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Water without earth will burst its banks; if the earth is solid, the flow is smooth. This is the natural principle. Earth is the mother of all things, and the emergence, filling, and hardening of smallpox lesions all rely on the generation and development derived from the Spleen and Stomach. If congenital vitality is weak and the Spleen Earth is damaged, the official responsible for transportation and excretion (Spleen and Stomach) fails in its duty, and the mechanism of transformation and production becomes diluted. Qi and Blood cannot fully fill and irrigate, causing the earth to collapse and water to float, leading to the eruption of blisters. However, once a blister erupts, the pustule sac becomes empty and not full. Some blisters form due to excessive Qi; this should be described as pathogenic Qi excessively impacting and causing blistering. Could it be that when Zheng Qi (Upright Qi) is solid, it cannot expel toxins and transform them into pus, instead causing the disaster of foul-smelling, itchy blisters? Some judge based on the Five Elements associated with body locations; although this seems reasonable, it leads to many divergent paths and does not fit treatment methods well. In short, the head is the dignity of the chief, the chest is the place receiving Qi, the neck is the passage of entry and exit, and the back belongs to the five Shu points. Even normal smallpox lesions are considered too numerous in these areas, let alone blisters! Only on the hands and feet, which are like lowly soldiers, are they rarely seen and harmless, yet this is also a clear sign of Spleen deficiency. If they spread to cover sheets or patches, it is an ominous sign, indicating the onset of foul smell and itching. Previously, there were cases where various sores or broken injuries had not healed, or newly healed spots were tender, and smallpox erupted in clusters turning into blisters; these were caused by external factors and were not internal diseases, thus posing no harm. According to ancient theories, the malignancy of blisters is similar to black sinking. Although the direction of expulsion (outward vs. inward) differs, the harm caused by toxin stagnation is the same. The toxic vapors are fierce, leading to depression and obstruction; at extremes, they conflict with flat or sunken areas, which are sites of obstruction. Blister sites are sites of conflict. Internal heat toxins lie dormant, driving out body fluids first. Internally, one should expel toxins and loosen blood stasis; externally, prick with a silver needle to release purple blood, then apply Gong Fen (Lead Carbonate) mixed with Wan Su Jiu (Coriander Wine).

When the smallpox color is dry red, it must turn purple after red, black after purple, and withered/sunken after black. This progression occurs due to blood heat and toxin stagnation, representing a certain mechanism of gradual internal heat change. The practitioner, during the dry red stage, should urgently resolve the exterior, cool the blood, reduce fever, and promote clearing and draining. Although the pustule crown may be flat or sunken, do not use Ginseng tonics for Qi deficiency; otherwise, excessive Qi will cause the blood to become even more dried up. Danxi said: For dry sores, one should reduce fire using only mild agents, such as Jing Jie (Schizonepeta), Sheng Ma (Cimicifuga), and Gan Ge (Pueraria). There is also what is called "Xian Fu" (Sunken/Fixed) and "Dao Ye" (Reversed Crusting). Their shapes are slightly similar, but symptoms differ. Xian Fu cases arise because the Stomach is originally weak, unable to allow Yang Qi to assist Ying and Wei (Defensive and Nutritive Qi), so eruptions lack Qi and Blood to respond, appearing and then disappearing. Spots may be white or black, stool is loose, urine is not dark, appetite is lost, fatigue or vomiting may occur, and limbs are cold. Due to internal deficiency preventing proper eruption, this is Xian Fu. One should use acrid-warm medicines to warm the Stomach, ensuring Ying and Wei flow without stagnation, allowing natural eruption. Formulas like Lizhong Tang (Regulate the Middle Decoction), Huoxue San (Invigorate Blood Powder), or Muxiang Yigong San (Aucklandia Overcoming Attack Powder) can be carefully selected. Dao Ye occurs when smallpox spots have emerged but are affected by external Wind-Cold, causing skin pores to close again, leading to Qi and Blood coagulation and stagnation. Symptoms include body pain, slight coldness in limbs, constipation of both bowels and bladder, stalled growth of lesions, or black/purple or flat/smooth appearance. These are all called Dao Ye. Urgently warm the muscles and disperse Wind-Cold using formulas like Shen Su Yin (Ginseng Perilla Drink) or Xiao Chaihu Tang (Minor Bupleurum Decoction), possibly adding Zi Cao (Arnebia), Chan Tui (Cicada Slough), or Jiang Can (Bombyx Batryticatus). Warming and dispersing Wind-Cold allows heat Qi to flow naturally, and smallpox will regrow. Furthermore, if Heat Evil causes dryness and stagnation with blocked urination and defecation, abdominal distension, panting, urgency, severe heat with delirium, and black sinking with scorched purple color, treatment should involve purgation. After purgation, if Qi is cold with chills, it is ominous; if Qi is warm and balanced, it is auspicious; if severely black, sunken, withered, and the tongue is black, it is untreatable. Regarding black spots on smallpox, the toxin should not be dispersed. Blood carries toxins upward to Yang positions; if Yang is insufficient, Yin takes advantage. Qi fails to retain blood, and blood fails to nourish, gradually becoming withered and black. Use Baoyuan Tang (Protect Origin Decoction) added with Dang Gui (Angelica Sinensis), Chuan Xiong (Ligusticum), and Rou Gui (Cinnamon Bark) to lift and tonify Qi, causing toxins to emerge and turn yellow. If not encouraged and released, Fire Depression remains inside. Like roasting beans, low fire makes them yellow and cooked due to retained moisture; high fire makes them violently black, as its nature is fierce and uncontrollable. Prolonged fire chars and dries them, leaving no possibility of restoring moisture.

Smallpox named "Ta" (Collapse) has a flat shape without protrusion because Qi and Blood cannot interact vigorously, the功 (merit/function) of formation is deficient, Zhen Yuan (True Origin) cannot gather, and the momentum of filling does not arrive, resulting in flat collapse and lack of fullness. Named "Xian" (Sink) refers to a deep and dangerous condition due to Yuan Qi depletion and evil Fire invading internally. The sac shell ulcerates, and true pus does not fill inside, causing pit-like sinking unable to raise defenses. This is always due to weak Yuan Qi failing to control blood to carry toxins to the surface, causing blood to separate and Qi to scatter. Though raised, it is not full, hence named Xian. Extreme Qi deficiency fails to constrain blood; unconstrained blood carries toxins out, hence named Ta. Ta and Xian seem similar but are actually different. Xian sinks deeply without rising, though the root base remains; Ta is flat with no trace, or with traces but no root. There are cases of Xian Ta (sunken and collapsed) before fullness; Dao Ta (fallen and collapsed) after fullness; Ding Xian (crown sinking) where the root base is established but Yuan Qi is weak, unable to sustain subsequent Qi, causing sharp momentum to wither; Hei Xian (black sinking) where Qi cannot store blood to nourish, combined with toxin stagnation and dried blood; Xue Xian (blood sinking) where Wei Qi is insufficient and Ying Blood is excessive, Qi fails to constrain and transform into pus, stopping midway; Bai Xian (white sinking) where Qi is insufficient, Blood is weak due to decline, both Qi and Blood are deficient, toxins have no way to resolve, eventually sinking to become white; Hui Xian (ash sinking) where Qi and Blood are weak, internal and external deficiency exists, externally resembling silkworm eggs, empty shells without pus, or hollow with root bases containing clear water, which is untreatable. Danxi said: Ash-white color indicates deficiency-cold. Observe if the patient is quiet or timid, confirming cold syndrome. If brave, dry, or inflamed, consider heat syndrome; do not generalize. You Du Xian (toxin sinking) occurs when Blood and toxins chase each other, Qi is weak and cannot constrain/transform, leading to coagulation without nourishment, dryness without moisture. Dao Xian (reversed sinking) occurs after seven days when root bases are sufficient and pus is full and glorious, but due to Wind-Cold attacking emptiness externally, Qi and Blood coagulate, toxins attack internally, or vomiting/diarrhea cause thirst and exhaustion of Qi/Blood/fluids, pus recedes, and toxins sink internally. In summary, it is never without deficiency. Further examine within deficiency: thin skin and white color indicate true deficiency. If the sac is thick and color dark, this is toxic vapor obstruction unable to reach the exterior, roots not loosened, named "Toxin Binding." Treating as deficiency increases collapse. Black represents the death of Fire. Colors ranging from bright red to scorched purple result from Fire. When force is exhausted, it stops. Thus, heat is red, stagnation is scorched, extreme is black. Just as living fire is red and dead fire is black, "turning black returning to Kidney" means toxic vapors return to the Kidney.

Anything internal and not emerging is called "Fu" (Hidden). Anything external and re-entering is called "Xian" (Sink). Smallpox with black sinking has four syndromes. First, due to contracting Wind-Cold closing skin pores, blood coagulates and does not flow, causing black sinking. Symptoms must include body pain, slight coldness in limbs, spots not growing, or turning black/blue-purple macules. This is Dao Fu (Reversed Hidden). Treatment should warm muscles and disperse, removing Cold Evil so Heat Qi flows again, and spots grow. Second, due to excessive toxic vapors steaming internally and externally, toxins re-enter the interior causing black sinking. Symptoms must include mental restlessness, mania, panting, delirium seeing ghosts, blocked urination/defecation, thirst, and abdominal distension. This is Dao Xian Fu (Reversed Sink Hidden). Treatment should strongly drain to expel bladder toxins, restoring Yang Qi and warming Spleen/Stomach. If after taking medicine, body heat returns, warmth improves, and appetite returns, Spleen overcomes Kidney. Although toxins are strong, interior Qi is strong enough to sustain later stages, driving toxins outward. Sunken spots should re-emerge, a sign of treatability. If accompanied by chills, cold sweat, and heat in ears/buttocks, death ensues. Third, due to internal deficiency failing to allow Yang Qi to assist Ying/Wei, eruptions appear and disappear. Spots are white or black. Patient cannot eat/drink, stool is loose, vomiting or coldness may occur. This is Stomach deficiency/internal weakness failing to erupt, called Xian Fu. Treatment should use warming middle agents to warm Stomach and restore Ying/Wei flow, allowing natural eruption. If caused by erroneous purgation leading to toxin entering interior and black sinking, first warm/nourish the interior, then use Gui Zhi (Cinnamon Twig) and Ge Gen (Pueraria) to release the exterior, allowing natural eruption. Fourth, due to exposure to foul odors from sexual activity etc., causing black sinking. Urgently use Zi Cao, Jiang Can, Dang Gui, Hong Hua, Shan Jia (Pangolin Scale), Chan Tui, Gan Cao (Licorice), and Sheng Di (Rehmannia), applying externally for fumigation and resolution. Ancient formulas for black sinking all use Pangolin Scale for its ability to penetrate intestines/membranes and move freely. Using Human Teeth (Ren Ya), being bone residue, can stimulate Kidney toxins. But these two substances serve only as guides; using them alone is useless. Some use burned human feces because it resolves epidemic toxins well. Since smallpox is contracted from seasonal epidemics, adding it to formulas that release exterior, harmonize middle, and detoxify is excellent.

Fu (Hidden) means toxins stored internally do not emerge. Xian (Sink) means toxins emerge then sink back. Fu presents as one syndrome, while Xian has several types. If Fu signs appear during the manifestation stage, after sores emerge, heat does not decrease, with irritability, thirst, and restlessness, visible latent toxins have not fully emerged. Xian appears after the manifestation stage. If blood gradually dries and turns black, it is called Hei Xian (Black Sinking). If pus fluid is not formed,破损 (broken/damaged), itchy, and collapsed, it is called Dao Xian (Reversed Sinking). If pus forms but turns back to water, refusing to scab, it is called Dao Ye (Reversed Crusting). Dao Ye is also a type of Xian. Any black sores are called Hei Xian. Hei Xian is called "Returning to Kidney" because Kidney belongs to Water and color is black, representing the appearance of the True Organ color, hence deemed untreatable. However, is this solely due to Kidney excess usurping power? Fundamentally, it is massive loss of Qi and Blood, inability to expel toxins to the surface, leading to withering. Why do people wrongly claim Kidney excess and insist on draining to make it more deficient? They do not know that the human body, broadly speaking Yin and Yang, narrowly speaking Heart and Kidney, constitutes True Water and True Fire. Smallpox Fire originates in the middle, relying on this bit of True Water to restrain its surge. If drained, Fire has no restraint, and the root is pulled out first. Moreover, dried blood must be black; fire-originated color is also black. Thus, the Classic says: "Fire erupts and obscures clarity." The root is already Water Deficient and Fire Excess, causing harm; how can one further claim Kidney Excess and drain Water? Purple-black sinking is due to blood momentum being dry and stagnant, Qi unable to circulate. Discussing deficiency with surplus, urgent treatment can still revive. If sinking reaches ash-white, Yuan Qi has failed and cannot rise, blood is scattered and cannot connect, representing insufficiency within insufficiency, making it difficult to treat. If reversed crusting involves unceasing bleeding from smallpox, named Hui Yang Quan (Returning Yang Spring), if it affects the chest/hypochondrium, ten cases save one; if elsewhere, quickly find Yan Zhi Pei (Vermilion Embryo) plus Xue Jie (Dragon's Blood) one qian, calcine until charred but preserve nature, apply to the spot. If bleeding stops and dries, it is cured.