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The ancient aphorism states: Deficiency manifests as itching, while excess manifests as pain. It is also said that all itching belongs to deficiency. This indeed serves as a key for differentiation. However, excess conditions often involve heat, whereas deficiency conditions often involve cold. For instance, the pain of sores and ulcers must stem from heat; now, since there is no pain but rather itching, it indicates the absence of heat. The absence of heat results from Yang deficiency, and Yang deficiency constitutes a cold syndrome. Those who attribute initial itching to fire (excess heat) are mistaken. Moreover, whenever chickenpox or smallpox lesions itch, it is mostly because the lesions fail to rise and fill with pus, subsequently sinking in, which is most alarming. Therefore, regarding the treatment of itching, although supplementation is indicated, warming is particularly indispensable. Only through warming and tonifying can Ying and Wei (nutritive and defensive Qi) harmonize, Qi and Blood circulate freely, and the lesions naturally rise. Once the toxin has risen and emerged, pain is common, where would itching come from? Thus, during the eruption phase of smallpox, pain is favorable, whereas itching is unfavorable.

However, there are several types of itching, which should be differentiated and treated as follows:

First, when smallpox spots begin to itch immediately upon appearance, this indicates pathogenic factors between the exterior and interior, hesitating to advance or retreat, primarily due to insufficient Yuan Qi (Original Qi), unable to reach the surface. One should rapidly warm and tonify Yang Qi, combined with dispersing methods. As long as the Cou Li (skin pores and interstices) become unobstructed, the lesions will naturally rise, and itching will cease. Liuqi Jian (Six Qi Decoction) added with Chuanxiong Rhizome (Chuanxiong), Angelicae Dahuricae Radix (Baizhi), Saposhnikoviae Radix (Fangfeng), and Schizonepetae Spica (Jingjie) is suitable. If the deficiency lies in the Blood aspect and the color is pale, Liuwu Jian (Six Elements Decoction) or Wuwu Jian (Five Elements Decoction) modified is appropriate.

Second, after the smallpox lesions have fully erupted, any occurrence of itching should generally be treated with Baoyuan Tang (Protect the Origin Decoction), or Liuqi Jian added with Chuanxiong, Angelicae Sinensis Radix (Danggui), Fangfeng, and Jingjie. Alternatively, Shiquan Dabu Tang (Ten Complete Great Tonifying Decoction) or Chantui Gao (Cicada Slough Paste) may be used.

Third, when blood seeps into the skin, causing itching due to the stimulating nature of saltiness on flesh and skin, this is also caused by Qi deficiency. Baoyuan Tang added with Paeoniae Radix Alba (Shaoyao) and Danggui to regulate blood, or Dingxiang (Caryophylli Flos) to treat the interior, and Guirou (Cinnamomi Cortex/Guigui) to treat the exterior, is suitable. When both interior and exterior are solid, itching will not occur.

Master Cheng stated: For itching occurring before and after, Baoyuan Tang added with Polygoni Multiflori Radix (Heshouwu), Arctii Fructus (Niubangzi), and Shaoyao is suitable. Heshouwu should be used in both red and white varieties.

Fourth, for dry smallpox lesions causing itching, nourishing Blood and moistening dryness is indicated. Wuwu Jian added with Fangfeng and Jingjie, externally using Artemisiae Scopariae Herba (Yinchen) fumigation, is appropriate.

Fifth, for damp smallpox lesions causing itching, tonifying Qi and removing dampness is indicated. Sijunzi Tang (Four Gentlemen Decoction) added with Fangfeng, Jingjie, and Cinnamomi Ramulus (Guizhi) to resolve the condition, externally using Yinchen fumigation, is suitable.

Sixth, the head and face are the convergence point of all Yang meridians. If itching leads to scratching and breaking the skin, Qi leakage will be severe. Rapid supplementation with Liuqi Jian or Shiquan Dabu Tang added with Fangfeng, Jingjie, and Heshouwu is required to cultivate and tonify. If the lesions swell and fill again, and appetite remains normal, there is no danger. However, if itching persists and the entire face is scratched open, death is inevitable.

Seventh, for generalized itching with scratched-open lesions oozing pus and blood, Shenqi Neituo San (Ginseng Qi Internal Support Powder) with doubled Danggui, plus Baizhi, Jingjie, and Aquipini Aromatica Rhizoma (Muxiang), is suitable to harmonize Qi and promote Blood circulation, stopping itching. Externally, Baicao San (Defeated Grass Powder) should be applied.

Eighth, for sores that itch, ulcerate, and stick to clothes and mats intolerably, internal administration of Shiquan Dabu Tang added with Fangfeng and Jingjie, and external application of Baicao San, is recommended.

Ninth, when smallpox lesions appear with bright red flesh and tender, watery skin during eruption, itching often follows later. Premature regulation and tonification are urgently required.

Tenth, when itching occurs as smallpox lesions are about to crust over, the pus is formed, and the sores are retracting. This indicates that pathogens are dispersing and Zheng Qi (Upright Qi) is recovering, leading to harmonious Ying and Wei circulation, hence the itching. Medication is unnecessary; careful nursing is required to prevent scratching and scarring.

Eleventh, when blisters are just beginning to form pus but are not yet mature, accompanied by restless whole-body itching, this is an ominous sign. Rapid warming and tonifying of Qi and Blood with Liuqi Jian or Liuwu Jian, added with Fangfeng, Baizhi, and Jingjie, is necessary until the itching ceases to ensure safety. If itching is severe and unceasing, with sores deteriorating and skin peeling off, causing the toxin to sink back in, termed "Itching Sunken," survival is impossible.

The Huayou Xinshu (New Book for Living Infants) states: For persistent itching, bind Jingjie Sui (Schizonepetae Spica) with paper and use it to prick the itchy areas to disperse stagnant pathogens, which stops itching. This is a frequently verified method. Internally, Xiaofeng Huadu Tang (Eliminate Wind and Transform Toxin Decoction) added with Renshen (Ginseng) and Danggui is used to resolve it.