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Pain caused by smallpox (Variola) can be due to excess or deficiency. Although it is generally said that "all pain is an excess condition," this statement should not be adhered to rigidly. If the body has high fever, constipation, restlessness, panting, abdominal distension, thirst, and pain resulting from these, this is excess pain. If there is no high fever, urination and defecation are clear and smooth, spleen qi is weak and not vigorous, defensive qi (Wei Qi) is insufficient, and nutritive blood (Ying Blood) loses its nourishment causing pain, this is deficiency pain. For excess conditions, detoxification and clearing heat are indicated; Decoction for Detoxification (Jiedu Tang) or Four-Ingredient Decoction for Disinfecting Toxins (Siwei Xiaodu Yin) should be used as the main treatment. For deficiency conditions, tonifying qi and blood is indicated; Decoction for Preserving Origin (Baoyuan Tang) or Six-Ingredient Decoction (Liuyi Jian) should be used as the main treatment.

The Classic states: "When heat is severe, swelling occurs." Generally, where toxin is abundant, swelling must occur; where toxin is slight, there is no swelling. Therefore, one can also observe whether there is swelling to ascertain the severity of the toxin. However, when pox lesions erupt according to their expected timeline, the toxin must gradually emerge completely; thus, the head and face will inevitably swell gradually. This is because toxic fire gathers in the regions of the Three Yang meridians (Taiyang, Yangming, Shaoyang), desiring to transform into pus and plasma, which is the natural course. Nevertheless, only mild swelling is appropriate. If swelling is severe, it requires specific attention. If at the time of eruption, the head and face show absolutely no swelling, it indicates that the pox lesions are sparse and distinct, and the toxic qi is light and superficial; this is the most auspicious omen.

1. When pox lesions gradually erupt, the face gradually swells, and during the stage of suppuration and scabbing, the swelling gradually subsides, this is a normal presentation. If swelling does not occur when it should, it must be due to insufficiency of primal qi (Yuan Qi); if swelling does not subside when it should, it must be due to surplus of toxic qi, requiring urgent treatment.

2. In some cases, before the pox lesions erupt, the head and face are pre-swollen, with skin that is smooth and tender, resembling a bottle gourd (Hu Gua). This is a sign of malignant toxin rushing upward. In another scenario, pox spots have appeared but remain faintly hidden within the skin, with flesh swelling while the pox fails to rise; this invariably leads to death. Wang Shi, in *Li Bian*, stated: At five or six days after the onset of pox, if the face and eyes swell first and appear shiny, this is yang invading the yin aspect, preventing the toxin from venting. Why? Blood is the root of qi, and qi is the branch of blood. If blood is deficient, the strength of the root is already compromised, leading to hyperactive deficient yang and erratic movement of qi within the flesh. How can such insufficient blood carry the toxin out? After seven days, when the transmission through the meridians is complete, qi retreats and toxin sinks; yin and yang each lose their proper state, leaving little hope for treatment. In all such cases, one must not fail to regulate qi and blood in advance; if one waits until the crisis, it will be too late to act.

3. When pox lesions are erupting and the head and face are swollen, one must strictly prevent scratching of the sores on the front of the face. Do not allow them to be scratched open. Even minor injury can cause primal qi to leak outward and pathogenic qi to erode inward, leading to the disappearance of swelling and sinking of toxin, often resulting in death. However, if broken lesions refill with pus and subsided lesions swell again, and diet and excretion remain normal, misfortune can turn to fortune. Full-Tonifying Great Supplement Decoction (Shiquan Dabu Tang) or combined with Sophora Root Pill (Kushen Wan) is suitable for treatment.

4. When head and face are swollen accompanied by pain and obstruction in the eyes and throat, urgent detoxification is required, treating both eyes and throat simultaneously. Decoction for Disinfecting Toxins and Resolving Macules (Xiaodu Huaban Tang) with Ephedrae Herba (Shengma, 升麻) removed, or Large Lonicera Decoction (Dalianqiao Yin), is indicated.

5. When pre-swelling of the head, neck, cheeks, and jaw occurs due to concurrent epidemic toxic qi, this belongs to conditions such as Big Head Wind (Datou Feng) or Mumps (Hamawen). It should be treated as an epidemic disease using formulas like Large Lonicera Decoction (Dalianqiao Yin) or Universal Benefit Decoction for Detoxification (Puji Xiaodu Yin). However, cases with such complications are mostly ominous with few favorable outcomes.