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A few spots, with a dull and dark color, restless convulsions and tremors, cyanotic complexion, upward deviation or strabismus of the eyes, and loss of consciousness, is called "Jing Bi" (Shock Closure); the toxin is latent in the Liver and Gallbladder, leading to death on the same day. The Varicella toxin is originally severe, attacking the Stomach all at once; the Stomach Qi is injured by Heat, unable to expel the toxin outward, inevitably resulting in Cyan, Purple, Blue, or Black macules, rotting of the Stomach, and death, mostly occurring between the fifth and sixth days. These four conditions are ineffective with conventional treatments; new prescriptions must be formulated to save them, seeking life amidst death, requiring rapid medication, where one or two out of ten may be saved. (*Racun Doujue*)

On the third, fourth, and fifth days:
An expert physician treating smallpox can determine auspiciousness or inauspiciousness upon first sight, and next, decide life or death on the third day. If unable to decide on the third day, one cannot speak of treatment. ○ In cases of Deficiency mixed with Toxin, the third and fourth days are the most difficult for medication. Heat-Toxin must be thoroughly cleared, yet Yuan Qi (Primal Qi) must not be neglected. I have used herbs such as Huanglian (Coptis Rhizome), Shigao (Gypsum Fibrosum), Xijiao (Rhinoceros Horn - *Note: Substitute with Buffalo Horn in modern practice*), Dihuang (Rehmannia Root), Zicao (Arnebia Root), Honghua (Carthamus Flower), Danpi (Moutan Cortex), and Zhizi (Gardenia Fruit), adding a small amount of Renshen (Ginseng Root) to supervise (prevent cold-natured herbs from damaging the healthy Qi). This is like using troops; one must select those with extraordinary strength to charge, but fearing their rashness, one must employ an experienced veteran to supervise from behind, ensuring the Heat-Toxin is transformed without injuring Qi and Blood, often achieving success. This method was discovered by my teacher and Mr. Fang Bojiu, which people at the time did not understand. Ancients used Renshen Su Yin (Ginseng and Perilla Decoction) and Renshen Qianghuo San (Ginseng and Notopterygium Powder) for releasing the exterior; Huanglong Tang (Yellow Dragon Decoction) for purging the interior; Xiaochaihu Tang (Minor Bupleurum Decoction) for harmonizing; Renshen Baibu Tang (Ginseng and White Tiger Decoction) for clearing the Stomach; and Renshen Lian Yin (Ginseng and Coptis Drink) for treating dysentery. All these are difficult to clear and resolve alone, situations where Renshen cannot be omitted despite difficulties. Drawing parallels for treating smallpox, why should it not apply? ○ For true Fire syndromes, cooling agents must be used. Cooling agents should not be used too early nor too late; they are most effective on the third and fourth days. If not cleared urgently during these days, later use will be ineffective as the pustules will not tolerate it. It is like watering seedlings at the time of planting; if the seedlings have grown tall, adding ash and manure afterwards is futile. ○ On the fourth and fifth days, pustules that are bright and lustrous are not good, nor are those that are dry and rough. One must grasp the balance between neither dry nor bright. ○ After three days, when spots reach the soles of the feet, it is considered complete. If dense but spots do not reach the feet, it is called "Wugen" (Rootless), and changes will surely occur later. If the feet are cold and not warm, wash with a decoction of Congbai (Scallion Stem) and Aiyi (Mugwort Leaf), cover warmly for a while; if spots gradually emerge, it is auspicious. ○ After the third day when spots are complete, whether to clear heat depends entirely on the lips and tongue. Only when the tongue is dry and lips parched, with constipation of stool and urine, can heavy cooling medications be used. If lips and tongue are pale and moist without interior signs, even if pustules are dense, dry, red, purple, or stagnant, only mild clearing agents should be used. Huanglian, Shigao, Xijiao, and Dihuang should not be used recklessly. If cooling is excessive, by the eighth and ninth days, itching, diarrhea, and internal attack of toxin often lead to death. ○ Not only should clearing agents not be excessive; upon seeing pale and moist lips and tongue, Renshen (Ginseng Root) and Huangqi (Astragalus Root) should be advanced early, combined with Danggui (Angelica Sinensis Root), Chuanxiong (Ligusticum Rhizome), Gancao (Licorice Root), Jiegeng (Platycodon Root), Fangfeng (Saposhnikovia Root), and Jiangcan (Bombyx Batryticatus) to guide the path of pus formation. Early pus formation facilitates toxin transformation; delayed pus makes toxin transformation difficult. Without excess Fire in the interior, reckless cooling prevents pus formation. Without pus, toxin cannot transform; how can one avoid complications? (*Racun Doujue*)

Mr. Weng said: On the third and fourth days, pustules should be complete, reaching the sole of the foot, and the condition should stabilize. In young children, whose Qi and Blood circulate easily, completion often occurs before three days. In older individuals, eruptions may continue beyond four days; if pustules are sparse and fewer than one hundred, reaching the sole is unnecessary. Distinguishing form and color, if the body is strong and the pustules are upper-middle grade, one can be reassured. However, in frail children, or those post-illness, or with concurrent diseases, one should not rashly declare the prognosis favorable. (Ye Tianshi)

On the third and fourth days, to promote fullness, use Niubangzi (Arctii Fructus) to vent the pustule tips and promote fullness. Jiangcan (Bombyx Batryticatus) is an excellent herb for promoting fullness; it plumps the pustules and assists pus formation. Once pustules are full, the goal is pus formation; this herb also treats "Youhong Dou" (Roaming Red Pustules) and can be used on the third, fourth, seventh, and eighth days. ○ If fullness is not achieved on the third and fourth days, Ji Guan Xue Jiu Ru (Chicken Comb Blood Wine Milk) can be added to the pus-promoting formula. Although wine might aggravate toxin and cause itching, it is generally acceptable. ○ Chanshanjia (Pangolin Scales) strongly promotes eruption and fullness; assisting with Jiangcan ensures fullness. (*Ren Duan Lu*)

By the fifth day, when external and internal signs are stable, promotion of eruption and reduction of redness should occur. Otherwise, Zheng Qi (Upright Qi) will become deficient; double the dosage of Renshen (Ginseng Root) and Huangqi (Astragalus Root) in the formula as a method to summon pus. (*Ci You Fa*)

Promotion of Swelling (Qi Zhang)
If pustules do not swell, death comes quickly. In the stage of swelling, Qi arrival is primary, Blood secondary. The mechanism of swelling involves Fire steaming and Water rising. Neglecting this and seeking swelling through aggressive expulsion is like pulling up seedlings to help them grow, akin to whipping a broken cart and weak horse to make it advance. Upon spotting, toxin disperses outward, Qi guards the palace, and Blood stays within. Now, if Qi does not arrive, it cannot push toxin outward, allowing toxin to linger inside the threshold, hence no swelling. Occasionally, swelling occurs but is hollow, dark, and thin because Qi arrival is weak and Blood succession is lacking, due to insufficient Fire steaming and Water rising. Like dying embers trying to dry up slight moisture, collapse and death follow soon. (*Huangdi Yidian*)

Before eruption, toxin lies dormant in Mingmen (Gate of Life), not interacting with Qi and Blood. When it erupts and rushes to the Stomach, which is rich in Qi and Blood and governs muscles, toxin interacts with Qi and Blood in the Stomach, causing pustules to appear. Having interacted, toxin and Qi/Blood mix into one; how can Qi and Blood tolerate toxin? Thus, they carry it out, where it grows, fills, and succeeds. When toxin solidifies into a scar, Qi and Blood return to the body. Any obstruction leads to myriad abnormalities. Therefore, after completion but before filling, if there is no room reserved, how can it accommodate? Thus, swelling is the crucial pathway for pus formation. Physicians must seek to pass this second barrier. ○ Some say: Swelling is like placing dough in a steamer basket; this analogy is precise. ○ For Blood-Heat pustules, with excessive Fire and blocked Toxin, Qi and Blood are scorched, and toxin knots internally, preventing swelling. Urgently cool Blood and resolve Toxin; as toxin resolves, Fire retreats, Qi and Blood separate, and pustules naturally swell. ○ Smallpox relies on Yuan Qi; swelling indicates Qi arrival. If Qi is deficient and cannot flow freely, swelling is impossible. Urgently use Baoyuan Tang (Preserve the Origin Decoction), assisted by herbs that loosen muscle and invigorate Blood, so Qi and Blood separate naturally. (*Racun Doujue*)

When swelling begins, if color is scorched purple, Toxin is excessive; if large, thin-skinned, and wrinkled, Toxin is excessive and Qi is deficient; if the apex is fully red, Blood is stagnant. Treat stagnation with blood-invigorating methods, scorching with clearing methods, and Qi-deficient/Toxin-excessive cases with tonification combined with detoxification. As long as one or two spots on the face are pleasing and lovely, regulate medication carefully; then dry spots become moist, thin spots become thick, and vitality flourishes. (*Ci You Fa*)

Sixth Day
Ancients said: Smallpox appearing before the sixth day is easy to treat; appearing after is difficult. Thus, the sixth day is the critical juncture of life and death. In favorable cases, the upper body has mostly progressed to pus formation by now; even in dangerous cases, the apex should be white and the base red, showing momentum toward pus formation. If Qi and Blood are indistinguishable at this point, success is impossible. ○ Pain on the sixth day is most auspicious; pain prevents adhesion, keeping pustules intact. Itching is detestable; for mild itching, instruct restraint and use Xian Lin Gong Du Yin (Fresh Scale Toxin-Attacking Drink); as pus forms, itching turns to pain. ○ Before the sixth day, if Toxin is untransformed and Zheng Qi is deficient, prioritize clearing with tonification as adjunct; after the sixth day, if Toxin is untransformed and Zheng Qi is deficient, prioritize tonification with clearing as adjunct. ○ On the sixth day, pus should fill. Large pustules should be bright and robust; fine ones may be dry and scorched, so prioritize large ones. If large pustules have depressed/apex-flat tops or are dry/scorched without pus, but fine ones contain true pus filling gradually, prioritize fine ones. Overall, vigorous promotion is necessary for success. ○ Before the sixth day, focus on the root base; without a root base, pus will not fill. After the sixth day, focus on pus color; without pus color, healing is difficult. Words of experience from sages are immutable. Further explanation: For absent root bases, promote consolidation; for absent pus color, promote resolution. Tonify Qi in Qi deficiency so Blood adheres; astringe Blood in Blood deficiency so roots do not scatter; clear Fire in Fire excess so Blood is not damaged. These three methods follow their respective principles; avoiding generic formulas prevents being trapped by stale theories. ○ For Qi deficiency with depressed apices on the fifth/sixth day, Buyi Zhongyiqi Tang (Tonify the Middle and Augment the Qi Decoction) is excellent. It contains Renshen and Gancao (Preserve Origin aspect), Baizhu (Assists Ginseng to strengthen Spleen Earth), Danggui (Harmonizes and generates Blood), and Shengma/Chaihu (Raises clear Yang and lifts depression). Used during the swelling/pus phase for deficiency cases, it surpasses Jiangcan and Zaoci Ci (Gleditsia Spine). (*Racun Doujue*)

By the sixth day, to promote pus, add Sheng Huangqi (Raw Astragalus Root), Yuanyan (Longan Aril), and Danggui paired with Fuxiong (Nourishing Chuanxiong), Jiegeng (Platycodon Root), and Chenpi (Tangerine Peel). Chuanxiong regulates Qi; Huangqi supports the interior; together with Jiegeng and Chenpi, they jointly promote ascent. Subsequently, gradually add Renshen (Ginseng Root), Shanyao (Dioscorea Rhizome), Lianrou (Lotus Seed Endosperm), and Nuomi (Glutinous Rice) until sufficient pus transforms toxin and achieves success. At this time, unresolved Fire remains, so Danshen (Salvia Miltiorrhiza Root) and Jiangcan (Bombyx Batryticatus) should be included. For true Cold-Deficiency, add Rougui (Cinnamon Bark) and Fuzi (Aconite Root). (*Douzhen Yuanzhu*)

Edema
Qi belongs to Yang, Blood to Yin; they should harmonize without separating. If edema appears on the head and face before eruption, this is Hyperactive Yang Fire, as Fire nature flares upward. The Classics state: Excess Heat causes swelling. This shows Toxin-Fire rising with Yang, while Yin Blood fails to adhere, indicating separation of Qi and Blood. If edema develops gradually on the head and face after eruption, this is Toxin-Vapor expanding and gathering in the Three Yang meridians, intending to form pus and blood; this is appropriate swelling. If eruption should occur but no edema appears, the pustules are likely distinct and toxin light; although pus may form, roots do not adhere, hence no swelling—this is a good omen. If pustules are dense and should swell but do not, toxin is latent internally and cannot expand; this is due to insufficient Zheng Qi failing to overcome Pathogen. Treatment should primarily support Zheng Qi. If pustules are sparse and should not swell but do, this is contracting Epidemic Toxin, known as Datou Wen (Great Head Plague). Treatment should address the epidemic Qi. Generally, for swelling, if it persists until pus is full and scabs form, toxin transforms, swelling subsides, and eyes open, it is auspicious. If swelling subsides and eyes open before pus is sufficient, this is insufficient Zheng Qi failing to transform toxin into pus, named "Dao Ye" (Inverted Scab), which is ominous. Therefore, swelling when it shouldn't, no swelling when it should, subsiding when it shouldn't, or persisting when it should, all require careful observation. (*Douke Bian*)

Pre-edema of head and face, with toxin failing to settle into its cavity, requires Dafupi (Magnolia Officinalis Bark) to be effective. (*Racun Doujue*)

Sealing (Feng He)
Upon pus formation, latent toxin and essence are forced outward, causing fluids to accumulate in orifices (eyes, nose, etc.), leading to sealing. However, this must await swelling and pus filling to be normal. Thus, sealing on the third/fourth days is inappropriate as toxin has not reached the exterior and Evil Fire flares upward; sealing after the fifth day is appropriate as Qi and Blood are充盈 (full) and essence does not leak. If sealed areas are glossy like gelatin, it is auspicious; if dry black like coal, organs are dry and fluids exhausted (inauspicious); if pus flows out, internal Toxin-Fire scorches and essence leaks (inauspicious). If sealed but opens on the sixth/seventh days, fear uneliminated toxin causing internal attack. Sparse pustules are exempt. (Feng Chuzhan)

For swollen eyes unable to open during pus regression, wipe away discharge with a water-moistened silk cloth, gently pull eyelids apart with fingers to create a slit, preventing membrane formation. (*Yixue Rumen*)

Seventh and Eighth Days
On the seventh day, Yin containing Yang reaches the exterior completely, leaving the interior empty. Like steam in a steamer, for every unit of Yang rising, Yin grows; thus, pus should gradually turn yellow, and the blood halo at the base should tighten, forming defined glandular rings without spreading or graying, without day/night pain, with doubled appetite, reduced stool, and slight fever—all auspicious. The reverse is adverse. At this stage, life or death depends on the tightness/dispersion of the blood halo and the authenticity of pus color. Authentic pus has precious luster; fake resembles earthy yellow. Tightness indicates Qi restraining Blood to transform toxin; dispersion indicates Qi deficiency scattering brilliance, approaching exhaustion. Absence of blood halo means death. Pus is transformed toxin. The maxim states: After the sixth day, focus solely on pus color. Hence, presence of pus means life, absence means death. If pus is intermittent, roots are not red, or flesh is gray-red, with itching, restlessness, sealed eyes wanting to open, diarrhea, dry retching, poor appetite, and little sleep, this is Qi deficiency failing to restrain Blood and transform toxin; urgent strong tonification is required. If black tongue with prickles appears, vitality is extinct; tonification is useless. (Cheng Huazhong)

On the seventh/eighth days, if facial pus is insufficient, drying into red scabs early, while the crown remains unfilled and lower body still filling, it is acceptable, but promote eruption and avoid early clearing/draining. ○ If facial pus is true but lower body is clear fluid, without teeth-grinding or diarrhea, Renshen and Huangqi fermentation can achieve success. If teeth-grinding and diarrhea occur, or skin breaks down failing to form scabs, it is "Waibo" (External Peeling), untreatable. ○ If earlier spots are resolving while later spots are just filling, only promote the later spots; avoid early clearing. ○ By the eighth day, sudden phlegm sounds in voice/throat, even if pustule color hasn't changed, requires vigilance; ninth-day shortness of breath and abdominal distension may begin here. (*Racun Doujue*)

By the seventh day, use Renshen and Huangqi to assist pus. Fear conflict with Fire-Toxin, so prior to the sixth day, effort must be made to clear, ensuring Fire-Toxin is completely eliminated. If clearing is incomplete and clearing/tonifying are combined, the power of Renshen/Huangqi is diminished, rendering medication ineffective. (Xu Zhongguang)

Pus Formation (Xing Jiang)
Failure to form pus stems from failure to swell; successful pus formation follows successful swelling. Pus requires equal abundance of Qi and Blood, balance of Water and Fire, isolating Toxin to ripen its root. Pus is toxin transformation. Transformation occurs when Qi arrives and Water fills; Water fills then Blood generates, preventing dryness and forming thin pus. Qi arrival ensures Water sufficiency and Fire movement; Fire movement ripens toxin, steaming it into thick pus. Fire needs Water to steam; Water needs Fire to rise. Failure to form pus blames neither Toxin nor Blood, but seeks Qi. Thickness failure implies incomplete toxin transformation; warm and support. Diarrhea-induced thinness implies Qi sinking; warm, support, and lift. Unchecked tonification in failure to form pus may luckily rot toxin, but exhausts True Yuan, halts Qi mechanism, resulting in "Banhuang" (Board Yellow), injuring both host and guest, leading to death. If mature pus fails to connect due to Qi inability, like a drawn bow hard to hold, sudden collapse and leakage occur, eyes open, crisis imminent. If pustule color hasn't changed, massive tonification within half a day may save life. Generally, life/death depends on pus presence; pus presence depends on swelling起伏 (rise/fall); swelling depends on Body Qi/Blood; Body Qi/Blood depends on Internal Water/Fire. Water is Postnatal Form-Qi; Fire is Prenatal Yuan Qi—the subtlety of swelling and pus formation. (*Huangdi Yidian*)

Pus formation starts at head/face. If "Yang" (luminosity/fluidity) exists, it flows downward, turning yellow/ripe. "Yang" is like cotton in jade, clouds in water, lively and bright. By day two, it passes shoulders; day three, knees. If head/face fills but lacks Yang, not passing shoulders leads to External Peeling; not passing knees leaves residual toxin. ○ My teacher orally instructed: Look for Yang in pus. Pus must float like fat; check pus at umbrella-top; pustules must resemble cooked beans, uniform in center. This description is apt. ○ Clear pus often indicates Body Deficiency. If skin is thick and not gray, ferment with Renshen, Huangqi, Milk-Wine, Chicken Juice, Lamb Meat to form pus and scabs. Thin skin, if rubbed, becomes External Peeling; diarrhea, teeth-grinding, internal attack are incurable. ○ Failure to fill has two patterns: Blood-Heat and Qi-Deficiency. Blood-Heat: toxin knots untransformed; urgently cool Blood/resolve Toxin. Qi-Deficiency: gray/white, depressed apex, toxin coagulated/unmoving; urgently tonify Qi. Other shapes fall into these two. ○ 70% of filling failures are Body Deficiency; 30% Blood-Heat. Clear or tonify, assisted by promotion, often succeed. For Deficiency with Toxin, or Heat injuring Qi, balance clearing/tonifying; life/death hinges here. ○ Pus filling should have a fishy smell; absence means no true pus; urgently promote. ○ "Snatching Pus": rare in sparse smallpox. In dense cases, before pus phase, a few grains fill yellow/ripe; this is Fire-Toxin forcing Qi/Blood to lose control, similar to premature graying in trauma; urgently purge Fire. ○ "Blood Pus": excessive Fire. Smallpox relies on Fire for success; Fire cannot be fully purged, nor should it be too strong. Warmly nourish, and pus forms. Pus is transformed Blood. Excessive Fire prevents Blood transformation, flowing immediately as Blood Pus. Do not urgently purge Fire; if purple/restless changes occur, purging Fire lightens color and thickens pus, leading to natural scabbing/healing. ○ Blood Pus differs from Purple Pustules: Intermittent purple spots crush to clear water; widespread redness on chest/back/waist/abdomen is Blood Pus, crushing reveals untransformed Blood pus. ○ "Stopped Pus": pus stops halfway. Not Qi/Blood deficiency, nor Toxin knotting, but Ying-Wei disharmony or reversal of Cold/Summerheat Qi. Adjust medication promptly; otherwise, mild cases develop "Ghost Swelling," severe cases internal attack. (*Racun Doujue*)

Seven days of pus flow: swelling should pass the neck, pus should pass the chest. Swelling indicates toxin exiting externally; passing chest indicates descending from top/bottom. Genitals should also fill, as they are the convergence of Zongjin (Convergent Tendons). Empty legs are acceptable. ○ Arms should also be full; otherwise, upon closure, refusal to eat and other changes occur. Arms are governed by Spleen. ○ Pearls need not be large, but clarity of body matters; pus need not be abundant, but correct color matters. Earthy yellow is yellow without luster. ○ During filling, if forehead resembles boil, skin/flesh red and dry, Qi is exhausted, unable to restrain Blood; Blood cannot attach to Qi to control Toxin; death is certain. If lips turn yellow/hard before other pustules fill, Toxin entered Spleen first, losing order; death is certain. Rubbed lesions with faint vitality indicate filth contact; do not treat as fatal. (Cheng Huazhong)

Method to inspect pus: Illuminate with fire; if内外光润 (internally/externally glossy) and soft/depressed on touch, no pus. If dark internally and drum-like on touch, pus exists. ○ During filling, ensure Toxin is fully resolved before focusing on warming/tonifying. For Cold patterns, add Ginger/Cinnamon. If Toxin unresolved, include Danshen to clear Fire; Jiangcan is wonderful for assisting pus and resolving Toxin. ○ When pus is sufficient, use cooling/detoxifying and diuretic methods to prevent internal toxin retention, excreting via urine, transforming dampness to dryness, aiding closure and sparing residual toxin. (*Ren Duan Lu*)

Leaking Pus