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The aphorism states: Deficiency manifests as itching, excess manifests as pain; this is a general statement. The itching associated with smallpox varies in presentation. Some patients experience whole-body itching and incessant scratching immediately upon eruption. This occurs because the pathogenic factor desires to exit, but the skin and pores are closed and dense, causing the fire-toxin to wander back and forth, resulting in itching. This is analogous to the body itching without sweating seen in Taiyang disease (disease of the Taiyang channel) in Shanghan (Cold Damage), and can be treated by promoting sweating to relax the skin, open the pores, allow the pathogen to escape, and resolve the itching once the lesions erupt. This aligns with the principle that "stagnant fire should be dispersed." Others experience itching just before scabbing. At this stage, pus has formed, the lesions are about to recede, the pathogen dissipates, and healthy qi recovers; the Ying and Wei (nutritive and defensive qi) flow harmoniously, causing itching. This is similar to the itching seen when abscesses and furuncles are nearly healed. Medication is unnecessary; careful nursing is required to prevent scratching, which could lead to swelling and suppuration. This represents a favorable healing process ("beautiful sores"). Some experience itching during the rising and pustule-filling stages. When blood has transformed into fluid, but the fluid has not yet fully become pus, and the toxin has not yet resolved, the patient suffers from whole-body itching and restless scratching. This is an ominous sign, analogous to the sensation of insects crawling under the skin seen in Yangming channel disease in Shanghan. This is described as external assault by deficient wind and internal strength of the pathogen, where persistent itching is called "leaking wind." In such cases, one must observe whether the lesions are dry or wet and administer wind-dispersing herbs accordingly. Itching must cease for it to be considered a good omen. If itching is severe and unceasing, leading to lesion rupture and skin shedding, with the toxin sinking back inward, it is called "itch-collapse" (Yang Ta), which is incurable. Generally, if the lesions appear with red and bright flesh, or rise with tender, watery skin, itch-collapse often follows.

In all cases of smallpox itching, one must carefully examine the color and form. If the lesions have been rising with red vitality, luster, fullness, and plumpness, but suddenly become itchy, this indicates contact with foul qi. Internal administration of Shiquan Dabu Tang (Complete Excellent Tonifying Decoction) and external application of Yinchen fumigation method are indicated. For ruptured lesions, Bailong San (White Dragon Powder) should be applied. If dry lesions develop additional itching, this indicates intense fire-toxin. If lesions originally contain fluid, with tender and thin skin, and then itch, this indicates warm-heat. Symptoms accompanied by head shaking, neck twisting, limb movements, and mental confusion indicate a fatal prognosis. For initial itching upon eruption, promote sweating using Guizhi Gegen Tang (Cinnamon Twig and Pueraria Decoction) supplemented with processed Mahuang (Ephedrae Herba) and Niubangzi (Arctii Fructus). For itching during the rising and filling stages, use Shiquan Dabu Tang supplemented with Fangfeng (Saposhnikoviae Radix) and Niubangzi. There are two patterns of itching during the rising stage: first, deficiency of blood and qi causes deficiency-type itching, treated with Shiquan Dabu Tang; second, inability to eat bland food causes itching, treated with Chantui Gao (Cicada Slough Paste). For dry and itchy lesions, nourish blood and moisten dryness using Siwu Tang (Four Substances Decoction) combined with Xiaofeng Huadu Tang (Wind-Dispersing and Toxin-Resolving Decoction) and Duoming Dan (Life-Snatching Pill), with external Yinchen fumigation. For wet and itchy lesions, tonify qi and eliminate dampness using Sijunzi Tang (Four Gentlemen Decoction) combined with Xiaofeng Huadu Tang and Duoming Dan, with external Yinchen fumigation. If mature lesions suddenly itch and are scratched open due to spleen and stomach weakness failing to nourish muscles, internally administer Sijunzi Tang supplemented with Huangqi (Astragali Radix) and Guigui (Cinnamomi Cortex), and externally apply Baicao San (Decayed Grass Powder). If diarrhea causes spleen-stomach weakness leading to itch-collapse, use Chen's Muxiang San (Aucklandia Powder) and Yigong San (Extraordinary Power Powder). If lesions itch before scabbing and are mistakenly broken, refusing to dry, apply Bailong San.

Danxi's method distinguishes deficiency and excess based on color, form, and pulse: excess presents with strong pulse and robust qi, while deficiency presents with weak pulse and depleted qi. Excess itching is urgent; deficiency itching is timid. Treat deficiency itching with exterior-consolidating agents plus blood-cooling herbs; treat excess itching with a small amount of cold-purgative herbs like Dahuang (Rhei Radix et Rhizoma) to purge accumulated feces. Cangzhou Weng's method addresses blood and qi deficiency using Shibu Tuoli San (Ten-Ingredient Interior-Supporting Powder) and Muxiang San supplemented with Dingxiang (Caryophylli Flos) and Guigui. Since the Stomach governs muscles, Sijunzi Tang supplemented with Xiong (Chuanxiong Rhizome), Gui (Angelicae Sinensis Radix), Muxiang (Aucklandiae Radix), and Zicao (Lithospermi Radix) is particularly suitable. If the patient fails to keep dietary restrictions and eats toxic foods causing itching, use Erwu Tang (Two-Substance Decoction), Baihua Gao (Hundred Flowers Paste), or Sijunzi Tang plus detoxifying herbs. Chen's method states that itching with scratched-open sores and dripping pus/blood results from declining blood/qi and weak muscles; use Muxiang San supplemented with Dingxiang and Rougui (Cinnamomi Ramulus), plus Baicao San. Cow dung ash must be strictly avoided.

Wenrenshi's method identifies two patterns: first, blood/qi deficiency causing deficiency itching, treated with Huoxue San (Invigorate Blood Powder) or Sijunzi Tang supplemented with Huangqi and Zhike (Aurantii Fructus); second, itching from inability to eat bland food, treated with Chantui Yiwu Tang (Cicada Slough Single-Substance Decoction). Wei's method uses Baoyuan Tang (Preserve Origin Decoction) with doubled Huangqi and added Shaoyao (Paeoniae Radix). Some suggest adding Niubangzi, Baishaoyao (White Peony Root), and Heshouwu (Polygoni Multiflori Radix) to Baoyuan Tang for head/tail itch-collapse. Heshouwu has red and white varieties (male and female); both should be used together for efficacy. Iron must be avoided. Wang Ruyan states that pale, weak smallpox with itch-collapse belongs to deficiency-cold, treated per Chen's method. Fever with vigorous red-purple eruptions and dry itching belongs to heat-toxin, treated with blood-cooling and detoxifying agents. Xue's view holds that these conditions result from blood/qi weakness; preventive care ensures harmony. Observe external signs: pale colors require Sijunzi-type formulas, red colors require Siwu-type formulas.

Yuan's view states that half-filled pustules itching can be treated with Renshen (Ginseng Radix), Huangqi, Shaoyao, Shengma (Cimicifugae Rhizoma), and Fuzi (Aconiti Lateralis Radix Praeparata); cold-dispersing drugs are contraindicated. Lesions scorched tight to the skin or empty-shell-like lesions itching are incurable.

Shenqi Naituo San treats interior deficiency itching, non-suppurating lesions, and inverted scabbing. Ingredients: Renshen, Huangqi (fried), Danggui (Angelicae Sinensis Radix), Chuanxiong, Houpo (Magnoliae Officinalis Cortex, ginger-processed), Fangfeng (each 5 fen), Jiegeng (Platycodonis Radix), Baizhi (Angelicae Dahuricae Radix), Guigui (each 2 fen), Muxiang, Gancao (Licorice Root, each 3 fen), Zicao (each 5 fen). Add a pinch of Nuomi (Glutinous Rice), decoct in water, and take appropriate amounts. Also suitable for chills, teeth grinding, thirst, and diarrhea.

Zicao Muxiang San treats interior deficiency itch-collapse with black depression and fever. Ingredients: Zicao, Fuling (Poria), Gancao, Baizhu (Atractylodis Macrocephalae Rhizoma), Muxiang, Renshen (equal parts), Nuomi. Powder form; take 3 qian per dose, decoct in water.

Xiaofeng Huadu Tang: Fangfeng, Huangqi, Baishaoyao, Jingjiesui (Schizonepetae Spica), Guizhi (Cinnamomi Ramulus), Niubangzi, Shengma (equal parts), Gancao (half dose). Crush. Add 7 leaves of Bohe (Menthae Haplocalycis Herba), 1 cup of water, decoct to 0.7 cups, strain, and take warm at any time.

[Dan] treats itch-collapse not covering. Ingredients: Baizhu (1.5 qian), Huangqi (roasted), Danggui, Chenpi (Citri Reticulatae Pericarpium, each 5 fen), Gancao (lightly roasted). Decoct in water, take warm.

Case Study: I treated a seven-year-old child. During the pre-eruption phase, he had several episodes of black diarrhea, no root formation, and after three days developed itch-collapse turning black upon scratching. He was thirsty. Roots resembled water blisters, lacked redness/luster, did not rise, and appetite was poor. Pulse was floating, rapid, and forceful superficially, but deficient deeply. I used Renshen, Huangqi, Danggui, Baizhu, Chenpi, and Roudoukou (Myristicae Semen) as sovereign herbs, with Zhi Gancao (honey-fried Licorice), Hezi (Terminalia Chebulae Fructus), and Guizhi as minister herbs. Decocted in water, taken with a little fine wine. Itching stopped immediately, appetite returned, roots became red/lustrous and rose. Two doses resulted in complete recovery.

Chanhua San treats generalized itching and scratching in smallpox/rubeola at any stage. Ingredients: Chantui (Cicada Slough, head/feet removed, washed, lightly fried, 1 liang), Digupi (Lycii Cortex, fried until black, 1 liang). Powder. Take one tea spoon, swallowed with water and wine. One to two doses yield miraculous effects.

Erwu Tang: Chantui (cleaned, 21 pieces), Gancao (roasted, 1 liang). Powder. Decoct in water, take frequently.

Hepi San: For sudden severe itching on day 8-9 of smallpox, the most critical condition. Ingredients: Fried Baizhu, Shaoyao, Shengdihuang (Rehmanniae Radix), Gancao, Shengma, Jingjie (Schizonepetae Herba), Fangfeng, Chenpi, Dafupi (Arecae Pericarpium), Jiangcan (Bombyx Batryticatus), Chantui. Decoct in water.

Zhenze Tang: Renshen, Huangqi, Shaoyao, Shengdihuang, Fangfeng, Gancao. Decoct in water.

Tianyuan Erxian Dan: Hundun Tang ingredients: Renshen (milk-soaked), Huangqi, Sheng Fuzi (raw Aconite, flour-roasted, each 1 liang). Grind these four finely separately, mix, and blend with white honey. Dosage depends on age: 1 qian for over 10 years, 2 qian for over 15 years. Follow with Zhenyuan Tang continuously to stop itching.

Qixing San: Huangqi, Shaoyao (each 2 qian), Renshen, Guixin (Cinnamomi Ramulus, each 1 qian), Black Carp (one fish). Grind the first four into powder, place inside the black carp, cook熟 in Shengma wine. Feed the medicine and fish to the patient. Eat head for upper jiao itch, body for middle jiao itch, tail for lower jiao itch. An effective empirical formula.

Bailong San: Use old dried yellow cow dung exposed to wind and dew. Burn to ash, take the white center, grind to powder. Wrap in thin silk bag and dust onto sores.

Bathing Method: Frost-exposed Sangye (Mulberry Leaf), Sugeng (Perilla Stem), Shengma, Jingjiesui, Fangfeng. Decoct boiling vigorously, cool slightly, and wipe the body. For severe itching, gently brush with bird feathers. Smoke incense made of Xiacha (Fine Tea), Danggui, Huangqi, Xuanshen (Scrophulariae Radix). Alternatively, heat an iron vessel red-hot, dip in strong vinegar, and fumigate the room.

[Dan] For mild cases, mix Tuhua Shi (Calcitum) powder with light honey water, apply with chicken feather.

[Chen] For unbearable itching leading to sores with pus/blood, use Baicao San. Strictly avoid cow dung ash, as it causes foul odor and scarring. (Formula see Scabbing Treatment). For children with unbearable itching, scratched sores, or stubborn scabs, apply high-quality white honey to the sores to facilitate scab removal without purple-black scars. For post-scabbing leprosy-like rashes caused by residual toxin, apply aged tallow fat. Another method: apply sheep bone marrow to sores.

[Crawling/Breaking] [Wan] If mature pustules are scratched open due to itching, they will repeatedly ulcerate and fail to scab. If scratched before pus formation, itch-collapse and death are inevitable. [Yuan] Why do some die from dripping pus/blood after scratching, while others die from dry peeling? Answer: Dry wood breaks naturally; dry soil cracks naturally. Empty pustules cause uncontrollable itching. Scratching in non-vital areas may allow survival; scratching vital areas (cheeks/nasolabial folds) leads to imminent death. Although dripping pus seems to nourish blood/qi, death occurs because the "water" (fluid source) is exhausted, leading to collapse of Yuan Qi (Original Qi). Commentary: Pus flow suggests life, but breaking the "golden" structure destroys it. Even with skilled treatment, losing the essence is fatal.

Xie Chongxiao claimed that skin loss could be patched with medicinal paper like Nüwa mending the sky; this is erroneous.

For scratched bleeding sores, use Heihu Dan (Black Tiger Pill). Verse: Silk gourd stem and sac skin, black gold from within, slow roast on new tile preserving nature... Jingjie, Fangfeng, Baizhi, Huangqi, Shaoyao perform miracles. Note: Ancient methods used Baicao San, Buckwheat flour, or Clam powder, none as effective as Heihu Dan.