Shengma Tang (see Yin Toxicity).

Tiaozhong Tang:
Cangzhu (1.5 qian), Chenpi, Sharen, Huoxiang, Chao Baishao, Zhigancao, Jiegeng, Banxia, Baizhi, Qianghuo, Zhike (1 qian each), Chuanxiong (0.7 qian), Mahuang, Guizhi (0.5 qian each), Shengjiang (3 slices). Decoct 2 zhong water to 1 zhong. Strain and take warm.

Dajianzhong Tang:
Danggui, Baishao, Baizhu, Zhike, Zhigancao (roasted), Rougui, Roushoucong, Chuanxiong, Fuzi, Banxia, Shudihuang, Fuling (Medium grade), Maidong, Huangqi (Superior grade), Shengjiang (3 slices), Dazao (2 pieces). Decoct similarly.

Renshen Sanbai Tang:
Baizhu, Baifuling, Baishao (Medium grade), Renshen (Superior grade), Shengjiang (3 slices), Dazao (2 pieces). For deep pulse/cold feet, add Fuziu (half piece). Decoct similarly.

Case of Black Macules in Cold Injury:
Treated a patient with seven-eight days of cold injury due to excessive cold medicine, resulting in cool body, cold limbs, whole-body black macules, only heart area warm (latent fire). Six pulses were deep/fine, stuporous, unconscious, aphasic, resembling corpse rigidity. Administered Renshen Sanbai Tang with Shufuzi (half piece), Ganjiang (2 qian), decocted in 2 zhong water to 1 zhong. Within an hour, macules turned reddish, limbs warmed...