Library

I. Origin of Smallpox (Disease)

The ancients said: In ancient times, there was no smallpox; it only appeared around the end of the Zhou Dynasty and the beginning of the Qin Dynasty. This indicates that in ancient times, the Qi of heaven and earth was harmonious and balanced, people's desires were simple and light, so diseases were rare, and even smallpox did not exist. As times changed and deteriorated, the consequences of warfare, floods, and droughts were sufficient to breed epidemic pathogens, while human desires increased daily, further depleting Yuan Qi (Original Vital Energy) and allowing latent pathogenic factors to accumulate within the Zang-Fu organs. These two factors interacting caused diseases to become increasingly complex, with smallpox being one of them. Investigating the origin of smallpox, it stems from congenital factors. Generally, at the time of conception, the residual toxic fire from parental sexual desire is stored deep within the fetus's bone marrow. When triggered by the epidemic toxins circulating in the seasons, it manifests externally. Therefore, if the mother observed prenatal education during pregnancy, even if the child develops smallpox, it is generally easy to treat. Conversely, if the mother indulged excessively in sexual activity during pregnancy, the child is most likely to die when developing smallpox. However, ancient smallpox cases were often severe and concurrent because, having both internal latent toxins and external epidemic toxins, their combination made the illness necessarily severe. Thus, the later invention of variolation aimed to guide the congenital toxin outwards, ensuring it did not merge and trigger simultaneously with the epidemic toxin. This approach effectively reduced the severity of the disease, which was a benevolent intention. The method involved inserting smallpox material into the nose. Since the nose is the orifice of the Lung, the Qi of the material enters internally. After a few days, its Qi transmits from the Lung to the Heart (Heart governs Blood vessels), from the Heart to the Spleen (Spleen governs muscles), from the Spleen to the Liver (Liver governs sinews/tendons), and from the Liver to the Kidney (Kidney governs bone marrow). Upon reaching the Kidney, it stirs the latent congenital toxin, which gradually reveals itself, transmitting from the Kidney to the Liver, then Spleen, Heart, and Lung, until the pustules appear. This is variolation, distinguishing it from natural smallpox triggered by epidemic pathogens. Since the invention of variolation, more patients have survived, and it has been widely practiced for a long time, praised for its convenience. However, there were still shortcomings: although the toxicity was lighter, the pustules were densely distributed all over the body, resembling natural smallpox. Weak individuals had difficulty raising the pustules (Qi Zhang) or filling them with pus (Jiang Guang). Treatment was often complicated, requiring strict avoidance of wind and cold and hundred-day recuperation, which was burdensome. During the pus-filling stage, even slight negligence could result in scarring (facial pockmarks). Consequently, this method faced gradual obsolescence. Coincidentally, Western cowpox vaccine was introduced to China. Used to induce immunity, it only causes pustules at the inoculation site, posing no danger during eruption. Besides dietary restrictions, there are no other heavy taboos, making it popular worldwide. Today, natural smallpox is rarely seen, undoubtedly due to the merit of the cowpox vaccine.

II. Pathology of Smallpox

The eruption of smallpox serves as a pathway for the body to excrete pathogenic toxins. Thus, its eruption moves from the interior to the exterior, similar to measles (Sha Zhen). The difference lies in the depth of the latent toxin: the toxin in measles is shallow, whereas the toxin in smallpox is deeply hidden in the bone marrow and originates from the Kidney. Because it originates from the Kidney, it often involves the Yuan Yang (Primary Fire) within the Kidney. If Yuan Yang is deficient, the pustules lack the supportive force to erupt properly, often leading to unfavorable outcomes (Ni Zheng). This explains the saying "Measles prefers cooling, while smallpox prefers warmth." However, when pathogenic toxins are vigorous, consuming Yin fluids, nothing is more severe than this. Hence, smallpox is known as difficult to treat because balancing cold and warm medications is challenging. Furthermore, since smallpox begins in the Kidney and ends in the Lung, affecting the whole body, almost every aspect is relevant. Therefore, treating smallpox emphasizes timing. Based on seasonal changes, methods such as releasing the exterior, clearing heat, and transforming dampness must be adjusted instantly to be effective. This complexity is why physicians throughout history prioritized eradicating smallpox. With the modern invention of cowpox vaccination, the goal of eliminating smallpox can be considered achieved. Some argue that since smallpox is a major childhood disease, people should avoid it during epidemics, and voluntarily contracting it via vaccination seems unnecessary. They fail to understand that the brilliance of cowpox lies precisely in voluntary administration before exposure. It is like catching a thief before they gain support, or removing weeds before they spread. Natural smallpox is dangerous because the toxin erupts late with severe consequences; cowpox is mild because the toxin erupts early with shallow consequences. Additionally, cowpox inoculation is typically done on the arms and legs, which is scientifically sound. The arms contain the Hand-Shaoyang meridians, and the legs contain the Foot-Shaoyang meridians. Shaoyang governs the pivot mechanism, facilitating the internal transmission of the vaccine Qi efficiently. Similarly, the expulsion of toxins is most efficient here. Thus, the entire cowpox process takes about ten days. However, after widespread vaccination, some vaccinated individuals still contracted natural smallpox. This occurs because the latent toxin was not fully cleared, differing from unvaccinated cases. Since the pathogen exits via the traditional pathway, elimination is easier, requiring less supportive warming. The treatment principle should lean slightly towards cooling or acrid-dispersing methods, avoiding warming tonification. Treatment methods for smallpox have thus undergone significant changes, which must be understood.

III. Symptoms of Smallpox

At the onset of smallpox, there are no obvious signs initially. As it is about to erupt, there may be slight aversion to cold, fever, or fever with cough. At this stage, one must check if the ears, nose tip, buttocks (Kao), and feet are cold. Coldness in these areas indicates smallpox. Checking for red threads protruding behind the ears and a pulse that is large, stringy, and rapid suggests the rash is about to appear (Bao Dian - reporting spots). Initially, small red spots appear. Within a few days, spots report. Early spots often appear first in the chest hollow or on the face, with patterns appearing between the cheekbones. Coldness specifically in the ears, buttocks, and middle finger are characteristic features of smallpox. Other common signs include tired eyes with watery discharge, yellow sclera or red eyelids, frequent startle during sleep, dark urine, and constipation. Causes include epidemic infection, wind-cold injury, dietary indigestion/vomiting, or fright/falls. This covers the general onset of smallpox. Onset usually reports spots after 3-5 days, followed by raising (Qi Zhang) after another 2-3 days. Raising means particles rise sequentially, with swelling at the base and skin boundary, preparing for pus formation. After three days of pus filling, toxins are transformed, leading to scabbing and recovery. This outlines the progression. However, severity varies (favorable vs. critical), changing unpredictably. A case may be favorable during fever but critical during spot reporting, or favorable during reporting but critical during raising, etc. Clinical judgment is essential. Generally, during fever, if heat is not burning, or there is aversion to cold/chills, normal bowel/bladder function, ability to eat, slight rough breathing without wheezing, and no abdominal pain, it is a favorable syndrome. If high fever burns to touch, wheezing with rebellious Qi, delirium/restlessness, abdominal distension/constipation, or slight aversion to cold with loose stools, fatigue, and poor appetite, it is a severe syndrome. If fever accompanies scorched skin, foul breath,急促 breathing/hoarseness, blue face/head shaking, vomiting/upward staring eyes, or intermittent spots, it is a critical syndrome. During spot reporting, if bases are red and round, tips are raised and rough to touch, sparse on head/face but distributed on limbs, with alternating mild heat and coolness, and regular bowel/bladder function, it is favorable. If spots are pale or bright red like cinnabar, fever is burning, or tips are white like millet grains with non-red bases, thin skin, abdominal/lower back pain, and diarrhea, it is severe. If spots erupt densely and brightly red, or are dark/dull, dry hair/skin, or appear on eyelids, lips, genitals, tongue, throat, chest, or back, or if muscles feel bruised with coma/anorexia, it is critical. During raising, if fever comes in waves, raising gradually, with round heads, red bases, and lustrous firmness, facilitating pus filling, it is favorable. If body is cool/not hot, raising is hidden/difficult, skin is thin/shiny, bases are not red, or accompanied by diarrhea/mild itching, it is severe. If raising shows white color/thin skin, easily broken, no redness at base, or high fever with purple/black pustules that do not rise, or facial edema preventing rising, it is critical. During pus filling, following maximum raising, pits fill, flat tops become elevated, full and lustrous, sequential filling, yellow bean-like color, normal bowels/bladder, and warm limbs indicate favorability. If bases are red but not moist, incomplete filling, diarrhea, dense/purple/non-elevating spots, sudden phlegm-wheezing during filling, or irritability/insomnia, it is severe. If pus contains clear water, shrinks/dries up, bases are purple/stagnant, body fills but head does not, or cough/wheezing/irregular bowels occur, it is critical. During scabbing, after full pus filling, color becomes mature/aged, starting from philtrum/face, moving to chest/abdomen/legs. No high fever, no aversion to cold, increased appetite, and regulated bowels/bladder indicate favorability. If body is heavy/feverish, difficult scabbing, blood-colored scabs, ulceration/difficulty healing, or chattering convulsions, it is critical. This summarizes favorable vs. critical differentiation. Post-recovery, Yuan Qi is depleted, requiring immediate regulation and tonification. Taboos during smallpox are stricter than measles; negligence leads to complications. These are noted below.

Modern cowpox symptoms are mild. One to two days post-inoculation, local redness/swelling appears, gradually raising and filling with pus. By day 10, pus is full, drying and scabbing by day 20. Fever may vary but lasts no more than a week. The best age for vaccination is 6-10 months, with boosters every 3-5 years. Care includes keeping the site clean, preventing rupture, and dietary restrictions to prevent secondary infection and ensure efficacy.

IV. Treatment Methods for Smallpox

For the first 1-2 days of fever, release the exterior to facilitate eruption. Days 3-5: clear heat and detoxify to promote growth. Days 6-9: warm and tonify Qi and Blood to aid pus filling. Days 10-12: clear, drain, and astringe to promote scabbing. This is the standard method. However, timing varies; early eruptions need no strong exterior-releasing, while late eruptions rely on penetrating and supporting. Do not use cooling herbs before all spots appear, as cold causes stagnation. Do not use warming tonics before heat-toxin is resolved, as warmth may cause accumulation and failure to form pus. Generally, red face, warm body, firm stool, and clear mind are auspicious. For favorable cases, minimal medication is needed. Mild exterior release initially allows spots to emerge sparsely. Then, slight clearing transforms internal toxins, ensuring proper raising. Once pus fills, warming tonics are unnecessary unless sinking occurs, requiring supportive tonification. Unred/blue/white face, subdued fever, loose stool, or fiery red face, burning fever, constipation, and delirium are severe. For pale face/loose stool, balance warming/tonifying with dispersing. For red face/constipation, balance purging/clearing blood. This is the general approach.

Variations in early stages:
(1) Sudden high fever, restlessness, spots appearing immediately upon fever indicates excess toxin. If stool is hard, use Liang Ge San to purge. If loose, combine acrid-cool and acrid-warm formulas.
(2) Joint/bone pain during fever indicates Six Evils invasion; use exterior-releasing and penetrating agents.
(3) Generalized itching indicates deficient exterior exposed to wind-cold, blocking toxin exit; use Gui Zhi Tang plus Huang Qi, Fang Feng, Bai Zhi, Chan Tui.
(4) Shivering/aversion to cold indicates weak Qi failing to expel pathogens; use Sheng Ma Tang plus Ren Shen, Shan Jia, Gui Zhi, Fang Feng.
(5) Abdominal pain/thirst indicates blocked toxin and steaming heat; use Xuan Ming Fen mixed with honey or Liang Ge San. Relief follows bowel movement.
(6) Lower back pain is critical, indicating pathogen reversing inward. Use Shi Gao, Ren Shen, tea, Xuan Ming Fen, and honey, or Baixiang Wan. Mild pain in deficiency is excluded.
(7) Vomiting/diarrhea indicates toxin dispersing. If spirit remains good and symptoms stop quickly, it is auspicious. Persistent vomiting/diarrhea after spots: Si Ling San plus Zhi Ke, Ju Pi, Shan Zha. For deficiency: Yi Gong San plus Huo Xiang, Mu Tong.
(8) Purple-black cracked lips/mouth indicates toxin attacking Spleen; use Xi Jiao Xiao Du Yin plus Shi Gao, Xuan Shen.
(9) Grinding teeth/wandering eyes indicates excessive Heart heat; use Dao Chi San plus Huang Lian, Chi Shao. If grinding/coma indicates Liver wind-heat; use Qiang Huo Tang plus Qing Pi, Chai Hu.
(10) Voice changes: use Xiao Du Yin plus Lian Qiao, Jie Geng. Sore throat: Gan Jie Tang plus Niu Bang Zi.
(11) Dark scanty urine indicates heat-toxin entering Bladder; use Dao Chi San plus Jing Jie, Lian Qiao, Niu Bang Zi.
(12) Epistaxis indicates pathogen exiting via nose. If bleeding persists, use Xi Jiao Di Huang Tang.
(13) No fever: assess deficiency/excess. Deep heat with cold extremities requires cold herbs. Weak Qi failing to penetrate requires Bu Zhong Yi Qi Tang or Bao Yuan Tang.
(14) Spots appearing densely like silkworm eggs on day 1, not rough to touch, or face like rouge/red patches everywhere are untreatable.
(15) Restlessness/vomiting, clear fluid under tongue, silence/sleepiness or agitation, abdominal pain/crying: check for worm signs (blue veins under tongue/black-white spots on lower lip). Use Jiao Mei Wan to lure worms, then Zi Cao Cheng Qi Tang to purge.
(16) Phlegm-wheezing, closed eyes/coma, dizziness/falling, convulsions indicate phlegm. Use Da Huang Gan Cao Tang to induce vomiting/diarrhea to clear phlegm.

Variations from spot reporting to raising:
(1) Spots like cinnabar, burning fever, turning dry/purple-black, restlessness, dry lips/bad breath: despite winter, use large dose Bai Hu Hua Ban Tang with massive Shi Gao.
(2) No high fever, spots fine like millet, weak spirit, closed eyes, overly rosy face/lips indicates Qi/Yang deficiency with scattering essence. Use heavy Ren Shen, Sheng Huang Qi, Sheng Ma, Wu Wei Zi, or modified Bao Yuan Tang.
(3) Abdominal pain indicates food stagnation; add digestion-promoting herbs to exterior-releasing formula. For distension/diarrhea, harmonize rather than abruptly stop or allow excessive loss.
(4) Mixed eruptions: wash with decoction of Willow Peach Branch, Locust Branch, and Zi Bei Fu Ping to eliminate mixed toxins and reveal true smallpox.
(5) Red/purple/dry/black depressed spots with constipation/dark urine/hot nose/dry mouth indicate interior/excess heat. Use Zi Cao, Hong Hua, Lian Qiao, Niu Bang, Mu Tong, Chan Tui, Jing Jie, or Huang Qin/Huang Lian. Exterior heat: clear exterior and separate turbidity. Interior heat: focus on detoxifying and clearing.
(6) Spots hidden for 3-4 days indicate Qi/Blood deficiency. Use Kuai Ban Tang or Tou Ji San. If limbs fail to raise, use Gui Zhi Tang plus Fang Feng, Huang Qi.
(7) Pale/depressed spots indicate Qi deficiency; use Shen Qi Nei Tuo San plus Nuomi. Non-red/depressed spots indicate Blood deficiency; use Si Wu Tang combined with Bao Yuan Tang. Delayed raising/clear pus: use Du Shen Tang.
(8) Red/itchy spots indicate Blood deficiency with heat; use Si Wu Tang minus Sheng Di plus Xi Jiao, Lian Qiao.
(9) White top with swollen flesh but non-swollen pustule indicates toxin failing to fill; use Hua Du Tang plus Sheng Di, Chuan Xiong, mixed with Er Bao San.
(10) Red/spread bases failing to raise indicate Blood heat with Qi disconnect; use Da Rat Niu Zi Tang plus Zi Cao.
(11) Complex heat/deficiency with violent toxin causing slow eruption and delirium: difficult to treat. Avoid cooling (may hinder) and warming (may fuel fire). Emergency measure: slice live rooster, apply to navel with liquor to draw out toxin and stop delirium. Body pain indicates Kidney meridian toxin; apply boiled black soybean paste to lower back. These are external remedies.