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[On Sealing and Closing / On Edema]

The internal Heart, Liver, Spleen, Lung, and Kidney correspond to the external ears, eyes, mouth, and nose. Therefore, excessive use of vision damages the Liver (Gan), excessive speech damages the Heart (Xin), excessive listening damages the Kidney (Shen), and excessive smelling damages the Lung (Fei). What the variola (smallpox) relies upon is nourishment by blood and expansion by Qi, so that it can become full and prominent. If the five orifices do not chase desires outwardly, Yuan Qi (Original Qi) will naturally circulate internally; if the five orifices are led by external objects emotionally, Yuan Qi will dissipate internally. Thus, the nose is the orifice of the Lung; the Lung governs the skin and hair and houses Wei Qi (Defensive Qi). The variola relies on Lung Qi for its beginning and end. If the nose is blocked (Feng), Qi does not scatter outward but finds a归宿 (return/gathering). The Liver governs the sinews and houses Blood. The eye is the orifice of the Liver; the variola relies on Liver Blood to moisten and prosper. If the eyelids close (Ge), Qi does not scatter outward, and Blood is nourished. Therefore, the variola must desire the state of "Sealing and Closing." If the variola emerges in the Yangming channel, harmonizing with the Spleen channel's righteousness, Yin and Yang assist each other; even if the nose is not blocked, Qi arrives naturally; even if the eyes do not close, Blood prospers naturally. However, if the path goes through the Heart and Lung but the variola does not seal and close, those passing through the Heart resemble pepper skin and iron leaves (hard/stubborn); those passing through the Lung resemble dry leaves and thin paper (fragile). Such is their momentum. Those that seal and close on the third or fourth day are easy to fill and easy to scab over; those that seal and close on the sixth or seventh day are difficult to fill and difficult to scab. "Sealing" without "Closing" means Yin cannot nourish Yang; "Closing" without "Sealing" means Yang cannot protect Yin. However, "Sealing" accounts for four or five out of ten cases, and "Closing" accounts for seven or eight out of ten cases, yet there are subtle distinctions within. If the nose is blocked but the nostrils externally are dry, death ensues. If there is mucus when blocked, it is a good omen. If the eyelids close but the orbital rim looks like blackened charcoal, death ensues. If the eyelids close and tears flow, it is an auspicious sign. As for turbidity like pus, flowing freely without restraint, this is a manifestation of toxic fire burning internally and body fluids escaping externally; this is an extremely malignant symptom and cannot be considered auspicious.

The Classics state: "Excess heat causes swelling." Generally, severe toxicity必然 leads to swelling, while mild toxicity does not. When all pox have erupted and reached the expected stage of rising, as the pox gradually grow and the head and face gradually swell, this indicates toxic fire dispersing and gathering in the three Yang regions, intending to form pus and blood, swelling gradually. With round, distinct, red, and vibrant pustules, where the swelling of the pox causes the skin and flesh to swell, this is the normal pattern and also a favorable course. If the lesions were originally distinct, the toxic qi was light and shallow, and the roots were not dense, so during the rising phase, there is little congestion or swelling; this is a sign of light toxicity and an even more favorable course. If the lesions were originally indistinct and did not swell during the rising phase, this indicates toxicity hidden internally without being expressed; this cannot be judged as light toxicity. If eruption occurs densely in clusters, losing individual grain-like definition, with bright red skin color, lesions connected in strings, adherent and flat; or if the lesion color is grayish-white, forming cakes like tin surfaces; or if the lesions are scorched purple without pus; these mixed flesh-pox cases, swelling all at once, are all ominous signs. Furthermore, if the head and face swell prematurely before the pox rise, with smooth, shiny, and bright skin resembling a gourd, this is evil toxic qi invading the clear and empty upper orifices. The essence of the five Zang organs gathers in the head and face and the Niwan Palace (brain), which is also the passage for the Yuan Chen True Person. Evil toxicity invading upward causes the loss of the five essences and the demise of Yuan Chen; losing essence and spirit, death inevitably follows from itching and collapsing. This involves skin toxicity qi, known as Da Tou Wen (Big Head Plague). At the initial stage, one must urgently administer Qiang Huo Jiu Ku Tang (Notopterygium Decoction for Saving from Bitterness). If the cheeks and jawline swell prematurely, this is called Ha Ma Wen (Toad Plague). It should be treated concurrently with epidemic qi, primarily using the aforementioned decoction, though this condition is mostly ominous with few auspicious outcomes. Even if swelling occurs on schedule, it is only excellent until the pus dries and scabs form, with toxin resolved and swelling subsided. During the swelling phase, one must strictly avoid itching, as any damage to the central face is unacceptable. If itching leads to rupture, the situation becomes uncontrollable, leading to internal sinking of toxic qi and external leakage of true Qi, resulting in death after swelling subsides. Only those whose ruptures refill with pus, whose subsidence reverses to swelling, who maintain normal diet, and whose urination and defecation are self-regulated can turn misfortune into fortune; at this time, it is especially appropriate to use Shi Quan Da Bu Tang (Complete Great Tonifying Decoction) to assist. If the lesion color is grayish-white and the face swells like a tin cake, one must examine the state of the Zang-Fu organs. If diet is unchanged, excretions are normal, and there is no other suffering, recovery is still possible. If unable to eat, vomiting and diarrhea occur simultaneously, or itching arises, death is certain.

Regarding edema, consider a grain seed: the seed must swell, allowing Yuan Qi to sprout and reach forth, then shoot up, bloom, and bear fruit. Moreover, since the variola originates in the Spleen Earth, and Earth is necessarily deficient, vegetation flourishes; thus, the variola must desire edema. Edema is toxic fire wandering between the high grounds (body surface), with Yin and Yang mutually overcoming and insulting. The Spleen governs muscles; therefore, muscle edema is caused by the overflow of toxic qi. If Qi and Blood are abundant, they naturally drive the toxin out to the exterior, directly entering the nest/cavity, becoming ulcerated and purulent; thus, both pox and flesh swell, which is a favorable course. If Qi and Blood are insufficient, although they carry the toxin to the surface, they lack the strength to penetrate directly into the nest, causing it to scatter across the skin; thus, flesh swells but pox do not, which is an unfavorable course. Upon seeing this mechanism, the practitioner should heavily employ Zao Ci (Gleditsia Sinensis Spine), Jiang Can (Bombyx Batryticatus), and Chuan Shan Jia (Pangolin Scale) amidst heavy tonification of Qi and Blood, so that the toxin has a destination and avoids reckless swelling.

Commentary by Zhang: The discussions of ancient sages can be said to be thorough and detailed. However, in the midst of greatly tonifying Qi and Blood, heavily employing Jiang Can and Chuan Shan Jia as attacking and supporting drugs, one inevitably relies on the fierce power of tangible medicines to drive away intangible, manifesting deficiency. If encountering severe deficiency with an unrooted foundation, Zheng Qi (Upright Qi) lacks the strength to hold command, inevitably yielding to the attacking nature of the drugs, leading to collapse without basis; the hazard of edema cannot be guaranteed against. I sought this truth in dreams and finally attained the supreme principle. Whenever fever begins and spots appear, treatment should be administered according to the pulse's Yin-Yang and Deficiency-Excess. If the pulse is surging and belongs to Yin deficiency, add stimulating/driving herbs to Yin-tonifying medicines. If the pulse is faint and belongs to Yang deficiency, add stimulating/driving herbs to Yang-tonifying medicines. Once Yin and Yang are harmonized, the variola spots will emerge smoothly, arranged evenly, distinct and plump, definitely avoiding clustering, fine density, or crooked irregular shapes, thereby preventing future scattering across the skin. When approaching the swelling and pus-filling stages, one must again assess the pulse's Yin-Yang and Deficiency-Excess, treating either from Yang or Yin, preparing in advance, and still adding stimulating flavors, so that strong Zheng Qi can control Xie Qi (Pathogenic Qi), leaving no deficiency for Xie Qi to exploit, thus aligning with Zheng Qi. Essentially, what the variola relies upon is Qi and Blood. To tonify Qi, one must focus on the Spleen Yuan; moreover, Earth virtue can transform toxins. To tonify Blood, one must nourish Water (Kidney), as nourishing Water also benefits Blood generation. However, the benefit of Spleen Earth also relies on True Fire to generate it, and the growth of True Yin relies on True Yin to warm it. Thus, Zhang deeply understood this purport. Whenever encountering Qi-deficient variola, ancients used Renshen Yin (Ginseng Drink) plus Rou Gui (Cinnamon Bark), named Bao Yuan Tang (Protect Origin Decoction); the book *Bo Ai Xin Jian* has already fully described its merits. For variola with Yang deficiency and insufficient Spleen Yuan, it is better to use Renshen Ling Zhu Tang (Ginseng, Poria, and Atractylodes Macrocephala Powder) with Ginger and Cinnamon. Fearing dryness, slightly add Jiuhuang Dang Gui (Wine-fried Angelica Sinensis); administering this yields rapid effects in raising swelling and filling pus. For Yin deficiency insufficiency and Water-depletion with Metal-dryness symptoms, ancients had no specific formula. I use Shu Di Huang (Prepared Rehmannia Root) as Sovereign, Shan Yao (Dioscorea Opposita) as Minister, with a small addition of Rou Gui (Cinnamon Bark). Decoct these three strongly, and separately decoct Renshen (Ginseng) to mix in. Use only Renshen, not Huang Qi (Astragalus), so that pus fills and matures, achieving miraculous results. Know that True Yin is Kidney Water, not Liver-Heart Blood. True Yang is Ming Men Fire, not Spleen-Lung Qi. Therefore, to tonify Kidney Water, heavily use Shu Di Huang and do not use Xiong Diao (Chuanxiong); to tonify Ming Men Fire, use Rou Gui, not Bai Zhu (Atractylodes). Thus, Zhang, during the critical stage of pus filling, uses only Di Huang (Rehmannia), Renshen, and Rou Gui. These interact favorably with Water and Fire, ensuring pure nature and potent force. Not combining Jiang Can and Chuan Shan Jia, which are not of the same category as Qi and Blood, allows clarity to uphold Zheng Qi and dispel Xie Qi. With Shu Di Huang's dedicated function of nourishing Water and Rou Gui's divine power of moving and transforming pus, Shan Yao nourishes the Stomach, and Renshen drives the process; Qi and Blood gain strength, naturally transforming toxin and succeeding. Pus formation, though originating from Liver Blood, actually draws support from True Water. Pus contraction, though relying on Spleen Earth, actually depends on True Fire. When releasing the exterior, using Gui Zhi (Cinnamon Twig) can enter the Blood level, reaching every minute detail. Before scabbing, it is still usable, as residual toxins are entirely transformed at the surface without lingering concerns. Wait until Qi transforms to pure Yang, pus erupts and ripens, then administer detoxifying and cooling formulas; this is like a cool breeze arriving suddenly in intense summer heat, appearing even more miraculous. Why use Gui Zhi instead of Fu Zi (Aconite)? Fu Zi reaches the Yin level directly, unlike Gui Zhi which moves and penetrates, reaching the surface and ascending further, directly entering the Blood level and returning dynamically. Using attacking/supporting drugs controls toxin by force. Using warming/moistening and stimulating functions transforms toxin by virtue. Control is forced and often recurrent; transformation is natural and consistent throughout. Seeking the supreme principle with heart, I dare to supplement what was omitted.