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When the smallpox/rash initially begins to fever, if the eyes are red and swollen, it is due to wind-heat attacking upwards. If the eyes are red after four or five days of onset, it is because fire-toxin is abundant and steaming upwards. If the eyes are red and swollen after the eruption, it is because residual toxin is stagnating in the Heart and Spleen.

If many rashes have erupted, by the time of pus-filling, the eyes will naturally close. However, after the scabs dry and fall off, the eyes should reopen. If they remain closed, this indicates that toxic vapors are attacking the eyes; one must urgently clear and resolve the residual toxins. In severe cases, Liang Ge San (Cooling the Diaphragm Powder) with Jingjie (Schizonepetae Herba), Niubangzi (Arctii Fructus), and Chantui (Cicadae Periostracum) should be used. Generally speaking, if the eyes do not open past the expected time, licking them moistly with the tongue to remove ocular discharge will cause them to open naturally.

Smallpox damaging the eyes does not occur in the initial stage but after the scabbing phase. This is all caused by dense rashes on the head and face where pus and blood become fixed, or where broken lesions swell and fill again, causing toxic fire to stagnate and steam, internally attacking the eyes. Alternatively, if the rash erupts too profusely and matures slowly, excessive use of acrid-warm herbs fails to clear and resolve the heat, or exposure to fire-qi occurs, or clothing/bedding is too thick, or contraction of wind-cold pathogens, or indulgence in eating various eggs—all these can damage the eyes. Treatment should focus on invigorating blood and resolving toxins; when blood circulation improves, the toxin resolves. One must absolutely avoid using cold/cold-natured medicines indiscriminately, lest they congeal the blood vessels and lead to chronic disease. Also, aromatic/pungent eye drops should not be used. Formulas such as Gujing San (Valerian Flower Powder), Jueming San (Cassia Seed Powder), Mimeng San (Buddleja Powder), Shengong San (Miraculous Efficacy Powder), or Lingyang San (Antelope Horn Powder) may be selected.

When the first spots appear, if rashes grow densely within the eyes, Yidao Dan (Rash Transferring Pill) must be urgently applied to transfer them out, thereby avoiding eye damage. Although this formula seems absurd, its efficacy is extraordinary; do not neglect it because of its strangeness. If three days pass and the root qi has stabilized, it cannot be transferred anymore. For mild cases, ivory ground in water can be dripped into the eyes to effect the transfer.

For cases of flat, inverted, or ulcerated smallpox lesions where medication allows scabbing to form, residual toxins have not been fully expelled and must exit via the meridians, manifesting as carbuncles/toxins. Medication should be chosen based on the affected meridian, primarily focusing on supporting the interior and resolving toxins. For un-ulcerated, swollen, and hard lesions, Pai Du San (Draining Toxin Powder) is used, adjusted according to the deficiency or excess of Yuan Qi (Original Qi). Externally, raw soybeans chewed into a paste can be applied, or rhubarb boiled in wine mixed with true mung bean powder for application, or snake skin dipped in raw soy milk applied. For ulcers that are swollen but pus has not penetrated, Jie Du Nei Tuo San (Resolving Toxin and Supporting Interior Powder) with Baizhi (Angelicae Dahuricae Radix) and Lingli Jia (Manis Squama) is used. Externally, Haishi (Magnitum) finely ground and mixed with honey is applied. For ulcers already drained of pus, Shi Xuan San (Ten Acupoints Powder) with Lianqiao (Forsythiae Fructus) and Rendong Teng (Lonicerae Japonicae Caulis et Flos) is used.

Whenever residual toxins from smallpox manifest as carbuncles: if the base is red and itchy, it indicates Qi deficiency; Si Jun Zi Tang (Four Gentlemen Decoction) with Danggui (Angelicae Sinensis Radix) and Shaoyao (Paeoniae Radix) is used. If red, hot, and painful, it indicates Blood heat; Si Wu Tang (Four Substances Decoction) with Shengdi Huang (Rehmanniae Radix Recens) replacing Shu Di Huang, plus Xijiao (Rhinocerotis Cornu), Lingli Jia, Lianqiao, and Rendong Teng is used. If swollen but not ulcerated, it indicates dual deficiency of Qi and Blood; Tuo Li Xiao Du San (Support Interior and Eliminate Toxin Powder) is used. If ulcerated but not healing, it indicates Spleen Qi deficiency; Liu Jun Zi Tang (Six Gentlemen Decoction) with Danggui and Rendong Teng is used.

If lesions appear on the skin surface, appearing as large or small patches like vermilion, or forming nodules that are painful, swollen, and untouchable, this is called Zi Dan Liu (Purple Carbuncle Nodule). This indicates extreme internal toxicity in the Five Zang organs; even with detoxifying herbs, resolution is difficult. If it arises from above and reaches the Heart, death ensues; if from below and reaching the Kidney, death ensues. Urgently prick with a porcelain blade to release evil blood. If swelling persists, prick again. Internally, drugs must be used to drain the toxin and promote excretion. If faint red macules or patches appear on the skin with itching, commonly known as Gai Dou Sha (Covering Rash Mumps), Xiao Du Yin (Detoxifying Decoction) with Fangfeng (Saposhnikoviae Radix) is used.

If, after safe scabbing, sudden coldness of hands and feet occurs, this is Spleen Qi deficiency; do not mistake it for a Cold syndrome. Cannei Tuo San (Ginseng Internal Support Powder) with Guizhi (Cinnamomi Ramulus) is used. If sudden spasms and inability to flex/extend limbs occur, this is external contraction of Wind, Cold, and Dampness; do not use dispersing herbs that consume Blood. Shi Quan Da Bu Tang (Complete Great Tonifying Decoction) with Guizhi and Cangzhu (Atractylodis Rhizoma) is used. For joint pain, add Qianghuo (Notopterygii Rhizoma et Radix) and Fangfeng.

If dysentery with pus and blood suddenly occurs after scabbing, toxic vapors have entered the Large Intestine. Allow this to continue for two or three days until fully evacuated, then clear heat and promote urination, followed by tonifying the Spleen and strengthening the Stomach. Do not use astringents. If heat-toxin accumulates in the Lung, blocking the throat, resulting in an open mouth without eating, desire to vomit but unable to, dry heaving, and hoarseness, this indicates rotting sores in the Stomach—a most ominous sign. Urgently use Xiao Du Yin with Gancao (Glycyrrhizae Radix), Jiegeng (Platycodonis Radix), Heishen (Black Ginseng), Niubangzi, and Zhuye (Bambusae Folium), and apply ground Xijiao (Rhinocerotis Cornu) water. Delay leads to throat rot and death.

If abdominal pain, distension, irritability, and rapid breathing occur, the toxin has entered the Spleen; use Zhishi Dao Zhi Tang (Immature Bitter Orange Regulating Stagnation Decoction) to purgate. Otherwise, panting, cold extremities, and difficulty treating arise. If appetite remains normal after smallpox but emaciation progresses daily, this is dual deficiency of Qi and Blood with deficient fire in the Stomach. Qian Shi Yi Gong San (Master Qian’s Extraordinary Efficacy Powder) and Si Wu Tang, both added with Huanglian (Coptidis Rhizoma), should be taken alternately. Dietary restriction is essential.

If constipation occurs, it indicates toxin excess and Blood dryness; Xiao Du Yin with Shengdi Huang, Haren (Cannabis Semen), and Xingren (Prunus Armeniaca Semen) is used to moisten. If dryness results from excessive heat herbs, Xiao Du Yin with Haren, Shaoyao, and Shanzhi (Gardeniae Fructus) is used. If mouth/tongue ulcers appear: red ones indicate Heart/Spleen heat—use Liang Ge San; white ones indicate Lung/Heart heat—use Qing Fei Tang. Wipe clean externally with a green cloth dipped in water, then apply Maming San (Horse Cry Powder).

During scabbing, mouth/tongue ulcers and dental caries (Chi Gan) are due to unresolved residual toxin attacking the Yangming Meridian and steaming the Upper Jiao. Clear Stomach heat and transform toxin using Ganlu Yin (Sweet Dew Decoction) with Xijiao and Lianqiao. Sore throat is also due to residual toxin lingering in the Guan Yue (throat/pharynx), where the Lung suffers from Fire hyperactivity causing swelling and pain; Ru Sheng Yin (Like Sage Drink) is used.

After scabbing, if eyes remain closed, or membranes form, causing pain and dim vision, cool Blood, resolve toxins, clear Heart heat, and drain Liver fire according to symptoms. If scabbing is incomplete and residual toxin suddenly erupts, reddening body, face, and eyes, prognosis is poor. Weng Zhongren stated: After scabbing, carbuncles indicate residual toxin. However, high-pitched breathing with wheezing, lifting shoulders and belly to breathe, indicates residual toxin in the Lung. Thick sticky phlegm, grinding teeth, incessant diarrhea with foul breath indicates residual toxin in Spleen/Stomach. Night sweats on the chest, afternoon fever/thirst indicates residual toxin in Pericardium. Startling during sleep, constant low-grade fever indicates residual toxin in Liver. Heat in ears and coccyx indicates residual toxin in Kidney. Eyes closed, edema, persistent high fever, depression indicate residual toxin in all meridians.

Furthermore, eruptions on the vertex and chest belong to Heart Meridian toxin; arm/elbow/back belong to Lung Meridian toxin; flanks/knees/tendon gatherings belong to Liver Meridian toxin; seven-joint region and coccyx belong to Kidney Meridian toxin; face and throat belong to Stomach Meridian toxin. Liver, Lung, and Stomach toxins are generally easy to treat; Heart toxin is critical; Kidney toxin is incurable.

Generally, eruptions due to Blood heat and toxin excess present with swollen, red lesions, good appetite, and constipation; use Xiao Du Yin with detoxifying and blood-cooling herbs. If Stomach Qi is solid, use Pai Du San to mildly purge. If eruptions are due to Qi deficiency and toxin excess, presenting with diffuse pale swelling, poor appetite, and loose stools, even with Renshen Nei Tuo (Ginseng Internal Support), prognosis is poor. Using Xijiao, Huangqin (Scutellariae Radix), Huanglian, and Dihuang (Rehmanniae Radix) accelerates death. Generalized weeping serous fluid that persists indefinitely is incurable.