Library

On the seventh day after the eruption of smallpox, it is a stage of "Yang within Yin." The body's righteous Qi (vital energy) is entirely directed outward to the surface, leaving the interior empty, much like the steam rising within a steamer basket; its subtlety is beyond words. For every unit of Yang that rises, a corresponding unit of Yin also grows. Therefore, the fluid within the pustules should gradually turn yellow, and the blood晕 (halo/redness at the base) under the root should gradually tighten, resembling a line encircling it, without spreading out or becoming grayish-dark. During this time, the patient experiences pain day and night, consumes double the usual amount of food, has fewer bowel movements, and exhibits a slight fever; these are auspicious signs. The opposite indicates an adverse condition. At this stage, life and death depend solely on observing the aggregation or dispersion of the blood晕 and the authenticity of the pus color. Authentic pus shines with a radiant luster and feels sticky when pinched; inauthentic pus appears earthy-yellow. Aggregation of the blood晕 indicates that Qi can constrain Blood to transform toxins; dispersion indicates Qi deficiency and scattering, with True Qi nearing exhaustion. If there is no blood晕 at all, death ensues. Pus is the transformation of toxins. The aphorism states: After the sixth day, focus exclusively on the pus color. Thus, those with pus survive, while those without pus die. If pus is present intermittently, the root is not red, or the flesh and skin appear grayish-red, accompanied by itching, restlessness, eyes closing then opening, diarrhea, dry heaving, anorexia, and insomnia, this indicates Qi deficiency failing to constrain Blood for toxin transformation. Urgent and vigorous tonification is required. If a black, prickly tongue coating is still present at this time, the vital potential is extinguished; not only is tonification contraindicated, but even if applied, it would be of no benefit. By the seventh day of fluid progression, swelling should extend over the neck, and fluid should fill the chest. Swelling signifies the outward expulsion of toxins. "Filling the chest" implies filling from top to bottom. Even the genitalia should be filled, as this is the convergence of the Zongjin (tendons). Filling of the legs is not essential, but both arms should be full; otherwise, during the crusting phase, anorexia and other complications will likely arise, as the arms are governed by the Spleen. If severe diarrhea occurs on the seventh day post-eruption, it indicates sinking of Qi, requiring urgent tonification and astringency. If the fluid color is normal and a line of blood tightly encircles the root, diarrhea is not problematic. However, if the fluid color is abnormal and Blood fails to consolidate, toxins remain internal. With toxins still present on the seventh day, life is precarious.

If the primary smallpox lesions retain a vibrant, red, and active blood晕 at the root, with clear spirit and robust appetite despite diarrhea, this is a Yang syndrome and is not detrimental. One must observe the tongue and administer herbs that simultaneously stop diarrhea for recovery. By the eighth or ninth day, if fluid seems sufficient but the eyes suddenly open and the lesions collapse, this indicates internal attack by toxins. Internal attack manifests as chest oppression, confusion, and restlessness, with the blood晕 scattering. If these symptoms are absent and the lips and tongue are clean, add Cinnamon Twig (Guizhi) and Prepared Aconite Root (Fuzi) to the formula. If the lips are dry and the tongue is crimson, add Coptis Rhizome (Huanglian) and Scutellaria Root (Huangqin) to detoxify.

In some cases, by the eighth day, the lesions are fully inflated and firm to the touch, yet yield no pus when pricked; this indicates toxins have sunk and become latent. This must not be mistaken for a favorable course, which would endanger the patient. The correct treatment is to administer Saichunlei Wan. If several doses fail to produce softening and pus, and the root blood晕 remains inactive, the prognosis is poor. However, this condition often stems from inner unrest of the Shen (Spirit). If the Shen is calm and the number of lesions is small, medication may not be necessary.

Itching during the pus-filling stage occurs in six or seven out of ten cases and is generally normal; treatment should be guided by the state of the lips and tongue. However, if scratching leads to pitted sores or if the lesions are dry without moisture, they are incurable. Pain during the fluid-forming stage is due to Fire-Heat and is considered an auspicious sign. Zhu Danxi stated: "All pain belongs to Excess," indicating pain caused by Qi stagnation. Add Bitter Orange Fruit (Zhike) and Hawthorn Fruit (Shanzha) to the formula. For pain caused by Blood-Heat, add White Peony Root (Baishao) and Rehmannia Root (Shengdi).

Chills and teeth-grinding on the eighth or ninth day indicate extreme deficiency, requiring vigorous tonification; no other method suffices. Head shaking, jaw trembling, closed eyes, and absence of Shen indicate an incurable condition.

Later, around the eighth or ninth day, some lesions appear earthy-yellow and hard, often mistakenly regarded as normal pus. This is actually due to dysfunction of Yin and Yang, causing fluid accumulation that becomes board-like and obstructed. Earthy-yellow refers to yellow without luster. In another scenario, where pus filling is adequate, sudden retention of stool on the ninth day indicates dryness of Blood in the Yangming channel. Double the dosage of Angelica Sinensis Root (Danggui) in the formula to moisten. Without treatment, after the scabs fall off, the patient will either suffer from dysentery or die from dry heat.

Excessive Qi causes puffiness and blistering during pus formation; add Atractylodes Macrocephala Rhizome (Baizhu) and Poria (Fuling) to the formula to promote diuresis and leaching out dampness. If lesions are broken, leaking fluid without encapsulation, cover them with Baicao San.

The most taboo signs on the eighth or ninth day are thin skin and clear fluid. Thin skin is tender and prone to rupture; clear fluid is watery rather than purulent. The classics state: "Fluid forms through toxins; toxins are transformed via fluid." Cases like this rarely recover successfully. If skin is thin and fluid is clear, and the patient becomes restless and agitated by the ninth day, the outcome regarding life and death is evident. For infants aged one year or six months, one need not wait until the ninth day; if they are restless and kicking by the seventh day, and lesions do not dry after being broken, less than one in ten thousand will survive. Why? The seventh day marks a boundary: before the seventh day, Qi and Blood move outward; after the seventh day, they move inward. When moving outward, toxins are expelled; when moving inward, retaining toxins is dangerous. Therefore, restlessness after the seventh day indicates internal attack by toxins. Internal attack invariably leads to death.

During pus formation, if the forehead resembles a boil from hot water, with red, dry skin and flesh, death ensues. If, upon initial pus formation, the lips turn yellow and hard first, death ensues.

Lesions that break without yielding pus or blood result in death. However, if broken lesions show subtle signs of vitality, it is due to contact with filth and should not be classified as a fatal case.