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Xia Yuzhu said: Smallpox (Tianhua) originates from the Zang organs and manifests in the Fu organs, primarily governed by the Large Intestine. The toxic vapors steaming the Lungs cause coughing. Predecessor medical texts did not mention this syndrome, likely because they considered it mild and ignored it. However, one should not know that although the exterior syndrome appears mild, if the toxin invades the Lung and Heart, it can often be life-threatening. I have encountered many such cases, which were mostly difficult to treat. Therefore, I do not spare my efforts to record them in detail in this chapter, to prevent the epidemic of infant smallpox.

The symptoms of smallpox include fever, inevitable coughing, slightly hoarse voice, slight swelling of the facial skin, and slightly red color on both cheeks; this is an auspicious sign. If the eruption is slow and incomplete, or if red spots appear on the face but are occasionally hidden due to wind-pathogen invasion, or if doctors, unaware of this syndrome, mistakenly use heat-clearing methods to remove the fever, causing the eruption to hide and abdominal pain to occur, there is no formula more miraculous than Tianbao Caiwei Tang (Heavenly Protection Mulberry Leaf Decoction), nor any more sagacious. A single dose will cause the eruption to appear; if some remain un-erupted, a second dose may be added. It has never failed. If the Lung organ is first deficient, and then attacked by Large Intestine toxins, the facial skin becomes pale white and floating like thin slurry, smooth and shiny; this indicates that Lung Qi has exhausted. Needling the Jing and Wei acupoints with opposite manipulation, if the voice does not come out, it is certainly a fatal case, and medicine is of no help.

In some cases, when the smallpox spots appear, they immediately recede inward, or green watery diarrhea occurs. Carefully examining, if it is not caused by Wind-Cold, and the lip color is pale white with weak breath, this is internal deficiency unable to send the toxin outward. One must not use draining and stopping-diarrhea methods, but only use Bazhen Tang (Eight Treasures Decoction) to support and push the toxin out. Externally, use about half a jin (approx. 500g) of Scallion Stems (Cong Bai), decocted with white wine, and wipe all over the body. If it still does not erupt, showing only slight spots on the forehead, use Liujunzi Tang (Six Gentlemen Decoction) for gradual regulation, and it will heal naturally.

In some cases, during initial fever, excessive Heart Fire severely restricts Lung Metal, causing the smallpox to fail to erupt. One must first administer equal parts of Coptis Rhizome (Huanglian) and Awlhead Pipestem Climber Stem (Mutong). Then, decoct and administer Saposhnikovia Root (Fangfeng), Schizonepeta Spike (Jingjie), Kudzu Root (Gegen), Bupleurum Root (Chaihu), Pinellia Tuber (Nanxing), Aurantium Fruit (Zhike), Red Peony Root (Chishao), Mulberry Bark (Sangbai Pi), Platycodon Root (Jiegeng), and Licorice Root (Gancao). The eruption will then appear.

In cases where Dysentery (Liji) coexists with smallpox, if smallpox spots appear, urgently decoct and administer Mosla Herb (Xiangru), Platycodon Root (Jiegeng), Aurantium Fruit (Zhike), Coptis Rhizome (Huanglian), Magnolia Bark (Houpo), Awlhead Pipestem Climber Stem (Mutong), Bupleurum Root (Shengma), Red Peony Root (Chishao), and Plantago Seed (Cheqian). Treat the dysentery only after the smallpox sores have fully erupted. This is the principle of "abandoning the light to address the heavy," which must not be ignored.

The fifth son of Tao Yigong (Yayu) in our county suffered from smallpox fever for only two days. The doctor mistakenly treated it as general fever using heat-clearing methods, causing the smallpox to lie dormant and not erupt. The condition resembled convulsions. An officer invited me to treat him. His complexion was mottled, he panted urgently without coughing, indicating internal toxin. I rubbed saliva on his Taiyang acupoint, revealing hidden red spots under the skin, knowing it was smallpox toxin attacking internally. Without heat, the eruption cannot emerge. I used Tianbao Caiwei Tang with increased doses of Bupleurum Root (Shengma) and Kudzu Root (Gan Ge). After one dose, spots appeared on the forehead, but the color was not red and did not rise. The complexion and lips were pale and lusterless, indicating internal deficiency. I immediately administered Guzhen Tang (Solidify True Decoction) for one dose. The whole body became hot. Mr. Tao was terrified. I said, "This is not failing to erupt due to heat." He continued taking Tianbao Caiwei Tang for another dose, and the eruption penetrated the whole body, leading to recovery. This is a verification that a mottled complexion indicates internal toxin.

A student friend of Peijilou, Fang Hengsui, had a son with smallpox. The eruption was hidden and did not appear, with severe symptoms. He invited me to treat. I saw his face was pale white, breath slightly cold, lips and tongue pale white, with loose stools. I immediately prescribed Bazhen Tang (Eight Treasures Decoction). After one dose, slight spots appeared on the forehead. Hengsui, because his nephew previously died from smallpox complicated by forced diarrhea, strongly demanded stopping the diarrhea. I said, "Draining fluids will further weaken the Spleen." He refused. Seeing that the family felt diarrhea threatened life, he reluctantly used Wuling San (Five-Ingredient Powder with Poria). Indeed, the diarrhea stopped, but the red spots on the forehead immediately hid. I then used Shiquan Dabu Tang (Ten Great Tonifying Decoction) for internal support and externally applied steamed scallion-wine extraction. Ultimately, it did not erupt. I was busy with official duties and went to the prefecture, later sending a letter instructing: Each blister on the skin, once broken, becomes a black cavity. Attached is a list of other doctors' formulas for attacking toxins. I replied: Flesh belongs to the Spleen. Breaking into cavities indicates extreme Spleen deficiency. How can one attack toxins? Only use Liujunzi Tang (Six Gentlemen Decoction) to protect the Spleen as the primary goal. It was indeed effective. This demonstrates that observing complexion and orifices is infallible; draining fluids damages the Spleen, as seen here.

Wu Dayan's fifth son from Sichengtang, a classmate friend, suffered from smallpox. The initial doctor, unaware of the smallpox pulse/syndrome, used Liu Yi San (Six-to-One Powder) to clear heat. He invited me to treat. I saw his tongue was purely purple, lips dry and cracked, urination and defecation both obstructed, and snoring continuously. I immediately prescribed Coptis Rhizome (Huanglian) 8 fen, Awlhead Pipestem Climber Stem (Mutong) and Phellodendron Bark (Huangbo) 1 qian each. After ingestion, white stool resembling cold dysentery was passed. Those present whispered that this was caused by cooling herbs, and I also hesitated. Could the viscera and orifices be inconsistent with this syndrome? Without hesitation, I asked what the previous doctor used for heat-clearing. Dayan said, "Liu Yi San." I suddenly realized that the lower origin was stagnated by the coldness of Liu Yi San, causing fire to fail to descend and instead scorching. There was no doubt. I then used fried salt to moxa/iron the area below the navel for a long time, and still used the previous herbs with doubled Coptis Rhizome. After ingestion, dry, hard stool resembling black dates was finally passed. This shows that distinguishing truth through orifices leads to accurate treatment, a verification of this principle.