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The syndrome of Blood Heat must be differentiated into deficiency and excess. There is Blood Heat caused by Blood Deficiency, which should be treated with cooling and tonifying methods; there is Blood Heat caused by Blood Excess, which should be treated with cooling and resolving methods. Why did the ancients not fully elucidate this? When pustules first appear as red spots, the internal heat is extremely severe, and the pulse is surging and rapid, yet the color of the pustules is white. Those who do not understand may mistakenly attribute this to Qi Deficiency. This is actually a condition of Qi Excess combined with Blood Deficiency and Blood Heat, so the pustules cannot become ruddy and fail to expel the toxin outward together. Because Qi is in surplus while Blood is insufficient, the pustule shape rises but the color is white. However, Blood Deficiency generates Heat. Therefore, when the disease progresses to the stage where blood enters the pustule base (douke) and after three or four days, the color changes to purple or black, or black spots appear, one then realizes it is Blood Heat, but it is too late to treat! Thus, one must know this in advance and prepare accordingly. Only those with robust Blood and Qi will have pustules that rise with a purple hue from the onset, making the symptoms of Blood Heat clear. However, for treating Blood Heat due to Blood Deficiency, it is highly appropriate to use cooling blood methods combined with blood tonification. This is because such cases often present with cleared heat potential, but without sufficient blood to fill the pustule pulp, leading to dry collapse. For Blood Heat due to robust Blood and Qi, it is highly appropriate to use solely cooling blood methods combined with resolution techniques. In cooling blood formulas, it is especially important to include lifting and promoting agents; otherwise, blood coagulation and toxin stagnation will occur. As for conditions of Qi Deficiency combined with Blood Heat, Blood Heat easily leads to dry purple discoloration, so cooling blood methods are essential. Yet, Qi Deficiency makes it difficult to tolerate harsh attacking and promoting drugs, so the intensity of promoting agents should be doubled with caution. Before the sixth day, if Blood Heat symptoms persist and fire energy remains, the presentation may seem like an Excess syndrome. As treatment clears the Blood Heat, the symptoms will gradually appear more deficient and colder day by day, inevitably leading to diarrhea and chills. Therefore, initially, only clearing and promoting methods are suitable. Once the trend of Blood Heat recedes by even a fraction, one must immediately prepare for the Qi Deficiency aspect. One must not blindly use herbs that damage the Spleen and deplete Qi just because they were used previously. Once Blood Heat is about to clear and Qi Deficiency becomes severe, it is best to add Ginseng (Renshen) to the cooling blood formula for tonification and promotion. The skillful combination of medicines is crucial: act urgently when needed, slowly when appropriate. This depends on the physician's acuity, derived from the mind and applied by the hand. Acting too early aids heat and causes disaster; acting slightly late fails to tonify deficiency adequately. It often happens that by the time chills and diarrhea appear simultaneously, tonics are administered, but the patient suffers immediate diarrhea after ingestion. Repeated dosing fails to retain the medicinal power in the middle jiao, rendering efficacy ineffective; this is the fault of delayed action. Conversely, when Blood Heat is slightly cleared and Qi Deficiency is not yet severe, and Ying-Wei (Nutritive and Defensive Qi) are harmonizing, showing signs of white pus formation, if the physician uses heavy tonics like Ginseng and Deer Antler (Lurong) too soon, it may generate heat internally, causing sore throat and hoarseness, and externally causing dry, red, collapsed pustules; this is the fault of acting too early. Therefore, when treating Qi Deficiency combined with Blood Heat, at the juncture where clearing-promoting herbs should cease and tonifying-promoting herbs should begin, careful examination is vital. Any excess or insufficiency can lead to life or death. For patients with severe systemic Qi Deficiency, dense pustules, and abundant toxins, where Blood Heat has cleared but Qi Deficiency is severe, if large doses of Ginseng are indicated, using approximately one tael per day is standard practice. However, this must be combined with interior-promoting herbs like Bombyx Batryticatus (Tianchong) and Gleditsia Sinensis Spine (Jiaoci), or supplemented with Ginger (Shengjiang) and Cinnamon Twig (Guizhi) to encourage function, allowing toxins to exit outward and pustules to fill properly. Otherwise, while internal tonification is correct, external expulsion will be slow. If one hesitates and reduces the dose of Ginseng when large amounts are needed, righteous Qi cannot overcome pathogenic factors, nor can it withstand the toxin. Although there may be temporary response after medication, the weak potency cannot last long, and the pustules quickly return to flatness, merely delaying time rather than resolving the toxin. For mild Yuan Qi (Primal Qi) deficiency, even small doses of Ginseng and Astragalus Membranaceus (Huangqi) allow righteous Qi to assist in circulating the medicinal power effectively. For severe Yuan Qi deficiency, lacking strength to support, one relies heavily on the strong momentum of Ginseng and Huangqi, aided by Ginger and Cinnamon, to achieve operational efficacy. Hence the saying that "insufficient dosage leads to stagnation." This method was sought by Zhang Xincheng and is recorded here to supplement omissions. If Qi Deficiency is accompanied by Lung Fire, use Ginseng but avoid Huangqi.

The granddaughter of Elder Jiang, aged only one year old, developed fever for half a day before appearing with pustules. Her complexion had always been pale. I predicted early on that her pustules would be fine, dense, and produce clear pus. Indeed, upon appearance, they were densely packed without gaps, resembling snake-skin patterns across the chest, back, hands, and feet. By the third day, facial pustules were dry, gray, and white; back and neck pustules were purple, sunken, and un-nourished. Knowing that Yuan Qi was both weak and stagnant, and Nutritive Blood could not circulate with Qi, the face appeared Qi Deficient while the body resembled Blood Heat. Actually, it was the failure of Qi and Blood to circulate uniformly, causing stagnation and purple discoloration. The bases were flat and scattered, truly caused by Qi Deficiency. I immediately prescribed warm tonifying and promoting decoctions, one dose each morning and afternoon, containing four qian of Ginseng per dose, taken mixed with other herbs. In the evening, another three qian of Ginseng were decocted separately and taken as a concentrated juice. The ingredients included Ligusticum Chuanxiong Rhizome (Xiong), Angelica Sinensis Radix (Gui), Huangqi, Cinnamon Twig (Gui), Tianchong, Jiaoci, Dioscorea Oppata Rhizome (Shanyao), and Licorice Root (Gancao). From the fourth to the seventh or eighth day, heavy tonification continued without relaxation. Flat areas gradually rose; dry, sunken areas became moist; clear fluids became thick. Areas resembling snake-skin nests turned into blisters and ulcers. This is a case record of treating apparent Blood Heat caused by severe Qi and Blood Deficiency, Blood Stasis, and Qi Stagnation.

A five-year-old child, whose stool had always been loose and diet scanty, and who suffered from internal heat causing skin sores, presented with severe fever and vomiting. Upon examination, two "thief pustules" (small, isolated pustules) were found on the right forehead for two days. They were pricked and sealed with oil and rouge. Severe choking cough required adding throat-clearing herbs to the exterior-releasing formula. On the second day, spots appeared, very red and purple. Throat-clearing, exterior-releasing, promoting, and blood-cooling methods were continued. Redness and purple did not diminish on the third day; head, face, and body were very dense, with flat, sunken tops. The previous formula was modified to increase promoting power. By the fourth day, redness/purple lightened slightly, but flatness remained. Fortunately, the voice was clear and painless, demonstrating the efficacy of throat-clearing. On the fifth day, tops still did not rise, purple persisted. To fully induce pus, Blood Heat was an obstacle; to cool blood again risked diarrhea due to Qi Deficiency. Thus, a semi-clearing, semi-tonifying approach was used to induce pus. By the sixth day, appearance remained unchanged. Ginseng was added to the previous formula. The next day, empty spaces produced numerous secondary pustules ("zeng dou"). Previous pustules had white tops but purple roots. Ginseng dosage was doubled. Gradually, 10-20% pus formed. By the eighth/ninth day, diarrhea and teeth-grinding occurred; pustule color turned gray-white. Blood Heat had slightly cleared, but Qi Deficiency was fully manifest. Baoyuan Tang with Ginger and Cinnamon stopped diarrhea and teeth-grinding, though pus quality remained poor. By the next day, some scabs formed. This case involved Qi Deficiency, Blood Heat, and Blood Deficiency, with dense pustules preventing pus formation. The emergence of secondary pustules helped vent the toxin. Early clearing and cooling prevented severe throat pain during pus formation. Commonly, in Qi Deficiency with Blood Heat, around days five/six, as Blood Heat subsides, Qi Deficiency worsens, leading to inevitable diarrhea, gray-white color, and collapse. Using Ginseng at this stage, if followed by diarrhea, loses its benefit; hence, preparation must be early. Herbs damaging Qi/Spleen are avoided. Promoting herbs aiding Spleen are used early. Even if Blood Heat is not fully cleared, if Qi Deficiency is urgent, Ginseng and Zicao (Arnebiae Radix seu Lithospermi Radix) are used. To counteract Zicao's coldness, sticky rice (Nimi) is added to moderate it. Although pus is thin, since toxins have exited externally, the patient eats without abdominal distension and breathes clearly without panting. Efforts should focus on regulating and tonifying to prevent Middle Qi collapse. After day twelve, slight recovery of Qi and Blood allows natural toxin expulsion via abscess formation. Indeed, on day fifteen, a large abscess appeared on the vertex, indicating a localized toxin amenable to tonification. Without tonification, scars would remain white and unable to resist toxins. External absorbent plasters promoted pus elevation; surrounding agents prevented toxin dispersion and muscle damage. Internal tonifying, promoting, detoxifying agents led to complete pus drainage and scab shedding by day thirty, resulting in full recovery with healthy red scars. This is a case record of treating inverted pustules due to Blood Deficiency, Blood Heat, and Qi Deficiency.

A Wang family child, over one year old, presented with pustules on the fourth day. Pustule bases were significantly raised. The forehead area was cloud-like, muddy, and gray-white. Tongue coating was white. I stated that the toxin had not been transmitted out, with cold hiding in the Dantian. Lifting and promoting therapy was highly indicated. One dose resulted in rising; two doses showed redness and vitality; by the third dose, pus appeared on cheeks and body. However, the forehead remained gray-white. Ginseng, Huangqi, roasted Licorice, and official Cinnamon were used to achieve heavy tonification and pus formation, leading to scabbing and recovery. Even "cloud covering the forehead," considered a fatal sign, should not be entirely abandoned. This is a case record of transforming Qi Deficiency inverted symptoms into favorable ones, achieving success through luck.

The great-grandson of Director Xu, under one year old, presented with very dense pustules. Cheekbones resembled silkworm eggs, colored like rouge. Symptoms included cough, loose stools, and weak spirit. History of skin sores indicated dual Qi and Blood Deficiency, constituting an inverted prognosis. Despite earnest requests for treatment, I heavily employed blood-cooling, blood-nourishing, and promoting herbs. By days three/four, redness/purple decreased, but cheekbone pustules began drying. I noted: Many pustules but little Blood, insufficient for filling; pus formation is difficult; internal attack of toxin is inevitable. We must strive against the toxin. If toxin attacks inward, we promote strongly; if Qi/Blood exhausts, we tonify strongly. If Qi/Blood regenerates, no black scabs will form on the surface; Zang-Fu Qi generates internally; Fire-Toxin resolves externally. Avoid negligence allowing toxin to invade. Heavy nourishing and promoting were used, two doses daily, each containing five qian of Ginseng. If one bowel movement occurred, three qian of Ginseng were decocted separately. Ingredients included stir-fried Rehmannia Glutinosa Radix Preparata (Shudi), Shanyao, Jiaoci, Tianchong, Ginseng, Huangqi, and roasted Licorice. Cinnamon Bark (Rougui) was added later. By days six/seven, white, tin-like areas turned yellow and moist; thin scabs adhering to flesh rose into thick crusts. Pustules on cheekbones and chin, previously without pus, formed pomegranate-like, high, bright crusts by days eight/nine. Did Ginseng create tangible results from intangible power? After day twelve, slight Yuan Qi recovery drove toxin outward, manifesting as ulcers, carbuncles, or mouth ulcers, treated symptomatically. Full recovery took two months. Peng Lingqin, deeply understanding medical principles, observed daily, stating: "This is not treating pustules, this is 'making' pustules." This is a case record of salvaging inverted pustules due to dual Qi and Blood Deficiency through heavy tonification.

A Zhu family child, nine years old, presented with burning fever, bad breath, purple macules, waist pain, and dense pustules resembling silkworm eggs, with sunken purple tops. This was true Blood Heat combined with true Qi Deficiency. I used large doses of promoting and cooling-macule-resolving formulas, including Tianchong, Pangolin Scales (Chanshujia), Moutan Cortex (Danpi), Rehmannia Glutinosa Radix (Shengdi), Carthamus Tinctorius Flos (Honghua), Scrophularia Ningpoensis Radix (Xuanshen), Plantago Asiatica Seed (Nanzi), Ligusticum Chuanxiong Rhizome (Chuanxiong), Saiga Tataricus Cornu (Lingyangjiao), Platycodon Grandiflorus Radix (Jiegeng), Tangerine Peel (Chenpi), and Licorice. Decoction was prepared with Earthworm (Dilong), plus three bamboo shoots and five qian of Zicao. After all pustules emerged, the previous formula was modified with five fen of wine-fried Coptis Chinensis Rhizome (Huanglian) for cooling and attacking promotion. By days four/five, fire energy lessened; Huanglian was removed. By day six, Blood Heat slightly cleared, followed by diarrhea. However, toxin did not sink due to strong promoting agents. I said: Now effort can yield survival. Although this case has ten parts Qi Deficiency and ten parts Blood Heat, if fire persists, tonics are hard to administer. With diarrhea now present, pure deficiency is revealed, allowing bold use of heavy tonics. However, history of Lung Heat with sore throat, hoarseness, and cough contraindicates Huangqi. Instead, double Ginseng and use herbs supporting Spleen, clearing Lung, and promoting pus. Two doses daily, each with five qian of Ginseng. By day nine, half-filled pus, mostly blisters, resembling scalds. Due to dense, snake-skin-like pustules with no space, thin constitution, and deficient Blood/Qi unable to circulate fully, fluid accumulated in sacs forming blisters. Tonification and Spleen-strengthening were continued to gradually generate Qi/Blood and digest residual toxin externally. By day thirteen, pustules ulcerated with foul odor. Pine pollen was applied externally; internally, tonifying, promoting, detoxifying, Spleen-supporting, and diuretic herbs were given. Gradual drying and scabbing occurred, like molting. This was a critical case salvaged by aggressive attacking and tonifying. This is a case record of treating true Blood Heat and true Qi Deficiency inverted symptoms, salvaged by aggressive methods.

Many historical case records exist; these few are cited to demonstrate the treatment of critical Qi Deficiency and Blood Heat. Records with similar syndromes or insufficient explanation are omitted.