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If the pustular fluid is insufficient, or if half-fluid cannot meet the requirements, this is due to a lack of detoxification power. One may choose burnt human feces ash, or fine powder from the bank of a cesspit, selecting one of these two, and adding Pangolin Scales (Chuan Shan Jia) powder; alternatively, Niuhuang San (Calculus Bovis Powder) can also be used. Ancient texts state: "Employ the method of repelling tonification to prevent excessive benefit, and advance cooling methods to assist scabbing." This means that when the pustular fluid is sufficient, Ginseng Radix et Rhizoma (Renshen) and Astragali Radix (Huangqi) should not be used again. If one does not understand this, seeing that the smallpox lesions do not converge, and tonifying further will only worsen the condition. ○ Huangqi (Astragali Radix) for promoting pustular fluid should only be used raw; during the stage of fluid formation, it should be honey-fried. (From *Ren Duan Lu*)

All insects and ants have attacking properties. Those without blood move in the Qi level, those with blood move in the Blood level. Flying ones ascend, ground-walking ones descend. ○ Fire-toxin returning to the Lung, I follow Sun Simiao's Weijing Tang (Ejunctum Calami Decoction), occasionally there are effective cases. (Ye Tianshi)

The ancients said that once red spots appear in smallpox, Shengma Gegen Tang (Bupleuri and Puerariae Decoction) should not be taken, fearing it might cause exterior deficiency. This was likely stated for cases where the rash is sparse and the toxin is light. Later generations did not understand the intent of this statement and rashly concluded that Shengma Gegen Tang should never be taken once any spots appear. They did not realize that the four ingredients of Shengma Gegen Tang are a formula for releasing the exterior and detoxifying, unblocking Qi and Blood, and regulating Yin and Yang. If the rash is too dense, it is precisely suitable to take this formula, to lift what has sunk, moisten what is dry, disperse what is stagnant, and calm what is excessive, thereby preventing Yin essence from depletion and Yang toxin from hyperactivity. In cases where the rash is sparse and toxin is light, even other medicines should not be taken, let alone Shengma Gegen Tang? (Wan Mizhai)

[Smallpox Vaccination]
There was an excellent ancient method for variolation, passed down to this day, which is very safe and appropriate. Because natural smallpox arises from external contraction of seasonal pathogens, variolation is performed when the child is free of disease. Is this not a wonderful method of avoiding danger and seeking safety? The key to variolation lies in good "seed" (variola material). The "seed" refers to taking the scabs from children who have undergone variolation, called "seedling scabs," which lack seasonal pathogenic qi. If one uses scabs from naturally occurring smallpox, called "seasonal scabs," they carry the prevailing epidemic qi. If used without discrimination, although nominally variolation, it is practically no different from transmitting seasonal smallpox. However, seedling scabs must be selected from cases where the rash is sparse, color is lustrous, fluid is thick, scabs are dense, and they are shiny, pointed, and round. These are superior seeds where Qi and Blood are abundant, and Yin and Yang are harmoniously integrated. Store them in porcelain bottles, tightly seal the mouth, place in a cool location, and avoid contact with foul odors. In the North, where the weather is cool, within one month in spring, or forty to fifty days in winter, they can still be used. In the South, where the temperature is warmer, within four to five days in summer, twenty days in spring, or thirty days in winter; if kept too long, the qi becomes weak and ineffective, and vaccination may fail. To obtain such seeds, visit families performing variolation and request a few grains, allowing for continuous supply. Or, clarify matters beforehand with honest and reliable variolators among colleagues, borrowing from each other, so the supply of seeds remains uninterrupted. Recently, some variolators, having run out of seedling scabs, temporarily use seasonal scabs. This often results in dense rashes and severe conditions. They do not know that seasonal scabs must also be transmitted through several generations of successful vaccinations to become mild and equal to seedling scabs. As for the method: for each child, take three or four grains of scab, place them in a teacup, add a few spoons of clear water, wet with fingertips, pour out the water, and grind with a small willow wood pestle for over ten turns until it forms a paste-like consistency. Pinch a small ball of new cotton, size like a jujube pit, length and thickness adjusted to the child's nostril size. The cotton ball should not be too loose, lest the seed qi escape easily. Dip one end of the cotton ball into the scab paste and insert it into the child's nostril, left for males, right for females. Do not insert too deeply, lest the child feel uncomfortable; nor too shallow, lest it fall out easily. It must be moderate in tightness and depth. After insertion, prevent the child from picking it out with their hands. If sneezed out, immediately reinsert. The duration for retaining the seed is six shichen (twelve hours). In hot weather, remove it earlier by a short while; in cold weather, leave it longer. The seed qi gradually spreads through the five Zang organs. On the seventh, eighth, or ninth day, fever occurs. After three days of fever, the rash appears. Just before fever, small lumps resembling phlegm nodules will appear on the child's neck. This is where the toxic qi gathers; once the rash emerges, it will be sparse. No treatment is needed; it will gradually subside after scabbing. If seasonal scabs are used, no such lumps will be identifiable in the neck. Whether a child is suitable for variolation depends on observing their constitution (deficiency or excess) and the presence of chronic diseases. Nursing methods include dietary moderation, adapting to temperature changes, and preventing fright. These are all well-known to variolators, so I will not repeat them here. (Ye Tianshi)

Those who develop fever and rash on schedule seven days after inoculation are considered to have "active seeds." Those who do not develop rash after inoculation have seeds that are not agile, stopping halfway. Like a clock losing time or a firecracker failing to ignite. ○
I recall Mr. Cheng Hanzhao's "Five Conditions for Not Variolating": Do not variolate if the fontanelle is open and eyes show excessive white sclera; do not variolate if muscles are soft and flaccid with much phlegm; do not variolate if skin is dry, yellow, and伴有 rickets/accumulation; do not variolate if nostrils are small; do not variolate if under one year old. If variolators can avoid these five situations, they will not make mistakes. ○ I believe that besides these five, there are "Three Conditions for Not Variolating": Do not variolate if recovery from illness is incomplete; do not variolate if sores and scabies are present on the body; do not variolate during an epidemic of seasonal smallpox. Fear of epidemic transmission, internal and external attack, makes the body unable to bear it. (From *Dou Jue Yu Yi*)

[Selected Cases]
The son of Censor Zhang Yuan'an, aged thirteen, returned from the south in June, contracting summer-heat. He suffered from restlessness, thirst, mania, and irritability. After taking Tianshui San (Talcum and Bupleuri Powder) without cessation, he switched to Dashun San (Great Harmony Powder), resulting in lethargy and obstruction of urination and defecation for five days. I prescribed Baihu Tang (White Tiger Decoction), using Gypsum Fibrosum (Shigao) decocted as tea. Within one day and night, he gradually felt relieved, urination increased slightly, but then high fever returned. I said, "This is the eruption of smallpox." Urgently administered Neituo Qingsan (Internal Support and Clearing Powder), still using Gypsum Fibrosum as the chief ingredient. Two days later, the rash appeared. Lips and tongue were dry and cracked. Using eighty-five jin (approx. 51 kg) of Gypsum Fibrosum and three jin (approx. 1.8 kg) of Coptidis Rhizoma (Huanglian) decocted and frequently administered, he finally achieved swelling and suppuration. Over twenty-seven days, total usage was eighty-five jin of Gypsum Fibrosum and three jin of Coptidis Rhizoma. Such a case of intense fire-toxin is rare in the world. Without the Censor's firm trust, how could survival be expected? ○ Huang Wugong Langzhong, aged five, had smallpox. The lower body was dense, the upper body completely devoid of rash. I said, "This is due to erroneous purgation." Changed to ascending and diffusing agents, allowing the rash to gradually spread upwards.恰逢 I crossed the river for a few days. Wugong listened to vulgar doctors and recklessly used Scutellariae Radix (Huangqin), Coptidis Rhizoma (Huanglian), and Rhinocerotis Cornu (Xijiao). By the eighth day, there was no pus/fluid. They sent for me. I administered Ginseng Radix et Rhizoma (Renshen) and Astragali Radix (Huangqi) for internal support, and the condition improved immediately. ○ Wu Gaomen's son, aged eleven, had inverted smallpox turning rotten. One month after recovery, suddenly developed widespread smallpox again. All erupted in one day, filled with fluid in three days. On the fourth day, the area became a mass of rotting flesh, lacking distinct pock marks, with dripping pus and water. Used pine pollen and buckwheat flour, but the more applied, the worse it became. Upon careful examination, I said, "Originally there was no smallpox toxin, but spleen deficiency with dampness predominance. Ultimately, it was caused by previous use of Ephedrae Herba (Mahuang) for sweating leading to putrefaction, consuming Yuan Qi, and failure to use Ginseng Radix et Rhizoma (Renshen) and Atractylodis Macrocephalae Rhizoma (Baizhu) for regulation and tonification." Internally administered Yigong San (Extraordinary Skill Powder), externally applied Ginseng Radix et Rhizoma (Renshen) powder. With each application, it dried instantly. Internally and externally, a total of one jin five liang (approx. 600g) of Ginseng Radix et Rhizoma (Renshen) was shared. To this day, the broken areas have absolutely no scars. ○ Fan Daosheng's son, aged thirteen, had smallpox. Doctors used Rehmanniae Radix (Disheng), Antelopis Cornu (Lingyangjiao), Scutellariae Radix (Huangqin), Coptidis Rhizoma (Huanglian), Gardeniae Fructus (Zhizi), and Phellodendri Cortex (Huangbai), causing excessive dampness and inability to form fluid. I said, "Rotting leaks Qi, and it is deep winter; suffering cold evil again will lead to unpredictable changes." From hand to foot, covered tightly with paper. Internally administered Shenmai Qingbu Tang (Ginseng and Ophiopogon Clearing and Tonifying Decoction), added Poria (Fuling) and Dioscoreae Rhizoma (Shanyao), regulating step by step. After fluid returned, the paper gradually wrinkled and opened, and scabs formed and fell off. (Cheng Huazhong)

Mr. Fang Bojiu treated the son of the Xu family, aged three, with smallpox. The child's constitution was originally deficient, with thin, delicate, pink skin. On the fourth day, Ginseng Radix et Rhizoma (Renshen) and Astragali Radix (Huangqi) were used. The head and face gradually swelled, reaching five to six parts fluid. On the seventh day, due to negligent care, the left cheek was scratched, the left eye suddenly opened, and the voice became hoarse. Fang said, "This is itching due to Qi deficiency after scratching." Swelling subsiding and eyes opening indicates leakage of Yuan Qi; hoarseness indicates Qi deficiency and toxin wanting to return to the Lung. Urgently support Yuan Qi; clearing heat would cause death. Thus, Dushen Tang (Single Ginseng Decoction) was given frequently to sip. Spirit calmed for a moment, then large doses of Ginseng Radix et Rhizoma (Renshen) and Astragali Radix (Huangqi) were continued. Face swelled again. Fang said, "Life is saved, but abscess formation is inevitable." The family still worried about hoarseness. Fang said, "Do not worry, wait for the toxin to erupt." On the twelfth day, the toxin reached the feet. An abscess like a cup erupted below the right Jianjing point. Five days later, pus matured. Observing the toxin was bright and soft, pricked with a silver needle, pus sprayed like a thread, and the voice cleared instantly. ○ Grandson of Cheng Jintang, aged five. On the fifth day of eruption, I saw his forehead and cheeks blurred, body densely covered, dry red-purple stagnation with black spots, lips and tongue scorched black, body heat with cold fingers, irritability, no eating or bowel movement. This is a syndrome of Blood heat and toxin congestion. Used Shishen Jiedu He Xijiao Dihuang Tang (Ten Divine Detoxification combined with Rhinoceros Horn and Rehmannia Decoction). Medication had no effect, deemed incurable. Old doctor Cheng Hanzhao examined and said, "The syndrome is excess fire, treatable within six days." First, apply finely ground swallow nest mud mixed with green onion juice to both temples and between breasts to draw out toxin; decoction uses Ephedrae Herba (Mahuang), Scutellariae Radix (Huangqin), Coptidis Rhizoma (Huanglian), and Phellodendri Cortex (Huangbo) one qian each, Rheum Palmatum Radix et Rhizoma (Dahuang) two qian, Lithospermi Radix (Zicao) three qian, with Rhinocerotis Cornu (Xijiao) and Antelopis Cornu (Lingyangjiao) separately ground and taken with the decoction. Bowel movements occurred several times, color like spoiled sauce, lips and tongue slightly cooled, able to eat. I said, "Internal symptoms reduced, but rash has withered, how to generate pus?" Cheng said, "Fire-toxin resolved, cannot generate pus, there is another method." It was severe cold. Placed copper basin with water inside blankets, threw red-hot white stones into water, steaming with hot air. Also fumigated with Rutae Fructus (Yunxiang). Also removed feathers and entrails of a rooster, placed a handful of Coriandri Fructus (Yansui) and three qian of Magnoliae Officinalis Cortex (Houpo) inside the chicken belly, boiled to make strong decoction, frequently administered, interspersed with cooling and blood-invigorating agents. I asked, "What is the explanation?" Cheng said, "Water vapor steams to penetrate the exterior; Yunxiang fumigation causes skin cracking. (Methods using swallow nests, white stones, Yunxiang etc. come from *Zhengzhi Zhunsheng*); Rooster strongly disperses, Houpo resolves accumulation, Yansui opens orifices, allowing toxin to emerge from hair follicles. Skin cracks, toxin exits, body flows with water, water flow transforms toxin, inability to generate pus, yet success can be achieved." Following this method, indeed bedding became wet, whole body skin shed, and recovered. I admired the brilliance of his treatment, beginning to see his skill in treating excess syndromes, perhaps less so in deficiency syndromes. Later treated Cheng Jintang's second son, young but constitutionally weak, heavy smallpox with poor fluid generation. Used sheep placenta, Ginseng Radix et Rhizoma (Renshen), Astragali Radix (Huangqi), Lycii Fructus (Gouqi), and Epimedii Folium (Yinyanghuo) boiled together in strong decoction, cured. What insight and courage! (From *Xiangcun Dou Jue*)

My son, forty days old, had a few smallpox spots, body not very hot. Observers said this was very mild. Two days later, body became densely covered with rash, forehead, face, and scrotum pure red, indistinguishable particles. Observers again said because the child was small and rash numerous, it was hopeless. Seeing the rash color was lively and red, and the child could suck milk, I thought it could still be treated. Used Ginseng Radix et Rhizoma (Renshen), Astragali Radix (Huangqi), and Glycyrrhizae Radix et Rhizoma (Gancao) decocted strongly, given between feeds. By the sixth day, head rash had fluid, but intermittent vesicles, limbs mostly fluid-poor. Child is small, Qi and Blood limited, not yet worrying. Only forehead and face pure red without fluid, believed must have pus for toxin to transform, still gave previous medicine. By the seventh day, one or two spots on the red forehead turned black. Frightened thinking it was a reversal, observed spirit was not exhausted. That night, scrotum also turned black. Realized it was not a bad omen, but scabbing. Because the child is small, Qi and Blood circulate easily, cannot stick to normal timelines. Ninth day, scabs fell off, body had high fever again. This is residual toxin wanting to erupt as an abscess. Took Dalianqiao Yin (Great Lonicaria Decoction), fever subsided, scabs fell off red areas, pus water not dry, used Phellodendri Cortex (Huangbai), Coptidis Rhizoma (Huanglian), Glycyrrhizae Radix et Rhizoma (Gancao), Lycii Cortex Radicis (Digupi), and Myrobalani Fructus (Wubeizi) powder applied, cured. Scrotum flowing water, cured with Mianjian San (Cocoons Powder). This was a very small infant, very numerous smallpox, very critical condition. Treating according to symptoms, immediately revived. People encountering small infants with numerous smallpox, and pure red vesicle syndromes, give up treatment, is this not a mistake! ○ Cousin, fifteen years old, dense smallpox. Eighth and ninth days, when supposed to fill with pus, pocks sank into pits. Doctors used Costi Radix (Muxiang) and Yigong San, sinking became worse. I saw color red-purple, vitality quite robust. Said, "This is not weakness, but toxin excess blocking Qi and Blood, hence sinking and failing to form fluid." Gave Qingdu Huoxue Tang (Toxin-Clearing and Blood-Invigorating Decoction) one dose, sinking immediately rose. Second dose, pus and fluid full. (Jiuwu)