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The eruption of macules (skin eruptions) ranges from mild cases resembling rashes to severe cases resembling patterns on brocade. Although the causes vary, they all stem fundamentally from the failure to resolve cold pathogens (Cold Pathogens). For instance, if sweating therapy is not applied when indicated, exterior pathogens remain unresolved; if purgation is not applied when indicated, interior pathogens remain unresolved; if clearing heat is not applied when indicated, excessive fire remains unresolved; if tonification is not applied when indicated, deficiency prevents the expulsion of pathogens; if purgation is applied too early, pathogens sink inward and remain unresolved; if Yang-patterns are mistakenly treated with warming and tonifying herbs, Yang hyperactivity remains unresolved; or if Yin-patterns are mistakenly treated with cooling herbs, Yin stagnation remains unresolved. Whenever pathogenic toxins remain unresolved, they penetrate directly into the Yin aspect, stagnate and transform into heat, leading to exhaustion of body fluids and depletion of blood. Consequently, macules appear on the skin surface. This represents a condition where pathogenic toxins are firmly consolidated, and both Ying (Nutritive Qi) and Wei (Defensive Qi) are severely compromised. However, macules vary in severity, and the disease course varies in intensity. Mild cases present as fine spots like mosquito bites, initially red then turning yellow; severe cases present as granular or patchy eruptions, initially red then turning crimson. Mild cases appear only on the limbs, while severe cases appear on the chest and abdomen. Mild cases have pale, faint colors, while severe cases have dark purple, prominent colors. If black macules appear, accompanied by spontaneous diarrhea, shortness of breath, or obstruction of both urination and defecation, nine out of ten patients will die. In cases of Cold Damage (Shanghan), if sweating, purgation, warming, and clearing therapies fail to resolve the condition, and symptoms such as cold feet, deafness, restlessness, cough, and vomiting occur, these are signs of macule eruption.

1. Cheng Wuji stated: "Intense heat damages the Blood. If heat does not dissipate, interior excess and exterior deficiency arise, allowing heat pathogens to exit through the skin due to deficiency, forming macules. Sweating must absolutely be avoided; if sweating is induced, causing further opening and leakage, it will only exacerbate the macule erosion." Subsequent scholars generally agreed with this view, but I disagree. Generally, pathogens of Cold Damage enter from the exterior; if they penetrate deeply and remain unresolved, they subsequently emerge from the interior. This mutual interaction between interior and exterior is inevitable and does not originally constitute an exterior deficiency pattern. As long as interior and exterior circulation is unobstructed, pathogens will surely resolve via the exterior. Take Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction), a crucial formula for treating macules. People know this formula cools the Blood and clears toxins, but fail to realize it is also effective in resolving the exterior and dispersing pathogens. If used appropriately, it induces profuse sweating throughout the body, instantly resolving heat pathogens. Why say sweating is impossible? Therefore, in cases with rapid pulse and no sweat, where exterior signs are still present, one must still employ dispersing methods.

1. When treating macule eruption, one must always examine the interior and exterior.
- If plague pathogens remain unresolved, heat enters the Blood Chamber, the tongue is scorched, and macules erupt due to irritability and heat, use Xijiao Dihuang Tang (Rhinoceros Horn and Rehnamia Decoction).
- If there is interior and exterior heat, Yangming syndrome with mania and agitation, intense thirst, and macule eruption, use Baihu Tang (White Tiger Decoction), or add Renshen (Ginseng).
- For Yang Toxin with red macules, delirious speech, and bleeding, use Yangdu Shengma Tang (Yang Toxin Corydalis Decoction).
- For epidemic macule eruption with intense heat and dryness, use Sanhuang Shigao Tang (Three Yellows and Gypsum Decoction).
- If fire is constrained within the meridians, cold pathogens remain unresolved, the pulse remains slippery and rapid, and macules erupt, use Yi Chaihu Yin (Single Bupleurum Infusion).
- For exterior pathogens of the Yangming channel and unresolved Yang Toxin, use Shengma Tang (Corydalis Decoction).
- If the Spleen and Kidney are inherently deficient, and exterior pathogens remain unresolved leading to macule eruption, use Wu Chaihu Yin (Five Bupleurum Infusion).
- If exterior pathogens of the Yangming channel remain unresolved, and heat-warmth leads to macule eruption, use Chaihu Baihu Jian (Bupleurum and White Tiger Decoction).
- If heat-warmth toxins are abundant, throat pain occurs, and macules erupt, use Xuanshen Shengma Tang (Scrophularia and Corydalis Decoction).
- If Yin deficiency with water depletion, blood heat leads to macule eruption, use Yvnu Jian (Jade Woman Decoction).
- If Yin deficiency with blood dryness, intense heat and thirst lead to macule eruption, use Guige Yin (Angelica and Pueraria Infusion).
- If interior deficiency with exterior excess, Yin excess repelling Yang leads to macule eruption, use Da Wenzhong Yin (Great Warming the Middle Infusion).
- If Taiyang and Yangming present with aversion to heat, constipation, and pathogenic toxins in the Fu organs lead to macule eruption, use Tiaowei Chengqi Tang (Regulating the Stomach and Directing Downward Decoction).

1. Cases that are originally non-Yang patterns but were mistakenly treated with cooling herbs often result in diarrhea, causing pathogens to sink inward and remain unresolved. I commonly use formulas such as Da Wenzhong Yin (Great Warming the Middle Infusion) or Liyin Jian (Nourishing Yin Decoction) to warm the interior and support the body's resistance to expel pathogens. This allows for profuse sweating; after sweating, pathogens reach the exterior. Often, red macules and wind-blisters appear with the sweat, emerging and disappearing quickly, leading to recovery within moments, saving many lives. From this, we can see the nature of macules caused by cold toxins. If internal support is insufficient, these toxins will never find an exit, becoming progressively deeper and more severe, making death difficult to avoid. This principle is subtle and must be carefully examined.