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[Wan] The human body is fundamentally based on Ying (Nutrient) and Wei (Defensive) Qi. Wei Qi is Yang Qi, responsible for opening and closing the Cou Li (skin pores), and moving the physiological pivot. Ying Blood is Yin Blood, responsible for filling the Zang-Fu organs and irrigating the limbs. Therefore, when Qi is deficient, the Shen Ji (spiritual mechanism) ceases; when Blood is deficient, the source of transformation is cut off. These two cannot be allowed to dominate excessively. The toxin of smallpox originates from the fluids of the five Zang organs, following the meridians and specific locations, directly invading Ying and Wei to emerge. Observing the eruption: if the vesicles are firm and dense, and the pustule bases are full and long, this indicates sufficient Qi. If the roots are red and vibrant, with lustrous color, this indicates sufficient Blood. When both Qi and Blood are sufficient, the smallpox will erupt and crust easily without requiring treatment, avoiding the error of "reinforcing excess" (making an excess condition more excessive). If the lesions are flat, depressed, tender, and thin, it is a disease of Qi; if dry, purple, and black, it is a disease of Blood. One must blame and treat these conditions, not allowing negligence that leads to regret. However, the Spleen and Stomach are the fathers of Qi and Blood; the Heart and Kidney are the mothers; the Liver and Lungs are their dwellings. The Spleen receives water and grain; its fierce Qi enters the Kidney to become Qi, which the Kidney stores in the Lung to become Wei Qi, warming the muscles, filling the skin and hair, thickening the Cou Li, and governing opening and closing. If Wei Qi is deficient, sores will not erupt; the toxin takes advantage of Qi deficiency to enter the Lung. If the Lung is affected, it leads to sinking and hiding of the rash, eventually returning to the Kidney. The Spleen receives water and grain; its essence enters the Heart to become Blood, which the Heart stores in the Liver to become Ying Blood, flowing through the nine orifices, pouring into the six Fu organs, and meeting at the hundred vessels. If Ying Blood is deficient, sores lack luster; the toxin takes advantage of Blood deficiency to enter the Liver. If the Liver is affected, it leads to itching, eventually returning to the Heart. In treating such cases, treat Qi diseases by regulating Qi, and Blood diseases by regulating Blood. For cold patterns, use warming methods; for heat patterns, use clearing methods; for deficiency patterns, use tonifying methods; for excess patterns, use purging methods. Always prioritize the Spleen and Stomach, and do not violate this principle.

[Wan] One who does not know how to distinguish between deficiency and excess cannot be a physician. The Classics state: Do not make deficiency more deficient, and do not make excess more excess. The distinction between deficiency and excess must be understood. The Classics state: First measure the fatness or emaciation of the body to regulate the excess or deficiency of Qi. This distinguishes deficiency and excess by physical form. It also states: Abundant food intake leads to abundant Qi; scanty food intake leads to deficient Qi. This distinguishes deficiency and excess by diet. It also states: Excessive pulse indicates excess Blood; deficient pulse indicates deficient Blood. This distinguishes deficiency and excess by pulse. It also states: When pathogenic factors are abundant, it is excess; when essential Qi is depleted, it is deficiency. This distinguishes deficiency and excess by the relationship between pathogenic and healthy Qi. Generally, excess refers to pathogenic excess, and deficiency refers to healthy Qi deficiency. The Classics state: Where pathogenic factors gather, Healthy Qi must be deficient. If they remain and do not depart, the disease manifests as excess. It is also said: Death from the "Five Excesses" refers to pathogenic excess; death from the "Five Deficiencies" refers to healthy Qi deficiency (applicable to general diagnosis). In smallpox cases, if the patient has a robust physique, good appetite, surging and forceful pulses, no prior illness, normal stool, and red, lustrous sores, this indicates both exterior and interior Healthy Qi are excess; medication is unnecessary. If the patient is frail, prone to illness, has poor appetite, weak pulses, frequent vomiting and diarrhea, and pale, tender sores, this indicates both exterior and interior Healthy Qi are deficient; Chen's warming and tonifying method can be used. If the rash is too vigorous, with swelling, pain, distension, persistent high fever, restlessness, thirst, drowsiness, and constipation of urine and stool, this indicates both exterior and interior Pathogenic factors are excess; Qian's cooling and purging method can be used. If the rash is originally dense, red, and vibrant, but accompanied by vomiting, diarrhea, and inability to eat, this indicates exterior excess and interior deficiency; add detoxifying herbs to tonifying decoctions. If the rash is pale white, fails to fully erupt, accompanied by constipation, yet the patient drinks heavily and eats greedily, this indicates interior excess and exterior deficiency; add dispersing herbs to resolving and diffusing formulas. Furthermore, pain in sores indicates pathogenic excess; activate Blood to resolve stagnation. If pain is like knife-cutting, with extreme restlessness and screaming, do not treat. Itching indicates healthy Qi deficiency; tonify Qi to dry dampness. If scratching is uncontrollable, with broken skin and peeling, do not treat. Ashen-white color indicates Qi deficiency; the efficacy of Ginseng Radix (Renshen) is significant. Dryness indicates Blood deficiency; the power of Angelicae Sinensis Radix (Danggui) and Chuanxiong Rhizome (Chuanxiong) should be increased. Tonify deficiency, purge excess; stop when the disease is addressed, without exceeding limits; this is the balance of treatment. If an excess pattern is mistakenly treated with tonification, toxins will proliferate, leading to ulceration, carbuncles, eye diseases, throat ulcers, or hemorrhage—all due to over-tonification. If a deficiency pattern is mistakenly treated with purging, Healthy Qi will further weaken, leading to vomiting, diarrhea, or cold extremities—all due to over-purging. The Classics say: Do not invite pathogens, do not lose Healthy Qi, and do not shorten life. This is what is meant.

[Weng] Qi has the function of generating Blood, but Blood has no mechanism to benefit Qi. Therefore, Qi must not be deficient; if deficient, Yang energy will be insufficient, and the round shape of the smallpox vesicle will not form. Blood must not be excessive; if excessive, Yin will invade Yang positions, and the disaster of inverted smallpox will occur immediately. Thus, smallpox presents differences in Qi and Blood deficiency and excess. Generally, cold patterns indicate deficiency, and heat patterns indicate excess. Qi deficiency requires warming and tonification; Qi excess with heat requires cooling; Blood deficiency requires tonifying Blood; Blood heat requires detoxification. One must aim for the harmony of Qi and Blood, neither excessive nor insufficient. What constitutes Qi and Blood deficiency and excess? For instance, excessive Qi leads to vesicles; excessive Blood leads to pustules. Insufficient Qi leads to depression and failure to rise; insufficient Blood leads to lack of pus and toxin attachment. Pale white rash, non-firm tops, sensationless to touch, and failure to swell all belong to Qi deficiency. Baoyuan Decoction is highly suitable, with doubled doses of Astragali Radix (Huangqi) stir-fried with wine, Cinnamon Twig (Rougui), Chuanxiong Rhizome (Chuanxiong), Clove (Dingxiang), human milk, and fine wine taken together. Non-red roots, or red but scattered roots that turn white upon touch, with hairs standing up on the rash, appearing dry and dull, all indicate Blood deficiency. Baoyuan Decoction should be added with Chuanxiong Rhizome (Chuanxiong), Angelicae Sinensis Radix (Danggui), Safflower (Honghua) washed with wine, and Hawthorn Fruit (Shanzha) to reduce the stagnation caused by Ginseng and Astragalus. Add Aucklandiae Radix (Muxiang) in small amounts to move stagnant Qi, so that Blood becomes active. Whenever using Astragali Radix (Huangqi), it should be after the rash has fully erupted. Whenever using hot herbs, one must wait until the toxin is completely resolved, then treat according to Qi and Blood deficiency and excess, ensuring efficacy. For tonifying Blood, Rehmanniae Radix (Dihuang) is used at the beginning and end; Ginger-processed forms prevent stagnation. Paeoniae Radix (Shaoyao) is avoided due to its sour-cold nature damaging Stomach Qi, or if used, must be wine-processed.

[Discussion on Nursing Deficiency Patterns] Smallpox treatment prioritizes Yuan Qi (Original Qi). When Yuan Qi is sufficient, toxins are easily expelled and transformed. Therefore, skilled physicians preserve Yuan Qi before it becomes weak, preventing depletion. What are the treatment methods? First, strengthen the Cou Li and secure the muscle surface; second, regulate diet and protect the Spleen Earth. If the exterior is secure, there is no worry about external sinking; if the Spleen Earth is solid, there is no worry about internal sinking. With the tonifying effects of Ginseng and Astragalus, Yuan Qi naturally becomes sufficient, making it easy for the rash to form pus, preventing complications, and ensuring smooth crusting. Therefore, cold and purging agents such as Rheum Radix et Rhizoma (Dahuang), Talcum (Huashi), Plantaginis Semen (Cheqianzi), Rehmanniae Radix (Shengdi), Arctii Fructus (Niubangzi), Leonuri Herba (Zicao), and Aurantii Fructus (Zhike) are prohibited, lest they purge and moisten downward, damaging the Spleen and Stomach. Damage to the Spleen and Stomach causes Yuan Qi to sink, leading to Qi collapse and internal attack, resulting in death—a certainty caused by the medicine itself. Slippery and dispersing agents such as Arctii Fructus (Niubangzi), Human Teeth (Renya), Bombyx Batryticatus (Chantui), Ephedrae Herba (Mahuang), Puerariae Radix (Gegen), Cimicifugae Rhizoma (Shengma), Leonuri Herba (Zicao), Platycodonis Radix (Jiegeng), Notopterygii Rhizoma et Radix (Qianghuo), Saposhnikoviae Radix (Fangfeng), and Schizonepetae Spica (Jingjie) are prohibited, lest they disperse too much, causing exterior deficiency. Exterior deficiency leads to external consumption of Yuan Qi, resulting in collapse, itching, and exfoliation, causing death. Whose fault is this?

[Supplementing Qi without Supplementing Blood in Deficiency Patterns] In weak smallpox cases, mental fatigue and blue-white complexion occur because insufficient Qi causes fatigue, and un-nourished Blood causes the complexion. Why treat deficiency by supplementing Qi but not Blood? Qi has spirit but no form; tonifying it is easy to fill. Blood has form but no spirit; tonifying blood yields slow results. Moreover, Qi is Yang and Blood is Yin; Yin follows Yang, and Blood follows Qi, which is logical. Thus, tonifying Qi makes it abundant, and Blood naturally follows to become abundant. Additionally, blood-tonifying agents like Angelicae Sinensis Radix (Danggui) and Rehmanniae Radix (Shengdi) moisten and slide downward; excessive use may cause loose stools. However, in some deficiency smallpox cases with white, sunken, un-nourished lesions, Danggui and Paeoniae Radix (Shaoyao) are reluctantly used. In cases of floating deficiency fire with numerous red spots resembling Blood heat, Leonuri Herba (Zicao), Safflower (Honghua), and Rehmanniae Radix (Shengdi) are reluctantly used for activating Blood and clearing Heat. All are wine-processed to counteract their sliding nature, using wine to reach the exterior. This achieves the subtlety of ascending and reaching the exterior within blood-tonifying and activating methods, avoiding intestinal lubrication and loose stools.

[Distinguishing Inevitable Deterioration in Deficiency Patterns] In Qi-deficient smallpox, initial symptoms include lingering low-grade fever, alternating hot and cold, relaxed skin, mental fatigue, blue-white complexion, reduced appetite, cold and hot extremities, vomiting, loose stools, faint and weak rash appearance, pale red thin skin, irregular eruption over 3-4 days, difficulty in growth, difficulty forming pus by day 5-6, shortness of breath with little food, diarrhea with food injury, collapse by day 7-8, ashen-white non-rising lesions, spontaneous sweating, slight thirst, abdominal distension, wheezing, thirst, diarrhea, collapse with itching, restlessness, grinding teeth, chills, warm head and cold feet. These are inevitable. Therefore, at the onset of Qi-deficient smallpox, Shensu Decoction, Renshen Baidu San, Huanglian Jiedu Tang, Shengma Gegen Tang, and Zicao Sandou Yin are inappropriate. Instead, use Renshen Huangqi Yin. Formulas causing rough breathing and dry skin are also contraindicated. Use Sizijunzi Decoction minus Ginseng, plus少量 Platycodonis Radix (Jiegeng) and Chuanxiong Rhizome (Chuanxiong), and Pericarpium Citri Reticulatae (Fupi). Adding mild ascending methods to tonification is excellent. Once spots are complete, heavily use Ginseng and Astragalus. By days 8-9, if no other ominous signs, proceed normally. If tops are depressed and ashen-white, not rising, with clear pus, spontaneous sweating, and slight thirst, add Cinnamon Twig (Guizhi) to major tonifying decoctions. For collapse, ashen-white, abdominal distension, and diarrhea, use Muxiang San. For collapse, itching, restlessness, abdominal distension, thirst, diarrhea, wheezing, warm head/cold feet, chills, and teeth grinding, urgently administer Yigong San.

[Deficiency Pattern Transforming into Excess] In Qi-deficient smallpox, if parents observe taboos, use correct medications, and manage care properly, Yuan Qi becomes sufficient, Cou Li solid, Spleen and Stomach strong, diet normal, and excretions regulated. However, excessive tonification, especially heavy use of Ginseng and Astragalus after pus formation, may cause abdominal distension and wheezing; use Zhike Tang. Mistaken use of Wuling San or Akebia Caulis (Mutong) in excess may cause constipation; use Kuanzhong San. Constipation with thirst calls for Ophiopogonis Decoction (Maimendong Tang). Overuse of Acorus Tatarinowii Rhizoma (Ding) and Cinnamon Bark (Gui) may cause sore throat, swelling, restlessness, and closed thirst; use Ziyin Runzao Tang. Wheezing, abdominal distension, hard constipation, restless thirst, and sore throat resemble excess patterns. However, Qi deficiency transforming into excess is not true excess; it is a mistake of shallow disease treated with deep/heavy medication. Careful adjustment is needed, not purging. Heavy purging will deplete newly generated Qi, leading to collapse.

[Deficiency Pattern Resembling Excess] In Qi-deficient smallpox, improper diet or care may damage the Spleen and Stomach, causing diarrhea. Fluids sink, deficiency fire rises, causing thirst. Yuan Qi sinks, deficiency Yang rushes upward, lower Qi fails to continue, causing wheezing. Thirst and wheezing are excess symptoms, but arising after diarrhea, they result from sudden fluid loss (thirst) and Qi deficiency (wheezing). Can real heat cause thirst and Qi rushing cause wheezing after diarrhea? No. Treat thirst with Shenling Baizhu San plus Muxiang. Persistent thirst and diarrhea call for Yigong San. Wheezing calls for Renshen Dingchuan Tang or Dushen Renxing Tang. Wheezing, thirst, and diarrhea call for Muxiang Yigong San. Restlessness, abdominal distension, internal attack of toxin, eyes closed, talking in delirium—this is loss of spirit. Mistaking this for excess shows great foolishness.

[Excess Pattern Resembling Deficiency] High fever, straight hair, dry skin, restless sleep, red cheeks, red eyes, rough breathing, restless thirst, abdominal distension, constipation, and wheezing are all excess patterns, caused by severe heat and heavy toxin obstruction. Vomiting may appear. Vomiting resembles deficiency, but if heat-toxin is internal and cannot expand, it rebels upward causing vomiting. The Classics state: All rebellious attacks belong to Fire. Cold invasion or irregular diet may damage Wind-Cold, preventing internal heat from expanding, causing rejection and vomiting. For toxin obstruction, ascending and dispersing is best. For rejection vomiting, guide downward using Polyporus (Zuling), Alisma Rhizoma (Zexie), and Tangerine Peel (Chenpi). Diarrhea may accompany these. Diarrhea resembles deficiency, but if caused by郁盛 heat-toxin roasting the Spleen and Stomach, preventing external release, toxin sinks and exits via orifices—this is heat-toxin pouring downward. Ancient texts say: Diarrhea before eruption indicates survival; diarrhea after eruption indicates death. Treatment involves ascending and dispersing to guide toxin to the exterior. Once toxin is resolved externally, internal leakage stops. If accompanied by food stagnation, add digestive agents; if severe, follow the pathogen. Lack of appetite is often considered internal deficiency, but郁热 patterns where toxin is trapped internally, blocking Cou Li, causing heat-toxin accumulation, abdominal distension, and lack of appetite are inevitable. Treatment involves ascending and dispersing to allow heat to expand, harmonizing Zang-Fu and restoring appetite. Mistakenly using hot herbs like Acorus, Cinnamon, and Pinellia for vomiting, diarrhea, or anorexia attacks heat with heat, worsening symptoms. Using tonics like Ginseng, Astragalus, Poria, and Atractylodes for abdominal distension and anorexia strengthens the pathogen, potentially killing the patient. This is the doctor's fault. Be cautious! Dragon Bone (Longgu) and Cardamom (Doukou) stop diarrhea; Medicated Leaven (Shenqu) and Hordeolum Vulgare (Maiya) aid digestion, but none are suitable for heat-toxin obstruction with anorexia. Future practitioners should note this.

[Heat Pattern Transforming into Deficiency] Blood-heat smallpox requires cooling and dispersing, not harsh bitter-cold agents. Overuse of cold agents like Cimicifugae Rhizoma (Shengma), Scutellariae Radix (Huangqin), and Coptidis Rhizoma (Huanglian), or slippery agents, damages the Spleen and Stomach internally and freezes muscles externally. Mild damage reduces appetite and causes loose stools; severe damage causes profuse watery diarrhea, leading to deficiency-cold. Frozen muscles prevent heat vaporization, close the Cou Li, prevent rash growth and pus formation, leading to hidden sinking. This is heat transforming into deficiency. Once deficiency is clear, treat as deficiency. Ginseng, Astragalus, Clove, and Cinnamon are not taboo. After 5-6 days, Muxiang Yigong San is appropriate. Judgment depends on careful examination.

[Obstructing Heat Transforming into Deficiency] Severe toxin obstruction requires ascending and dispersing as primary, assisted by cooling and detoxifying. Stop when balanced. Excessive dispersing empties the exterior, depletes Yuan Qi, leading to clear pus penetration, empty shells, itching/collapse/exfoliation, or non-healing ulcers. These indicate exterior deficiency. Exterior deficiency leads to Yuan Qi leakage and internal instability. Minor dietary errors cause diarrhea, leading to deficiency-cold and Qi collapse, with restlessness, thirst, chills, and teeth grinding. Once deficiency is known, treat as deficiency. Ginseng, Astragalus, Atractylodes Macrocephala Rhizome (Baizhu), Clove, Cinnamon, Ginger, and Aconite Root (Fuzi) are not taboo. After 6-7 days, even Muxiang Yigong San should be administered urgently. Adjust based on examination.

[Distinguishing Use of Yigong San for Obstructing Heat] Real heat obstruction often uses cold agents, causing ice-like fixation and diarrhea, or excessive dispersing causing exterior deficiency. Once ice-hard, use mild medicines; Ginger and Cinnamon heat are not taboo. After diarrhea, heat dissipates, True Qi becomes deficient. Deficiency requires tonification. Qi deficiency implies cold; clear deficiency-cold requires warming and tonification. Thus, although initial blood-heat obstruction exists, by days 3-4, if the body is cool and skin cold, and rash does not grow, mild agents like Official Cinnamon (Guigui), Dried Ginger (Ganjiang), and Chuanxiong Rhizome (Chuanxiong) are necessary to warm internal Qi, harmonizing external Qi. After diarrhea, the interior is definitely deficient. Even with abdominal distension, restlessness, thirst, and wheezing, it is not real heat, but internal deficiency with hidden sinking and internal toxin attack. Therefore, real heat cases with diarrhea on days 7-9 are treated as deficiency. If Muxiang Yigong indications exist, use Muxiang Yigong. Without ice-hard signs, do not mistakenly use warming agents. Without diarrhea, do not mistakenly use Muxiang Yigong. Collapse, inverted crusting, dryness without ice-hardness or diarrhea are usually due to internal heat-toxin attack; thus, Baixiang or Zhuwei formulas are appropriate.