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Zhao Xianke stated that there are two types of macule eruptions (macules): one is warm-toxin macule eruption (warm toxin-induced rash), and the other is heat-disease macule eruption (heat-pathogen-induced rash). He further explained that when the exterior is deficient and the interior is excess, heat toxins invade the skin due to deficiency, causing macules, sores, and urticaria with patterns resembling brocade. The *Suwen* refers to this as "zhen" (urticaria/rash). Upon detailed examination of Zhang Zhongjing's treatises, I found no mention of this specific syndrome or treatment. However, Hua Tuo stated: if heat toxins have not yet entered the stomach and purgatives are used prematurely, it leads to stomach qi deficiency and inward penetration of heat, rotting the stomach; conversely, if heat has entered the stomach but purgatives are not applied in time, the heat cannot be vented, also resulting in stomach rot. The macules are the size of a chicken head, slightly raised, and tend to appear on both hypochondriac regions. Wang Zhonggong said this occurs because purgation was too early, allowing heat to enter the stomach via deficiency; or purgation was too late, leaving heat retained in the stomach, which also causes 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. All these conditions should be treated with Baihu Jia Renshen Tang (White Tiger plus Ginseng Decoction), also known as Huaban Tang (Macule-Resolving Decoction), as well as Ejiao Daqing Tang (Donkey-Hide Gelatin and Starwort Decoction). Furthermore, Su Shi's new book states that patients with Yang Du (Yang Toxin) present with macules resembling moxibustion marks, about the size of a finger, dark blue-black, all of whom die. The ancients' statement about "stomach rot" is thus credible. Some people today claim that some macules survive while others die, but these are not true macules; they are all zhen (urticaria). Their appearance resembles small red spots from mosquito bites, which explains their prevalence. What is currently described as urticaria with brocade-like patterns is actually zhen, not ban (macules). Therefore, equating ban with zhen is incorrect. The assertion of "exterior deficiency and interior excess" is also inaccurate. As discussed above, how can there be only these two types?

Hai Zang stated that Yang-syndrome macule eruptions have four categories: warm-toxin macule eruption, heat-disease macule eruption, seasonal-qi macule eruption, and cold-injury macule eruption. The macules resemble brocade patterns, appearing on the extremities, face, chest, or back. Red macules indicate stomach heat; purple-black macules indicate stomach rot. These result from premature or delayed purgation, respectively, arising from exogenous heat diseases. Suitable treatments include Yuanshen Shengma Tang (Scrophularia and Cimicifuga Decoction) and Baihu Tang (White Tiger Decoction). (Wang Chaofeng noted: red macules imply five deaths per one survival; black macules imply ten deaths per one survival. Both are treated with Baihu Jia Renshen Tang and Ejiao Daqing Tang, combined with Zixue San (Purple Snow Powder) for excellent results. If purgation is indicated, use Tiaowei Chengqi Tang (Regulate the Stomach and Direct Downward Decoction).)

Wu Youxing stated that macule eruptions generally fall into six categories: 1. Cold injury (Shanghan); 2. Seasonal qi (Shiqi); 3. Warm toxin (Wendu); 4. Yang toxin (Yangdu); 5. Internal cold injury (Neishanghan); 6. Yin syndrome (Yinzheng).

1. Cold injury macule eruption usually arises from failure to sweat when sweating was indicated, or failure to purge when purgation was indicated, leading to heat toxin accumulation in the stomach. The *Qianjin Fang* states: red macules indicate stomach heat; purple-red macules indicate intense heat; purple-black macules indicate stomach rot. Thus, red macules carry a prognosis of five deaths per one survival; black macules carry ten deaths per one survival. Generally, bright red macules that rise clearly are auspicious, even if extensive, provided they are not dense and confluent. Purple-red macules are difficult to treat; those mixed with black are especially difficult. Once macules have erupted, 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 weak 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 Rhizome). Once macules have erupted, avoid further ascending and dispersing herbs. Sweating should be avoided as it exacerbates macule erosion; premature purgation should be avoided as it drives the toxin inward. If the pulse is surging and rapid, with intense heat, irritability, and thirst, treat with Ren Shen Huaban Tang (Ginseng Macule-Resolving Decoction). To eliminate macule toxins, use Xijiao Yuanshen Tang (Rhinoceros Horn and Scrophularia Decoction) or Daqing Siwu Tang (Starwort Four-Yin Decoction). If internal heat toxin is severe, causing irritability, insomnia, delirium, and groaning, treat with Huanglian Jiedu Tang (Coptis Detoxification Decoction) added with Yuanshen, Shengma, Daqing, and Xijiao. For severe heat with irritability, thirst, wheezing, and cough, combine Jiedu Tang with Huaban Tang. If macules subside 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 cold injury for eight to nine days who developed macules, rigid limbs, stupor, delirium, unconsciousness, and constipation for four to five days. One dose of Tiaowei Chengqi Tang resolved the condition. If purgation is not yet appropriate but tidal fever, irritability, and thirst persist, temporarily use Xiaochaihu Tang (Minor Bupleurum Decoction) without Banxia, adding Huanglian, Zhizi, Huangbai, and Gualougen. Adding Daqing is also beneficial. If Daqing is unavailable, substitute with Dalan Ye (Isatis Leaf) or Zhen Qingdai (True Indigo Naturalis). Generally, resolving stomach heat and rot toxins requires Huanglian, Daqing, Xijiao, Yuanshen, Shengma, Qingdai, Shigao, Zhimu, Huangqin, Zhizi, and Huangbai. Crucial is assessing the condition and applying suitable treatments.

2. Seasonal qi macule eruption is caused by epidemic qi. Infection leads to aversion to cold with high fever, body stiffness, vomiting, wheezing, chest oppression, restlessness, headache, dry nose, and insomnia. These are signs of macule eruption. Inspect the face, chest, limbs, and back with a lit lamp; red spots indicate eruption. Li Dongyuan stated: large red spots on the skin surface are "ban" (macules); small red spots within the skin are "zhen" (urticaria). Zhen is mild; ban is severe. Bright red and sparse macules at onset are auspicious; needle-like, dense, purple-red macules are ominous; mixed black macules are difficult. Rapid onset appears after one to two days of fever; slow onset appears after three to four days. Treatment must assess yuan qi deficiency/excess and pulse strength. For weak pulses and deficient yuan qi, first use Sanbai Tang (Three Whites Decoction) with doubled Renshen to support true qi. Then, for macules not fully erupted, use Shengma Gegen Tang (Cimicifuga and Kudzu Decoction). For weak stomach and deficiency, combine Sijunzi Tang (Four Gentlemen Decoction) to form Shengjun Tang. For unruptured macules, adding Zicao Rong (Arnebia Root) per *Zhizhi Fang* is good. For initial eruption with exterior symptoms (aversion to cold, high fever, headache, body pain, limb stiffness, chest fullness), use Sanyin Jiawei Qianghuo San (Sanyin Formula Modified Qianghuo Powder). Adding Zicao is acceptable. For dense macules or throat obstruction, use Xijiao Xiaodu Yin (Rhinoceros Horn Detoxification Drink) or Yuanshen Shengma Tang. For rapid, large pulse with irritability and thirst after eruption, use Ren Shen Huaban Tang. For unresolved fever or tidal fever, use Xiaochaihu Tang modified, or Renshen Baidu San (Ginseng Resisting Toxicity Powder). For vomiting after eruption, use Chenpi, Banxia, Shengjiang, and Huanglian. For persistent wheezing/cough, use Zhimu, Beimu, Gualouren, Huangqin, and Shigao. For sore throat, use Lianqiao, Niubangzi, Hei Yuanshen, Shengma, Kujiegeng, and Gancao. For severe toxin, use Xijiao, Daqing, Yuanshen, Huanglian, Huangqin, Huangbai, Zhizi, Shigao, and Zhimu. Northern regions call this "Red Eye Child Sore Qi," avoiding fragrant/odorous substances. Do not use cold-cooling agents or drink cold water before/during eruption 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 pathology) exists, prioritize supporting yuan qi.

3. Warm toxin macule eruption. The *Ren Shu* states: in early spring, macules and urticaria like brocade appear on muscles, accompanied by cough, chest stuffiness, and vomiting. Winter cold toxins manifest in spring. If exterior syndrome persists after sweating/vomiting/purgation, or toxins remain dispersed, macules erupt. Treat with Hei Gao (Black Plaster). Alternatively, winter warmth allows abnormal qi invasion; illness starts late winter, worsened by accumulated cold in spring, preventing toxin release. When weather warms, warm toxin erupts as skin fever, macules, vomiting, and clear fluid vomit. Treat with Gegen Jupi Tang (Kudzu and Tangerine Peel Decoction).

Wu Youxing stated: Winter should be cold but is warm; infection by this abnormal qi is called "Dongwen" (Winter Warmth). If macules erupt, it is "Wendu" (Warm Toxin). Treatment is similar to seasonal qi macules but more severe. The *Ren Shu* recommends Hei Gao for brocade-like warm toxin macules, or Yuanshen Shengma Tang, Xijiao Daqing Tang, Ren Shen Huaban Tang, or Qingdai Yiwu Tang. Spring warm diseases and summer heat diseases with macules are treated like cold injury. This arises from internal郁结 (stagnant) heat emerging outward, indicating a serious condition.

4. Yang toxin macule eruption. Symptoms include delirium, diarrhea, sore throat, red face, and brocade-like macules. Use Yangdu Shengma Tang, Daqing Siwu Tang, Ren Shen Huaban Tang, or Zhizi Ren Tang. (See detailed section below.)

5. Internal cold injury. Occurs in summer after heatstroke, followed by consuming cold foods/sleeping in cold places. External/internal cold forces summer fire to float on the surface, causing macules. Haizang treated General Wanyan for alternating chills/fever, scattered macules, slight nasal bleeding, deep/sluggish pulses, enlarged skin without heat. Diagnosed as internal cold injury; cured with several doses of Tiaozhong Tang. Add Xiangru and Bian Dou for summer-heat involvement.

6. Yin syndrome macule eruption. *Lueli* states: macules appear on chest/back/extremities, sparse and pale red. Caused by inherent yuan qi deficiency, sexual exhaustion damaging kidney qi, or excessive cold medicine usage, leading to yin syndrome with latent cold forcing rootless fire to gather in the chest, steaming the lungs and skin. Macules resemble insect bites, not large red spots. Treat with Tiaozhong Wenwei Tang (Regulate Middle and Warm Stomach Decoction) plus Huixiang and Chao Baishao. For severe cold and faint pulse, use Dajianzhong Tang. True yang returns, yin fire descends, curing the disease. This treats the root, not the branch. Generally, warm body/feet and surging pulse indicate favorable prognosis; cool body/feet and faint pulse indicate unfavorable. Treating macules requires assessing pulse depth and syndrome deficiency/excess, not just treating the rash. Negligence leads to error. Hou Guohua suffered cold injury for 4-5 days with slight macules and thirst. Pulse was deep, string-taut, nearly absent (Jueyin). Warm herbs failed. Ginger/Aconite restored slight yang/pulse. Thirst led to drinking water, causing pulse regression. Head/eyes drooped due to post-illness sexual activity ("Yang Yi"). Shaosan (Burnt Underwear Powder) alone was insufficient. Used Wuzhuyu Tang with Shaosan, inducing heavy sweating over two days, resulting in recovery.

Formulas for Yang Syndrome Macule Eruption

Shengma Gegen Tang: Ascends and vents macules desiring to erupt. Contraindicated if already erupted.
Shengma (3 qian), Gegen, Baishao (2 qian each), Zhigancao (1 qian). Decoct in 2 zhong water to 1 zhong. Strain and drink. *Zhizhi Fang* adds Zicao Rong (1.5 qian) for unruptured macules. 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/urticaria with chills, high fever, headache, body pain, chest discomfort.
Qianghuo (High grade), Duhuo, Chaihu, Qianhu, Zhike, Jiegeng, Renshen, Fuling, Chuanxiong, Shengma (High grade), Baishao, Gancao (Low grade), Shengjiang (5 slices). Decoct similarly. Add Zicao Rong (1.5 qian) if unruptured. Double Renshen for deficient pulse; add Baizhu (2 qian) for weak stomach/poor appetite or loose stools (remove Zhike). Add Jingjie, Bohe, Fangfeng, Niubangzi, Lianqiao (1.5 qian each) for severe eruption, irritability, or sore throat. Add Huangqin, Huanglian (1.5 qian each) for internal heat/bitter mouth/irritability. Add Shigao (2 qian), Zhimu (1 qian) for severe heat/dry tongue/thirst. Effective for wheezing/cough. Add Gualouren (1.5 qian) for phlegm-heat/chest oppression. Add Yuanshen, Xijiao (1 qian each) for severe toxin.

Modified Xiaochaihu Tang: For macule muscle heat, tidal fever, alternating chills/fever, bitter mouth, dry throat, dizziness, deafness, hypochondriac pain, chest fullness, irritability, dry retching, thirst, wheezing, cough.
Chaihu (High), Renshen, Huangqin, Banxia, Gancao (Low), Huanglian, Shengma, Baishao, Yuanshen, Shengjiang (3 slices), Dazao (2 pieces). Decoct similarly. Remove Banxia, add Gualougen (1.5 qian) for dry mouth/thirst. Add Jiegeng (2 qian), double Gancao for sore throat. Retain Banxia, remove Gualougen, add Shengjiang, reduce Gancao for vomiting. Add Xijiao Xiao (1 qian), fried/stud Niubangzi (1 qian) for severe toxin; add Daqing (2 qian) for extreme toxin. Add Gualouren (1.5 qian) for chest oppression. Add Jiegeng (1 qian), Beimu, Zhimu (1.5 qian each), Gualouren (1 qian), Sangbaipi (1 qian) for phlegm-fire wheezing. Add Shigao (3 qian) for wheezing, dry tongue, thirst, surging pulse. Add Zhike, Jiegeng (1.5 qian each) for hypochondriac pain/chest fullness. Add Zhishi (1.5 qian), double Huanglian for epigastric hardness.

Xijiao Xiaodu Yin: For macules, urticaria, sore throat, or toxic congestion.
Zhen Xijiao Xiao (High), Niubangzi (fried/stud, Medium), Jingjiesui, Fangfeng, Gancao (Medium). Decoct 2 zhong water to 1 qian. Strain, warm drink. Add Kujiegeng (2 qian), double Gancao, Yuanshen (2 qian) for sore throat. Add Lianqiao, Bohe. Add Huangqin, Huanglian (1 qian each) for internal heat.

Jiedu Fangfeng Tang: For macules, urticaria, itching, pain.
Fangfeng (High), Digupi, Huangqi, Chibaishao, Jingjie, Zhike, Niubangzi (fried). Decoct similarly. Alternative formula adds Danggui, Hei Yuanshen (1 qian each).

Xijiao Yuanshen Tang: For severe macule toxin, irritability, delirium, sore throat.
Xijiao Xiao (High), Shengma, Shegan, Huangqin, Renshen, Hei Yuanshen (High), Gancao (Low). Decoct similarly.

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

Xijiao Daqing Tang: For severe macules, irritability, high fever, delirium, groaning, insomnia, sore throat.
Xijiao Xiao (High), Daqing (High), Yuanshen (Medium), Gancao (Low), Shengma, Huanglian, Huangqin, Huangbai, Zhizi (Medium). Decoct similarly.

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

Hei Gao: For warm toxin/seasonal qi macules like brocade.
Shengdihuang (4 liang), Danshichidou (half sheng). Fry in 1 jin pig fat until thick liquid. Add Xionghuang (5 fen), Muxiang (1 fen). Mix, form pills like quail eggs. Dissolve in white soup. Repeat if ineffective.

Gegen Jupi Tang: For winter warmth not immediately manifesting, suppressed by spring cold, erupting in summer with heat. Symptoms: skin macules/urticaria like brocade, cough, chest stuffiness, vomiting clear fluid.
Gegen, Jupi, Xingren (skin removed, bran-fried), Zhimu, Huangqin, Mahuang (nodes removed, boiled), Zhigancao (half liang each). Cut into pieces. Take 5 qian, decoct in 1.5 zhong water to 1 zhong. Strain, warm drink.

Loulu Lianqiao Tang: For heat toxin macules, anhidrosis, solid stool.
Loulu, Lianqiao, Huangqin, Mahuang, Bailian, Shengma, Gancao (1 qian each), Zhishi (2 qian), Dahuang (3 qian). Add Mangxiao (2 qian) for severe heat. Decoct in 2 zhong water to 1 zhong. Add Mangxiao, boil briefly. Strain, warm drink. Repeat if no effect after walking distance equivalent to 5 li. Stop upon bowel movement.

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

Huanglian Yiwu Tang: For heat disease causing pea-sores.
Huanglian (1 liang). Decoct in 2 zhong water to 1 zhong. Strain, drink.

Wuwu Muxiang Tang: For painful pea-sores.
Qingmuxiang (2 qian), Xunluxiang, Dingxiang, Fanshi (1 qian each), Muxiang (0.5 fen). Decoct in 2 zhong water to 1 zhong. Strain, warm drink. Add Xijiao Xiao (1 qian) for severe toxin, or substitute Shengma (1.5 qian). Remove Fanshi for mild cases.

Sun Zhao Zhizi San: For severe heat toxin, widespread macules, pea-like sores.
Mudanpi, Zhizi Ren, Huangqin, Dahuang, Mahuang (2.5 qian each), Muxiang (0.5 fen). Decoct in 2 zhong water to 1 zhong. Strain, warm drink.

Topical Formula for Macules/Pea-Sores:
Grind Mangxiao to fine powder, mix with pig bile. Apply to sores, do not disturb. Wait for natural shedding without scars. Lie on yellow earth powder. Prognosis is fatal if urine is scant/bloody, internal sores rot, black crusts form without pus.

Xijiao Daqing Tang: For severe macule toxin heat and pain.
Daqing (5 qian), Xijiao (2.5 qian slices), Zhizi (10 pods), Xiangchi (small handful). Decoct as before.

Huanglian Jiedu Tang: For severe heat macules, irritability, insomnia.
Huanglian (3 qian), Huangqin, Huangbai, Zhizi (2 qian each). Decoct in 2 zhong water to 1 zhong. Strain, warm drink. Add Daqing (2 qian) or Zhen Qingdai (1 qian) for severe toxin. Effective for wiry-rapid pulse, internal/external heat, delirium (combine with Xiaochaihu Tang) or surging-rapid pulse, dry tongue, thirst (combine with Huaban Tang).

Modified Sanhuang Shigao Tang: For purple-red macules, thirst, surging-rapid pulse.
Huanglian (High), Huangqin, Huangbai, Zhizi, Shigao, Zhimu, Shengma, Chi Baishao, Yuanshen (Medium), Gancao (Low), Jingsmi (2 scoops). Decoct similarly. Add Daqing (2 qian), Xijiao Xiao (1 qian) for severe toxin. Honey application is effective for epidemic macules. Another method: honey-boiled Shengma applied topically.

Formulas for Internal Cold Injury and Yin Syndrome Macules:
Tongmai Sini Tang (see Diarrhea), Yindu Shengma Tang (see Yin Toxin).

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 in 2 zhong water to 1 zhong. Strain, warm drink.

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

Renshen Sanbai Tang:
Baizhu, Baifuling, Baishao (Medium), Renshen (High), Shengjiang (3 slices), Dazao (2 pieces). Add Fuziu (0.5 piece) for deep pulse/cold feet. Decoct similarly.

Case of Black Macules in Cold Injury:
I treated a patient with cold injury for 7-8 days who took too many cold medicines. Body became cold, limbs chilled, whole body black macules, except for warmth at the heart center (latent fire). Six pulses were deep, thin, and sluggish...