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To predict the auspicious or ominous signs of smallpox, one should deduce the qi and color primarily from the face; the Shangen (山根, root of the nose) at the "Nian Shang" area is particularly critical. A radiant red hue is auspicious, while a dull cyan suggests suspicion. Between smallpox/rash (Chuangzhen, 痘疹) and Cold Damage (Shanghan, 伤寒), which may appear similar, one can refer to the symptom differentiation methods of the ancients. Do not rashly try diaphoretic agents first; dispersing methods are only suitable when the exterior and interior are harmonious. Rashes belong to Yang patterns and require heat to mature; slight fever indicates a peaceful state. If the fever is high like fire, detoxification should be employed to clear the urine. The ability to eat throughout the course is excellent, indicating strong Spleen and Stomach function in daily life. Reduced appetite warns of weak Middle Qi; prolongation may lead to ulceration. Quietness signifies a peaceful pattern where there is no pathogen in the exterior or interior, and the mind is naturally calm. Sudden restlessness requires careful examination; loss of spirit turning into coma is most feared. Sunken lesions must be differentiated into Excess and Deficiency; Excess patterns suit mild support (Tuo, 托). For Deficiency-Cold, warming and tonifying are appropriate, likened to spring returning to a secluded valley, bringing relief. Seasonal treatments must be distinguished clearly; summer-heat, dampness, wind-cold, and pathogenic qi must not be neglected, as they can cause chaotic transformations. The pulse in smallpox should be peaceful, with a long and clear Stomach Qi being paramount. Wiry, rapid, floating, or full pulses indicate Excess; faint, deep, short, or choppy pulses indicate Deficiency causes.

The pulse is the evidence of Zang-Fu excess or deficiency, the sign of Qi and Blood strength, and the verification of Water and Fire balance. Therefore, treating all diseases requires relying on the pulse for medication to avoid error. Smallpox treatment especially depends on pulse diagnosis for success. Generally, the eruption of smallpox relies entirely on Righteous Qi (Zhengqi, 正气) to fill and support it to the surface. The suppuration of smallpox relies on Qi to nourish and Blood to moisten. This nourishing and moistening is not solely due to Qi and Blood but also involves True Water and True Fire as their roots, enabling effective nourishment and completing the virtue of Qi and Blood. The scabbing phase relies on the Earth element's ability to transform toxins and embodies the principle of things returning to storage. Thus, Qi and Blood are the branch, while Water, Fire, and Earth are the root. Moreover, various sores and toxic swellings result either from disharmony of Qi and Blood or sudden exposure to external heat, without fixed transmission stages, allowing them to linger. One may harmonize Qi and Blood to resolve swelling internally, or use cooling and detoxification to prevent suppuration. Smallpox originates at birth, rooted in the Kidney, manifesting in the Heart, and transmitting to the Liver, Spleen, and Lungs. It follows a specific timeline: within fourteen days, it progresses from the head and face downward, showing spots, swelling, suppuration, and scabbing. Internal resolution or failure to suppurate is impossible. Therefore, one must regulate Qi and Blood, send toxins out via the exterior, and complete suppuration, transforming toxins externally and restoring origin internally. Even if external pathogens attack, there is little to fear. Thus, treating smallpox before the seventh day, when the momentum is rising like a budding flower and Qi is high, supports Qi and Blood to fill the head and face with fluid. When Qi transitions to the middle, it supports filling the chest and back. When Qi transitions to the lower body, it supports filling the legs and feet. Borrowing the operation of toxin-fire makes filling easy. With this medicinal power replacing the function of Qi and Blood, after suppuration, Qi and Blood remain unharmed, and spirit remains intact. If one fails to tonify Qi and Blood and recklessly uses cooling/detoxifying methods, delaying time, after seven days, like fading flowers, Qi declines. Trying to raise Qi and Blood to the head later is too late! As Qi and Blood decline, filling becomes difficult; severe cases involve internal organ attack, mild cases generate other symptoms. Ancient infants had abundant innate endowment, so ancient formulas focused on releasing the exterior and clearing the interior for easy eruption and resolution, assuming sufficient Qi and Blood. However, modern infants have weak constitutions; though called "Pure Yang," Yin is insufficient and Yang is also deficient. Many suffer dual deficiency of Yin and Yang during congenital manifestations, making eruption and suppuration difficult. If initially treated only by releasing the exterior, those with Exterior Deficiency cannot contain the eruption, leading to uneven Qi and Blood distribution and difficulty in filling/scabbing. Those with Interior Deficiency have weakened Middle Qi, unable to carry toxins to form shape; ignorant practitioners using harsh toxic drugs is like cooking rice without grain, leading to internal collapse or溃烂 (ulceration) resembling silkworm cocoons or snake skins. If focusing only on cooling/detoxification for pus, Yang Deficiency leads to water stagnation internally, Yin Deficiency leads to dryness externally, hindering Water/Fire transformation and Qi/Blood formation. Infants with thin constitutions cannot tolerate disease; fever damages Middle Yuan Qi. Adding exterior-releasing and supporting methods further depletes Qi and Blood. Fewer spots, even if deficient, may not endanger life; dense spots, if damaged, destroy vitality. Therefore, Zhang sought profound principles. If the six pulses are full, rapid, and forceful, follow ancient methods to release muscle layer. If six pulses are faint, deep, and weak, warm the middle and support the interior to prevent Middle Qi weakness. Encouraged Qi and Blood will drive out toxins, causing swelling and suppuration spontaneously. If six pulses are wiry, rapid, and weak, nourish Water while assisting Fire to ensure effective nourishment and spontaneous transformation. In the Renwu year in the capital, treating the granddaughter of Censor Jiang, who had dangerous and adverse smallpox, Zhang used mental/heart method to turn both favorable, showing that smallpox is the branch, Qi and Blood are the root. As the book says: "Recognize the branch, treat the root; treat thousands without loss." I add this to broaden understanding.

Censor Jiang's granddaughter was eight years old with the weakest innate constitution. She suddenly developed slight fever, cyan face, cold limbs, abdominal pain vomiting water, neck stiffness, fatigue, very faint pulses (barely felt on heavy pressure). I said: This is Middle Cold and internal injury to Yuan Qi. Although preventing smallpox eruption, releasing muscle layer is difficult. Rely on pulse, warm to disperse; this removes disease and allows handling smallpox. The book states: "Many internal injuries require only warming and tonifying; once Righteous Qi is strong, it expels cold pathogens." Prescribed: Roasted Astragali Radix (Huangqi, 黄芪) 2 qian, Stir-fried Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) 3 qian, Wine-fried Angelicae Sinensis Radix (Danggui, 当归) 1.5 qian, Poria (Fuling, 茯苓) 1.5 qian, Roasted Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) 0.6 qian, Sweet Cinnamon Bark (Rougui, 肉桂) 0.8 qian, with baked ginger and jujube as guides. Next day, spirit improved, cyan faded, limbs warmed, pulse rose slightly, neck less stiff, fever intensified, smallpox signs appeared. Following formula minus Huangqi, next day high fever, then spots appeared, spirit strengthened slightly. Pulse still weak without fullness. Seeing few spots, I knew density would increase, dared not attack fiercely, continued warming/tonifying Qi and Blood for gradual eruption. By day 3-4, eruption was dense, fortunately without silkworm/snake-skin appearance, demonstrating the wonder of warming/tonifying Qi and Blood to send toxins out. Toxic attacks would cause溃烂 (ulceration) like chaff. Added Ginseng to formula for warming/tonifying; smallpox, spirit, and diet improved daily. Soon after, her ten-year-old brother developed fever at midnight, spots on forehead/temples next morning, confluent but not red. Lower back pain, fatigue, rootless pulses. I knew dual Yin-Yang deficiency and weak Spleen/Stomach Middle Qi, unable to control toxins, allowing them to invade Yang positions. Spleen/Stomach deficiency meant inability to send toxins out meridians, risking internal collapse. Prescribed: Rehmanniae Radix Preparata (Shudi, 熟地) 8 qian, Danggui 3 qian, Baizhu 4 qian, Fuling 3 qian, Gancao 0.8 qian, Rougui 1.5 qian, Cimicifugae Rhizoma (Shengma, 升麻) 0.6 qian, fresh ginger and jujube. Next morning, spots erupted on cheeks like chaff, dense seamless, pulses faint/deep, fatigue/anorexia, fortunately back pain resolved. I thought: With such Middle Deficiency, if not supporting Root Yuan, how could toxins exit? Since Righteous Qi is extremely weak to govern, allowing toxins to spread wildly, one must urgently replenish Middle Qi and regulate Ying-Wei when toxins are fully outside, to enable filling/suppuration and toxin transformation. Removed Shengma from previous formula, decocted separately 3 qian Ginseng, took concentrated juice. Patient comfortable. Next day, 5 qian Ginseng taken. Next morning, spirit strengthened, diet slightly improved, cheek spots swelled reddish, forehead spots no longer pure white. I said: Previous 3 qian Ginseng assisted Fuling/Baizhu to secure Middle, letting blood tonics act first. More blood tonics attract Qi tonics to tonify blood. Current color is tender, not firm; clear fluid/itching/collapse is inevitable. Must urgently tonify Wei Qi. Prescribed: Ginseng 6 qian, Raw Astragali Radix (Huangqi, 黄芪) 4 qian, Stir-fried Dried Rehmanniae Radix (Shudi, 熟地) 5 qian, Stir-fried Baizhu 3 qian, Wine-fried Danggui Shen 2 qian, Fuling 3 qian, Gancao 0.8 qian, Peeled Rougui 1.2 qian, baked ginger/jujube. One dose morning/evening. If bowel movement occurs, take separate Ginseng juice. Treatment increased diet/spirit, thickened pus. On day 7, itching caused half-face scratching. Fortunately, filling occurred before scratching; toxins transformed externally, medicine filled internally, causing no harm. Continued adjustments until day 10+, spots ripe with slight odor. I said: Toxins fully transformed externally. Reduced Ginseng, added Yin-nourishing/Yang-retreating/detoxifying agents. Scabs fell, scars red/rosy, spirit/diet doubled. Ancients avoided Ginseng before day 3; here, forced by condition/pulse, used Baizhu/Ginger/Cinnamon early, Ginseng on day 2, strong tonification on day 3. Truly necessary due to critical condition.

Indeed, medicine has no fixed form, medicines no fixed prescription. I treated a nephew of Han Zong in Wangdian Town, age 7, addicted to alcohol, eating little. Alcohol consumes True Yin; lack of food empties Yuan Qi. Upon smallpox fever, he was comatose all day, mute/blind upon waking. Doctors used exterior-releasing/supporting methods; spots didn't rise, convulsions worsened. I examined him: six pulses full/rapid/huge, body hot like fire, palms burning. I said: Extreme True Yin deficiency fails to constrain Yang; Spirit has no basis, floats/scatters. Further releasing consumes Yin; further supporting confuses Spirit. Muteness means Heart cannot function; blindness means Yin cannot brighten eyes. Burning five hearts mean extreme organ dryness. How can organs flow smoothly, Qi form shape, Blood colorize, and spots arrange on muscles? Each convulsion scatters Spirit more; convulsions damage Spirit before smallpox damages life. Must seek root for non-treatment treatment. Prescribed: Rehmanniae Radix (Dihuang, 地黄) 1 liang, Raw Rehmanniae Radix (Shengdi, 生地) 6 qian, Ophiopogonis Tuber (Maidong, 麦冬) 2 qian, Schisandrae Fructus (Wuweizi, 五味子) 0.6 qian, Peeled Cinnamomi Ramulus (Rougui, 肉桂) 1.2 qian. Some doubted Wuweizi's sour astringency. I said: Alone it astrings; with powerful Rougui, astringency intensifies pungent dispersion, capturing floating Yuan Yang, guiding it via Rougui's warmth to Kan Palace Life Gate. True Fire returns to center, Yin-shadow toxins show externally, Spirit clears, speech returns. It worked. Also treated niece of Chancellor Wang, age ?, with smallpox convulsions, blindness/coma, difficult eruption, slight fever, faint/rootless pulses. Extreme Righteous Qi deficiency cannot bear toxin-fire attack; convulsions weaken Qi, making eruption harder. Previous case (full/rapid pulses) blamed True Yin deficiency failing to constrain Yang. This case (faint pulses) blames True Yang/Qi deficiency failing to carry toxins out. Prescribed: Stir-fried Baizhu 3 qian, Wine-fried Danggui 1.2 qian, Fuling 1.5 qian, Gancao 0.4 qian, Peeled Rougui 0.6 qian, baked ginger/jujube. One dose: eruption; two doses: clarity; three doses: vision, spots bright, diet/spirit doubled. Both had convulsions/blindness, but pulses differed (full/rapid vs. faint/deep), so treatments differed (Yin vs. Yang rescue). Thus, early mild fever with no spots by day 3-4 isn't always mild toxin/few spots. If spirit clear, eating, spots round/red, changing quickly, it is mild. If fever clears but fatigue/anorexia by day 3-4, spots pale/no shine, unable to rise, it is Qi/Blood weakness failing to send toxins out. Urgently warm middle/boost Qi, encourage Ying-Wei to support. Severe cases need 3-4 doses to strengthen Middle Qi to transport toxins; many spots will emerge. Ignoring this leads to internal toxin attack by day 5-6, incurable. Dry mouth/tongue treated with cooling/detox increases internal ice/toxin risk. Can we fully believe ancients' "mild fever = mild smallpox"? Can we rigidly follow "no warming/tonifying before day 6"? Must distinguish Excess/Deficiency/Cold/Heat. Excess-Heat: release stagnation to drive toxins. Deficiency-Cold: tonify Qi/Blood to send toxins. Smallpox has dangers: severe toxin or weak body. Early death (3-5 days) due to severe toxin; guide顺势 (following trend) out, don't block with cold/detox. Late death (scabbing) due to weak body; check deficiency, tonify, don't cool/detox. Then even weak bodies survive.

Doctors hold human lives; must be careful, generalize to find comprehensive rescue strategies. Surgical texts say carbuncles/furuncles are leaking diseases that drain True Qi profoundly. Indeed, "leaking" is key. Children have delicate Zang-Fu, fragile skin, incomplete spirit, prone to Deficiency/Excess changes. Smallpox leaks everywhere, draining True Qi severely. *Xin Jian* emphasizes securing Yuan Qi. Modern constitutions are weaker than past; relying on shallow transmitted formulas, lightly using Jingjie/Fangfeng/Qianghuo/Duohuo for dispersal upon fever injures Wei Qi and Middle Qi, initially failing to drive toxins out, later failing to fill/mature. Lightly using Xijiao Dihuang Tang for cooling stagnates Ying Blood, causes Spleen/Stomach cold, blocks toxins internally, then freezes growth. Lightly using Chuanjia/Niu Shi (toxic drugs attacking toxins) overburdens Deficient Zheng, causing溃烂 (ulceration), empty shells, or clear blisters. Smallpox often arises from falls/fright, wind-cold/food stagnation, touching accumulated toxins. Post-illness, Yuan Qi is injured; smallpox consumes Qi/Blood. Pulse diagnosis is crucial. Faint/weak pulses aren't internal toxin retention but Qi deficiency failing to drive toxins; secure Middle/regulate Yuan (assist Zheng to send toxins out). Huangqi, Baizhu, Danggui, Fuling, Tianchong, Chanui, Gancao, Guizhi, Baked Ginger, Jujube are appropriate. Full/rapid/weak pulses aren't excess toxin but True Water deficiency. Excess Fire: Shudi, Danpi, assisted by Niubangzi, Zicao, Shengma, Gegen. Fake Fire: Shudi, Zhuru, Dan, Fuling, assisted by sweet Rougui to encourage shape. Must include pungent/warm/loosening flavors to aid growth, ensuring internal Zheng Qi, external Ying Yin, smooth Qi/Blood circulation, like sifting rice separating bran. Like seedlings needing sun/wind/rain, not pulling stalks to force growth. Commoners' children with strong constitutions and full/forceful pulses/excess external pathogens may temporarily use dispersal ("when sick, the drug bears the burden").