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Nie Jiwu said: When smallpox lesions appear for eight or nine days, and the pustules are full with a grayish-yellow color, this is an excellent sign. If there are no other symptoms, medication may be omitted. However, if the smallpox lesions are dense but the pus is not sufficiently full, at this stage dietary intake often decreases while phlegm and saliva increase; it is appropriate to use Yangwei Kaitan Decoction (Stomach-Nourishing and Phlegm-Resolving Decoction). [Ingredients: Ginseng Radix et Rhizoma (Renshen), Atractylodis Macrocephalae Rhizoma (Baizhu), Poria (Baifuling), Prepared Licorice Root (Zhigancao), Lotus Seed (Lianrou), Tangerine Peel (Chenpi), Pinellia Tuber (Banxia), Chinese Yam Rhizome (Shanyao), Platycodon Root (Jiegeng), Hawthorn Fruit (Zharou). Decoct and take warm. During the pus-filling stage, avoid using Baizhu, Baifuling, and Banxia, as they may dry up body fluids and hinder pus formation. They can be used during the scabbing stage. For thirst, remove Banxia and add Ophiopogon Tuber (Maidong) and Schisandra Berry (Beiweimei); for vomiting and reflux, add Agastache Herb (Huoxiang) and Amomum Fruit (Sharen).]

When scabs form with a waxy yellow color, and within one or two days the scabbing extends from the head down to both legs, covering the chest, abdomen, feet dorsum, and forehead simultaneously, healing after shedding is auspicious. If chills or trembling of hands and feet occur during scabbing, accompanied by failing qi, death is indicated. (Urgently use herbs that tonify qi and blood and nourish the spleen and stomach to rescue.) If the entire body becomes foul and rotting during scabbing, emitting an odor like rotten cakes that is unbearable, and the eyes lack spirit, death is indicated. If the entire body itches during scabbing, scratching reveals no pus, and the skin curls like bean shells, death is indicated. If the smallpox scars should fall off but do not, it is due to excessive fire. It is appropriate to use Chai Ling Tang (Bupleurum and Poria Decoction) plus Chen Sha Liu Yi San (Cinnabar Six-to-One Powder), mixed with honey water for oral administration, and apply Talcum Powder (Huashi) externally. If the scabs do not shed and there is no thirst, but chills and teeth grinding occur, it belongs to deficiency-cold; Muxiang San (Costus Root Powder) is appropriate. If itching occurs, treat with Angelica Dahurica Root (Baizhi), Dang Gui (Angelica Sinensis), and Cicada Slough (Chantui). When smallpox pustules are fully filled and heat-toxins have resolved, but during the scabbing phase some do not dry for several days, as long as the lesion color remains original, there is no harm. (Use Bazhen Tang (Eight-Treasure Decoction) plus Niubangzi (Arctium Fruit) and Mutong (Akebia Stem) to tonify the spleen and promote urination for natural peace.) If post-smallpox scars are snow-white with no blood color, urgently use herbs to tonify qi and blood and nourish the spleen and stomach; perhaps treatment is still possible. At this time, if there is coughing and retching (desire to hiccup), it indicates stomach qi rebelling upward. Smelling real yellow earth near the nose will stop it immediately. If the pustules are full but affected by cold, causing the lesions to turn purple-black like purple grapes, panic ensues; urgently grind high-quality Cinnamon Twig (Rougui) into decoction or administer orally, and recovery will be seen immediately. With chills and teeth grinding, this indicates true qi emerging externally while internal deficiency-cold exists. Jianzhong Tang (Middle-Warming Decoction) is appropriate for major tonification. [Ingredients: Ginseng Radix et Rhizoma (Renshen), Honey-fried Astragalus Root (Huangqi), Atractylodis Macrocephalae Rhizoma (Baizhu), Angelicae Sinensis Radix (Guishen), Szechwan Lovage Rhizome (Chuanxiong), Prepared Aconite Lateralis Radix (Fuzi), Roasted Ginger (Paojiang), Cinnamon Twig (Rougui), Prepared Licorice Root (Zhigancao), Clove Bud (Dingxiang), Fresh Ginger (Shengjiang). Decoct together and take warm. One dose stops it immediately; severe cases require no more than two doses. For chills and teeth grinding after scabbing, regulate with this formula. Some say chills and teeth grinding can be either heat or cold: if lesions are bright red-purple, swelling and heat are prominent, irritability and thirst exist, stool is constipated, urine is red and scanty, and pulse is flooding and rapid, it is heat. Stomach heat causes teeth grinding; lung heat causes chills. If lesions are pale white, skin is thin and depressed, body is cool and aversion to cold exists, bowel movements and urination are free, and pulse is deep and slow, it is cold. Stomach cold causes teeth grinding; lung cold causes chills. This theory is correct. However, nineteen percent of these cases are cold, ten percent are heat. Heat appearing before the seventh or eighth day is occasional; heat appearing after the seventh or eighth day is rare. Therefore, no specific formula is provided for heat.] On the ninth or tenth day, when pus is sufficient and color is grayish-yellow, fever and steaming sensation must occur; this is the stage of fluid return. True yang transforms fluids, naturally evaporating them for scabbing; this is a deficiency-cold syndrome. The body must be cool with cold extremities; major tonification of qi and blood is required to assist scabbing. Wenbiao Tiaozhong Tang (Warm Exterior and Regulate Middle Decoction) is appropriate. [Ingredients: Ginseng Radix et Rhizoma (Renshen), Atractylodis Macrocephalae Rhizoma (Baizhu), Poria (Baifuling), Official Cinnamon Bark (Guangui), Honey-fried Astragalus Root (Huangqi), Szechwan Lovage Rhizome (Chuanxiong), Angelicae Sinensis Radix (Guishen), Prepared Licorice Root (Zhigancao), Roasted Ginger (Paojiang), Saposhnikovia Root (Fangfeng), Angelica Dahurica Root (Baizhi), Clove Bud (Dingxiang), Prepared Aconite Lateralis Radix (Fuzi), Fresh Ginger slice. Decoct together and take warm.] Those who steam with fever and fail to scab when they should, have unresolved toxin-waste. Resolving the heat allows the smallpox to resolve naturally; Qingbiao Sandu Tang (Clear Exterior and Dispel Toxin Decoction) is appropriate. [Ingredients: Cortex Lycii (Digupi), Ophiopogon Tuber (Maidong), Trichosanthes Root (Huafen), Arctium Fruit (Niubang), Forsythia Fruit (Lianqiao), Angelicae Sinensis Radix (Danggui), Polyporus (Zhuling), Alisma Rhizome (Zexie), Scutellaria Root (Huangqin), Akebia Stem (Mutong), Raw Licorice Root (Shenggancao). Decoct in water and take warm. Alternatively, mix half a wine cup of sugar cane juice with boiling water to make one bowl, take warm; this is called Ganlu Huitian Yin (Sweet Dew Heaven-Returning Drink), which can reduce heat and help scabbing, but may not be effective if toxins are strong.] For regulating vomiting and diarrhea, differentiate cold and heat for medication, same as previously described. If external ulceration with dripping pus occurs during scabbing, it is called "water scab." Use powder made from new roof tiles, sifted very finely, packed in silk bags, and applied to the affected area. If dry scabs pile up without falling and pus accumulates inside, apply tile powder mixed with duck egg white to achieve immediate resolution and shedding. (This occurs when pus is full, heat is extreme, and ulceration happens.) If sudden abdominal pain occurs during scabbing, localized at the Zhongwan point, it is due to heat-toxin stagnation and blood stasis causing pain. Xiaodu Sanxue Tang (Detoxify and Resolve Blood Stasis Decoction) is appropriate. [Ingredients: Arctium Fruit (Niubang), Raw White Peony Root (Shengbaishao), Peach Kernel (Taoren), Rhubarb (Dahuang), Safflower (Honghua), Myrrh (Moyao), Frankincense (Ruxiang). Decoct in water; one dose stops pain immediately. Sudden abdominal pain due to evil invasion results in death.] If scabs are thick and solid with no other symptoms, no medication is needed. If fever or irritability/thirst occurs after scabbing, differentiate deficiency/excess and cold/heat for regulation. If fever is intense, with heat in chest, abdomen, hands, feet, head, and face, constipation, and red/scanty urine, residual toxin is strong; detoxification is required, primarily using Dalianqiao Yin (Large Forsythia Drink). If detoxification is delayed, carbuncles will likely erupt after scab shedding. [Ingredients: Forsythia Fruit (Lianqiao), Arctium Fruit (Niubang), Bupleurum Root (Chaihu), Angelicae Sinensis Radix (Danggui), Red Peony Root (Chishao), Saposhnikovia Root (Fangfeng), Akebia Stem (Mutong), Plantago Seed (Cheqianzi), Schizonepeta Spike (Jingjie), Scutellaria Root (Huangqin), Talcum (Huashi), Gardenia Fruit (Shanzhi), Licorice Root (Gancao), Cicada Slough (Chantui). Decoct together. Add wine-fried Rhubarb (Dahuang) if constipated.] If fever is slightly milder, head is hot but face is not very hot, palms and soles are hot but backs of hands and feet are not, spirit is fatigued, and bowel/urinary functions are free, it is deficiency-heat. Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction) is appropriate. [Ingredients: Ginseng Radix et Rhizoma (Renshen), Astragalus Root (Huangqi), Atractylodis Macrocephalae Rhizoma (Baizhu), Angelicae Sinensis Radix (Guishen), Bupleurum Root (Chaihu), Cimicifuga Rhizome (Shengma), Szechwan Lovage Rhizome (Chuanxiong), Prepared Licorice Root (Zhigancao), Tangerine Peel (Chenpi). Add Ophiopogon Tuber (Maidong) and Schisandra Berry (Wuweizi) if thirsty.] After scab shedding and restoration, or halfway through shedding, if sudden whole-body high fever occurs, residual toxin is attempting to erupt as a carbuncle. If one or two areas on limbs, neck, chest, or back are intensely hot, those are the sites of carbuncles. This often happens when pustules were insufficient but scabs formed thinly and fell quickly. Urgently use Dalianqiao Yin to reduce heat; add wine-fried Rhubarb if constipated to mildly purge. If heat persists, continue for several doses until heat subsides and body cools, allowing internal resolution of carbuncles. If sudden severe headache at the vertex occurs, residual toxin is attacking upward. This may also result from excessive consumption of warming herbs. If not treated urgently, toxin will invade the eyes, causing severe eye disease. Use Dalianqiao Yin removing Mutong, Cheqianzi, and Huashi, adding Cimicifuga Rhizome (Shengma), Platycodon Root (Jiegeng), Szechwan Lovage Rhizome (Chuanxiong), and Mint (Bohe) for several doses to resolve upward-attacking toxin, thereby avoiding eye complications. If fatigue, reduced appetite, heat in chest/abdomen/head/palms/soles, and irritability/thirst occur after scab shedding, it is internal deficiency. Continue using Buzhong Yiqi Tang. If there is no fever but fatigue, desire to lie down, anorexia, cold extremities, dry mouth/thirst, or white/non-red scars (critical blood deficiency), these are signs of internal deficiency. Buzhong Yiqi Tang is also appropriate; otherwise, other syndromes may arise. Note that abundant smallpox eruption depletes the true qi of the five zang organs and exhausts blood and qi throughout the body during scabbing and restoration. Although residual toxin may remain, righteous qi is extremely deficient. Therefore, when using cooling herbs for detoxification, they must be wine-fried. For weak constitutions, occasionally add Ginseng (Renshen), Astragalus (Huangqi), Angelica (Danggui), and Szechwan Lovage (Chuanxiong) to rescue blood and qi. Do not abruptly administer raw Sanhuang (Three Yellows: Scutellaria, Phellodendron, Gentiana), raw Gardenia (Zhizi), raw Rhubarb (Dahuang), or raw Gypsum (Shigao) just because heat signs exist. At this time, righteous qi is weak; sudden use of harsh cold purgatives often leads to death. Beware! Treaters of smallpox must be cautious at the beginning and the end. There are two unpredictable dangers in smallpox: one is severe toxin, the other is weak constitution. Death within three to five days before eruption is due to strong toxin. Death upon taking wrong medicine or food during scabbing/restoration is due to weak constitution. For strong toxin preventing eruption, guide it out by following its trend without reckless detoxification that blocks flow; thus, previous warnings emphasize caution at the start. For weak constitution, observe deficiency and tonify, avoiding harsh purgatives; this ensures safety. Neglecting caution during scabbing/restoration often leads to errors; thus, warnings emphasize caution at the end.

Xi Taishun said: By the eighth or ninth day, smallpox should have formed dry red scabs. If there is slight irregularity, pustules may only now form. Once pus is full and scabbing proceeds in order, good. If heavy body and fever cause stagnation of pus and difficulty in scabbing, this is hyperactive yang and yin deficiency; use cooling and astringent methods. Full pus with shortness of breath may be due to phlegm obstruction; sudden fright or constipation of small urine may occur. If qi deficiency causes collapse, inverted scabs turning black and scorched appear. One case responds to warming tonification; another to resolving attack. Diarrhea calming indicates great deficiency with little toxin; lung cold causes sticky pus discharge; intestinal toxin causes bloody stool; throat trauma with hoarseness, full pus flow, collapsing itch, teeth grinding, firm stool, and clear voice indicate survivability. Hard scabs with changes, finally no scab shedding like bran, worry about residual toxin attacking; excess may cause difficult-to-manage ulceration. Body heat burning others, blistering with hot pus is fearful; empty shell remaining without scab formation indicates clear pus. Severe heat with abdominal distension, panting, and collapsed scabs all result from toxin attacking internally. Lesions lacking yellow pus/scabs, resembling blood red, if detoxified early, prognosis is excellent. Extinction of stomach qi causes swollen/hard lips; severe liver heat causes staring white eyes. Panting after diarrhea always indicates qi extinction; diarrhea causing irritability/thirst is not excess heat. Persistent diarrhea with unrelenting thirst requires lifting; excessive drinking worsening thirst makes heat hard to save. Qi deficiency with chills, smallpox is safe. Even if warm disease has full pus but hard to collect, firm stool with steaming heat requires clearing/detoxifying with cooling to aid scabbing; use tonification to prevent over-benefiting. Balance is suitable, avoiding regret.

Also said: Smallpox forming scabs means life intent is established, but residual toxin changes are not yet pleasant. Eye closure with abdominal distension steps into crisis; floating deficiency not receding brings disaster. Scab formation followed by loss of voice fears black scabs; swelling not subsided but eyes open first suspects internal attack. Extreme yang causes screaming/panting; intestinal/stomach injury causes restless crying. Wind-cold entering stomach causes dysentery with sticky pus; heat seeping into bladder causes hematuria. Heat-toxin lingering fails to transform; scabbing with high fever and aversion to cold leaves residual toxin in meridians, tidal fever at dusk. Morning onset is excess syndrome: irritability, thirst, red cheeks; afternoon onset is yin deficiency: adjust diet reducing intake. Other signs: lip puckering/tongue playing indicates heart meridian heat; holding belly/lifting chest indicates lung/stomach toxin impact. Burning body heat with constipation fears violent convulsions; lingering tidal fever with loose stools slowly transforms into slow spleen wind tremors. Verify blindness via eye closure/photophobia; distinguish mouth ulcers via scorched lips/black gums. Excess heat sinking downward causes large intestine constipation; deficiency-cold lodging in viscera causes diarrhea. Panting/thirst must differentiate deficiency/excess. Verification must not err. Observing post-scab shedding, re-examine scar root color. Peach-red glossy indicates healthy defensive and nutritive qi; purple-black dry indicates lingering heat-toxin. Powdery white indicates qi/blood deficiency, extending beyond expectation implies death; gum erosion resembling wind movement is ominous, visible after a month as driving force. Whole-body red spots indicate failure to clear/detoxify; whole-body cyanosis fears wind-cold invasion. Residual toxin not eliminated causes intermittent carbuncles/furuncles; early exposure to wind fears recurrence of sores. This is the secret of prior kidney transmission; do not pass it carelessly to unworthy persons.