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If the Kidney Qi is exhausted and the pathogenic toxin is deep-seated, it will certainly be difficult to save. However, for men who have engaged in sexual intercourse (breaking Yang) after marriage, if they develop chickenpox/smallpox with lower back pain, it can still be treated because their deficiency lies in the acquired constitution; whereas for children who develop chickenpox/smallpox with lower back pain, it is mostly difficult to treat, as this is due to congenital insufficiency, representing a true deficiency. (From *Feng Shi Jin Nang*)

Lower back pain appearing during the eruption of chickenpox/smallpox is the most ominous sign. The ancients stated that detoxification should drain the pathogen from the Shaoyin channel, and releasing the exterior should unblock the Taiyang channel, preventing the pathogen from penetrating deeply. Even if the eruptions are dense, recovery might be possible. This can indeed be considered knowing the treatment method. I believe that to drain the Shaoyyin pathogen, Black Soybean (*Sojae Semen Nigrum*) should be the main herb; to unblock the Taiyang channel, Notopterygii Rhizoma et Radix (*Qianghuo*) should be used as a guiding herb. ○ Lower back pain from miscellaneous diseases mostly prevents supine posture, while lower back pain from chickenpox/smallpox mostly prevents flexion. (From *Dou Jue Yu Yi*)

The conditions of eruptions turning black and lower back pain both result from excessive fire and extreme heat. Fire scorching the skin causes black color; when fire is extremely hyperactive and Kidney Water is depleted, lower back pain occurs. Have you not observed cases where lower back pain precedes the eruptions? Their color is dry and withered, either red or purple, or purple or black. Thus, it is clear that the conditions of turning black and lower back pain belong to fire. Treatment must heavily employ cooling and detoxifying herbs. At the initial appearance of spots, one should cautiously use purgation to resolve the heat-toxin, then regulate Qi and Blood, so that there might be a slim chance of recovery. (Weng Zhongren)

When lower back pain appears at the initial onset of chickenpox/smallpox, Ren Shen Bai Du San (Ginseng Decoction to Overcome Pathogens) should be used to disperse and vent. If there is no purple discoloration, using purgation will certainly fail to save the patient. Generally, emphasizing dispersion to vent out the toxin is truly the superior strategy. (Zhu Yilin)

Abdominal Distension and Pain

Abdominal pain in chickenpox/smallpox arises from toxin stagnation in the Three Yin channels. Above the umbilicus belongs to the Taiyin Spleen channel; directly at the umbilicus belongs to the Shaoyin Kidney channel; the lower abdomen belongs to the Jueyin Liver channel, and they must be treated separately. Abdominal distension indicates toxin accumulation in the intestines and stomach. The treatment method should generally involve ascending and dispersing, resolving and benefiting the chickenpox/toxin, combined with separating and draining urine, so that the toxic qi dissipates up and down, and the pain and distension will naturally stop. Hence it is said: pain resolves with free passage, distension dissipates with drainage. There are also cases of abdominal distension caused by food stagnation, where digestive herbs should be added to ascending and dispersing formulas, carefully assessing the cold or heat nature of the ingested food. In cases of several days without bowel movement, once stool passes, pain and distension stop spontaneously; one should not abruptly use Magnolia Bark (*Xiebai*), Mirabilite (*Mangxiao*), or Rhubarb (*Dahuang*). (From *Jing Lu*)

Toxin stagnation causing pain and distension is severe; food injury causing pain and distension is mild. ○ Food-injury abdominal pain is located in the epigastrium and around the umbilicus; abdominal pain due to slow eruption is located below the umbilicus. (Xu Xuanzhi)

Thirst

Thirst in rashes indicates interior heat. The Sanjiao (Triple Burner) is the pathway for water and grain; Jin Ye (Body Fluids) are the essence of water and grain, transforming and circulating to irrigate the Sanjiao. The fire of rashes originates internally, consuming water and grain, preventing them from transforming into Jin Ye to irrigate the Zang-Fu organs, thus causing thirst. Additionally, since the rashes are dense, Jin Ye leaks externally and transforms into pus, failing to nourish True Qi, also causing thirst. Mild thirst is a common condition and requires no treatment; severe thirst must be treated according to deficiency or excess. One must not give cold water, pears, melons, etc., lest they damage the Spleen and Stomach and cause further complications. ○ If severe thirst occurs immediately upon fever, the heat is in the interior; Ge Gen Jie Du Tang (Kudzu Root Decoction to Resolve Toxin) is the primary formula. If it persists, add Coptis Rhizome (*Huanglian*) to drain excess Heart Fire; add Phellodendron Bark (*Huangbai*) and Anemarrhena Rhizome (*Zhimu*) to nourish deficient Kidney Water. A moist tongue indicates survival; a tongue like thorns indicates death. The tongue is the sprout of the Heart, and the Shaoyin meridian connects to the root of the tongue. If fever is accompanied by spontaneous diarrhea and thirst, it indicates insufficient Jin Ye; Huang Qin Tang (Scutellaria Decoction) plus Ginseng (*Renshen*), Atractodes Rhizome (*Baizhu*), and Ophiopogon Tuber (* Maidong*) is indicated. ○ Danxi said: For initial fever, irritability, and thirst with desire to drink, urgently use cooling herbs to resolve the branch symptoms. ○ Qianyi said: For body heat, irritability, thirst, abdominal fullness, wheezing, scanty dark urination, restlessness, and severe vomiting, one should promote diuresis. (From *Zheng Zhi Zhun Sheng*)

Thirst during chickenpox/smallpox is common but must be distinguished as appropriate or inappropriate. If occurring on days 2-3 with fever and thirst, the toxin is stagnant in the interior, scorched by heat; treatment should focus on venting and supporting. If occurring after day 4 with fever and thirst, Jin Ye has leaked externally to form pus; treatment should focus on tonification. These are appropriate responses. Only if thirst occurs after scabbing, when the toxin has transformed and no pathogen remains, is it inappropriate. This indicates consumption of True Yin and blazing fire-toxin; urgently administer Yin-nourishing and detoxifying herbs to preserve fluids and generate Jin Ye. If thirst decreases, it is auspicious; otherwise, it will likely transform into wheezing and distension, becoming critical. ○ Generally, thirst belongs to heat, but all result from dryness and withering of Zang-Fu Jin Ye, not actually an excess of heat. As for cases of thirst with abdominal distension, or thirst with diarrhea, or cold feet with thirst, or palpitations with fright and thirst, or warm body with thirst, or fever with pale face and thirst, or chills with thirst, or rapid breathing with teeth grinding and thirst, or drinking yet remaining thirsty—these nine conditions are especially not excess heat. Urgently employ warming methods to rescue the interior and nourish Jin Ye. If treated as heat, danger and death will follow immediately. (From *Feng Shi Jin Nang*)

Patients with chickenpox/smallpox are rarely without thirst from beginning to end, due to external leakage of Jin Ye. Do not treat all as heat. (From *Jing Lu*)

Constipation

During fever from chickenpox/smallpox, stool should be moist. If it does not pass for two or three days, urgent relief is needed. Fear that intestinal blockage will hinder Ying and Wei circulation, causing eruptions to become denser. (Wan Mizhai)

Constipation should be divided into upper, middle, and lower sections: Upper constipation benefits from descending Qi and cooling; middle constipation benefits from moving Qi and invigorating Blood; lower constipation benefits from honey suppositories. If no bowel movement occurs four or five days after eruption, this is because Qi and Blood are forming pus, and due to blood heat, no special treatment is needed; only cooling and blood-invigorating measures are required, and stool will pass naturally. (Weng Zhongren)

During the swelling stage, if there is no bowel movement for several days accompanied by irritability and pain, this is toxin excess causing constipation. Qing Du Huo Xue Tang (Clear Toxin and Invigorate Blood Decoction), removing Ginseng [and another herb], adding Achyranthes Root (*Niuxi*), doubling Purple Perilla Seed (*Zicao*) and Angelica Sinensis Root (*Danggui*), taken with raw honey, is indicated. If still blocked, pig bile drops inserted into the anus may be used. Do not use Mirabilite or Rhubarb for strong purgation, lest complications arise. (From *Ci You Fa*)

The ancients said: During the swelling and suppuration stages of chickenpox/smallpox, if there are no internal symptoms, allow stool to remain absent for several days; do not recklessly purge, to avoid draining Yuan Qi. The world regards constipation as precious; some even have heat-stagnation patterns but dare not use purgatives, instead adding warming tonics to secure, causing heat stagnation to worsen, preventing toxin release and Qi smoothness, leading to unpredictable complications. This is all due to mismanagement of heat stagnation. Mild purgation should be used to drain stagnant heat, but the cause of constipation must be assessed; reliance on Mirabilite and Rhubarb should be avoided to prevent damaging Yuan Qi. (From *Feng Shi Jin Nang*)

No bowel movement during swelling and pus formation is acceptable; only diarrhea leads to death, never constipation. (From *Xiang Cun Dou Jue*)

Diarrhea

Diarrhea on days 1-2 is mostly heat-clinging; only venting is needed, no need to stop diarrhea. ○ Diarrhea multiple times on days 4-5 with sudden fading of rash color requires treating diarrhea; if rash color is acceptable, only ascending and dispersing is needed. ○ Sudden continuous diarrhea during swelling is critical; if Yi Gong San (Four Gentlemen Decoction Modified) fails, Doucheng Wan (Areca Seed Pill) and Baizhu San (Atractodes Powder) should be used urgently to stop it. For heat-toxin diarrhea, Jia Wei Si Ling San (Modified Four Poria Powder) is used. ○ Sudden severe diarrhea on day 7 indicates Qi sinking; urgent astringency is needed. If pus color is normal and base is tight, diarrhea is harmless; if pus color is abnormal, base is unresolved, blood is scattered and not consolidating, toxin is internal, life is at risk. ○ Diarrhea on days 9-10 during partial scabbing need not be worried about; this is Yang Qi returning internally, different from the pus-filling stage. Bao Ying Dan plus Poria (*Fuling*) and Atractodes Rhizome (*Baizhu*) is used. Strictly avoid astringents; misuse will lead to anorexia and dysentery due to retained heat-toxin. (From *Ci You Fa*)

The taboo in rashes is internal deficiency causing diarrhea. Whenever abdominal pain or borborygmus is felt, or urgency to the lower abdomen occurs, indicating impending dysentery, Jiu Wei Li Zhong Tang (Nine-Ingredient Regulate Middle Decoction) treats it. If it persists, this is open-intestine profuse diarrhea, only astringents can collect it, using Doucheng Wan. If still not stopping, real Opium mixed with Lotus Seed powder stops it. Quack doctors dare not use these, fearing they trap pathogens, not knowing that astringents remove sliding just as cold herbs remove heat and hot herbs remove cold; these are correct symptomatic treatments. Now that sliding diarrhea is unceasing, astringency is natural, why doubt? If astringents fail, the root is uprooted, and nothing can be done. *Neijing* says: Failure of granaries to store indicates loose gates. *Jingui Yaolue* says: Six Fu organs Qi exhaustion externally causes cold hands/feet; Five Zang organs Qi exhaustion internally causes unceasing diarrhea. Among the Five Depletions, this is the worst. But if Zheng Qi collapses internally, death comes slowly; if pathogen sinks internally, death comes with irritability and thirst. (From *Zheng Zhi Zhun Sheng*)

Treating diarrhea with Terminalia Chebula Fruit (*Hezi*) and Areca Seed (*Roukou*) to stop it, combined with Atractodes Rhizome (*Baizhu*) and Poria (*Fuling*) to leach dampness and strengthen Spleen/Stomach, should also include heavy use of Cimicifuga Rhizome (*Shengma*) to ascend and vent the toxin to the exterior. If treating only diarrhea, fear the toxin will not ascend, leading to collapse. ○ In Qi-deficient rash cases, improper diet damages Spleen/Stomach, causing diarrhea. Jin Ye sinking and deficient Fire rising causes thirst; Yuan Qi sinking and deficient Yang obstructing upward causes shortness of breath. Thirst and shortness of breath are excess patterns arising after diarrhea, indicating fluid loss and Qi deficiency. Treat thirst with Baizhu San; persistent thirst and diarrhea with Yi Gong San; treat shortness of breath with Du Shen Tang (Single Ginseng Decoction). (Weng Zhongren)

Vomiting and Diarrhea

Initial vomiting and diarrhea in chickenpox/smallpox should not be stopped abruptly; vomiting expels heat, diarrhea expels toxin. Because heat-toxin blocks the stomach gate, Fire flares upward, only venting the rash is suitable; vomiting stops when rash emerges. Do not use acrid-dry herbs. Acute illness is not cold, especially since chickenpox/smallpox is inherently heat-toxin. Post-rash dry retching indicates Chong and Ren vessel deficient Fire rushing up, attacking clear pathways, a bad omen of organ failure and toxin attack. Differentiate Yin/Yang, promote diuresis. Treating dry retching prioritizes diuresis. (From *Feng Shi Jin Nang*)

Initial vomiting/diarrhea is fine; post-eruption vomiting/diarrhea is taboo, especially during swelling. Vomiting/diarrhea with wheezing/thirst, roundworm expulsion, fixed gaze, and passing intestinal mucus indicate death. (From *Yi Xue Ru Men*)

Initial fever with vomiting/diarrhea uses Huang Qin Ban Xia Tang (Scutellaria and Pinellia Decoction). During swelling/suppuration with simultaneous vomiting/diarrhea, treat urgently. Cold type: Yi Huang San (Benefit Yellow Powder), Li Zhong Tang (Regulate Middle Decoction); Heat type: Huang Qin Ban Xia Tang. Post-rash vomiting/diarrhea also differentiates cold/heat: Cold: Yi Huang, Li Zhong types; Heat: Si Ling San, Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction), Zhu Ru Tang (Bamboo Shavings Decoction). Examine vomit/stool: sour vomit, yellow/green foul stool indicates heat; clear watery vomit, clear stool without odor indicates cold, do not treat as heat. (Wan Mizhai)

Roundworms

Seeing roundworms before day 3 in rash cases is due to heat-toxin attacking internally, intestines/stomach unable to accommodate, so worms exit. If rash is dark red and dense, condition is critical. If rash is bright/moist and sparse, treat to calm worms and clear fire, using Ping Wei San plus Sour Plum (*Wumei*), Quinine (*Shijunzi*), Coptis (*Huanglian*), Saposhnikovia Root (*Fangfeng*). After days 5-6, roots slightly red with worm exit indicates mostly Spleen deficiency; Bao Yuan Tang plus Ginger (*Shengjiang*), Cinnamon Twig (*Guizhi*), Sour Plum (*Wumei*) is used. Worms vomited on days 13-14 indicate death; many passed in stool indicate凶 (ominous). Living worms can be treated; dead worms cannot. ○ Post-rash heat-toxin in Stomach causes vomiting worms; in Intestines causes passing worms. If not treated urgently, worms eat viscera/anus, forming Huhu syndrome. ○ Some do not vomit/diarrhea but vomit worms upon smelling food; this is Stomach deficiency, worms lacking attachment, forced by heat, often with quick hunger after eating. Treat with Li Zhong Tang plus Wumei, Sichuan Pepper (*Chuanjiao*), Huanglian. If cold-deficiency, cannot eat. (From *Ren Duan Lu*)

Cough

Lung governs Qi; its change manifests as cough. Cough is a Lung pattern. Initial fever with cough indicates Lung, the canopy of Zang organs, scorched by rash fire, causing Lung leaves to wither and Qi to rebel. Post-eruption worsening cough indicates throat ulcers causing itching/gagging sensation. Post-scabbing cough indicates weak Wei Qi, loose pores, wind-cold invasion, rebellious Lung Qi failing to consolidate. ○ Severe cough during abundant eruptions indicates Lung fire or throat ulcer itch; Gan Jie Tang (Licorice and Platycodon Decoction) plus Bullseed (*Niubangzi*) is beneficial. (From *Zheng Zhi Zhun Sheng*)

Choking on Water

Pharynx swallows food; Larynx regulates Qi. Pharynx connects to Stomach; Larynx connects to Lung. Lung has no lower opening, like a bellows, accepting only pure Qi, not solid matter. The Epiglottis hangs above the larynx. When food enters, tongue presses palate, epiglottis closes larynx, so food/water enters pharynx, not larynx. If rash forms on epiglottis, tongue becomes stiff, opening/closing impaired. Solid food may enter pharynx, but liquid leaking into larynx causes choking; medicine cannot enter, so untreatable. ○ Or ulcers on tongue cause pain/stiffness, preventing swallowing, causing choking/vomiting; resolves when ulcers heal. (From *Zheng Zhi Zhun Sheng*)

Before day 7, red/purple rash with this symptom indicates Fire flaring up, heat-toxin blocking; gray/white non-elevated rash indicates Qi/Blood deficiency, Lung/Stomach injury. Both are adverse. After day 7, external rash growing with this symptom indicates internal rash also growing; resolves spontaneously when external scabs. Observe toxin-heavy rashes; before throat dryness, use Gan Jie Tang to detoxify, plus Ophiopogon (* Maidong*), Trichosanthes Fruit (*Gualou*), Bullseed (*Niubangzi*), Scrophularia Root (*Yuanshen*), Schizonepeta (*Jingjie*) to clear airways, preventing heat-toxin invasion. (Weng Zhongren)

Loss of Voice

Initial rash with loud voice: Form ill, Qi well. No voice before eruption: Form well, Qi ill. Voice starts but fails: Form and Qi both ill. ○ Heart Fire insulting Lung causes loss of voice. Lung governs Metal/Voice, has 24 hollows; speech is air vibrating in hollows. Metal sounds when hollow, is mute when solid. Rash fire rises from Heart to Lung, Lung Qi distends/stagnates, orifices block, voice lost. Dao Chi San combined with Gan Jie Tang plus Niubangzi treats it. ○ Kidney-directed toxin causes loss of voice. *Neijing* says: Epiglottis is the door of voice. Dark/depressed rash means toxin returns to Kidney; pathogen lodges in epiglottis, impeding movement/opening, causing sudden muteness. ○ Throat/tongue ulceration causes loss of voice. Throat governs respiration/voice, like a pipe. Toxic fire insults throat first;贲门, epiglottis, tongue base gather rash. Poor early treatment causes throat swelling/blockage, narrow pipe, stiff tongue, difficult breathing, no voice. These two are hard to treat. ○ Loss of voice during pus formation after day 7 indicates throat rash, initially tiny/unnoticed; when surface rash fills pus, throat rash also fills, toxin blocks, pipe narrows, voice unclear/muffled. Generally, pre-day 7 loss of voice is adverse; post-day 7 resolves spontaneously as external scabs heal. Use Gan Jie Tang prophylactically to clear airways. This preventive method is essential. ○ Post-scab loss of voice indicates residual toxin attacking throat, causing swelling/dryness/no voice. Gan Lu Yin (Sweet Dew Drink), Gan Jie Fang Feng Tang (Licorice, Platycodon, Schizonepeta Decoction), Yuanshen Shengma Tang (Scrophularia and Cimicifuga Decoction) are indicated. (Wang Haogu)

Chills and Teeth Grinding

Chills and teeth grinding in rash cases: Some say Heart Fire extreme causes shivering, mimicking Water transformation (internal heat); others say all belong to Cold, like winter, latent Yang inside cannot withstand cold, causing limb tremors/teeth moving. Neither is accurate. This condition has sequence; treatment has urgency. Pre-day 7 chills: Heart Fire extreme insults Lung Metal, orifices block, causing chills; treat as exterior heat. Pre-day 7 teeth grinding: Yangming Stomach channel runs through gums, pathogen merges Yangming, causing grinding; indicates Stomach heat, clear it. Post-day 7 chills: Yin condenses on Yang, Yang deficiency allows Yin to enter airway, causing chills; treat as Qi deficiency. Post-day 7 teeth grinding: Yang sinks into Yin, Yin deficiency allows Yang to enter blood vessel, causing grinding; indicates Blood deficiency, tonify it. Pre-day 7 signs are heat/adverse; post-day 7 are deficiency/treatable. Must check rash color for prognosis. However, these two signs mostly occur post-rash, definitely deficiency, any heat is residual. (From *Jing Lu*)

Dividing by pre/post day 7 is correct, but dividing by early/mid/late stage is better. Early stage, pale face with chills/teeth moving: Cold binds exterior, toxin cannot vent, warm to disperse. Post-rash Qi deficiency/flaccidity: Warm tonify to establish Middle. These are standard. Only on days 5-7, during pus transition, sudden chills/grinding requires distinguishing deficiency/excess via appearance/color. (Xu Xuanzhi)

Sweat

Spontaneous sweating in rash cases: Yin-fire reaches exterior from inside, skin relaxes, pores open, Jin Ye circulates, causing sweat. If body remains moist, this is Yin-Yang harmony, blood vessel smoothness, a good sign. Heat reduces with sweat, toxin disperses with sweat, pathogen stays not, easy eruption/resolution, no treatment needed. However, slight sweat is suitable, not heavy sweat. Excessive sweat drains Qi, weakens Wei, risking poor scabbing, itching/collapse/chills. Urgently secure exterior to收敛 (astringe) sweat. If sweat continues with increased heat, pathogen heat is in exterior, Yin disturbed by Yang, urgently clear fire/detoxify; as Yang pathogen retreats, sweat收敛s. (Zhang Jingyue)

Delirium

Delirium involves hallucinations and incoherent speech. Caused by heat excess and Zheng deficiency, leading to unclear consciousness. Speech is Heart's voice; Heart heat causes talking. Murmuring in sleep is mild heat; awake incoherence is severe heat. Stomach heat delirium accompanies hard stool/few bowel movements. ○ I believe previous cases resulted from initial heat excess untreated. Causes include unresolved toxin, Stomach heat, Lung heat, Heart/Spleen heat. Thirst, fever, cold fingers, constipation with delirium all indicate internal heat. ○ Delirium with initial fever is ominous: toxin attacks interior, Heart spirit confused, consciousness unclear. ○ If no delirium during fever, but develops after days of constipation, this is internal heat. First use Xuan Feng San to resolve heat, then Dao Chi San...