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There are children in the world who are born with a robust and obese physique, seemingly indicating an abundance of blood and qi. Why do they suffer from smallpox, where the pustules remain empty, fail to fill with pus, and result in death on the eighth or ninth day? This is because the innate Yuan Qi (vital energy) cannot be constrained by physical form, nor can blood and qi be determined solely by constitution. Those who are physically thin but have abundant Yuan Qi will naturally see their smallpox erupt, fill, and heal successfully. Conversely, those who are physically large but have weak and inferior Yuan Qi will find their smallpox dry, astringent, and difficult to grow. Therefore, treating smallpox requires assessing the patient's Yuan Qi; one must not speculate based on physical appearance. Moreover, smallpox varies in meridian pathways and locations, number and size, seasonal influences, and the efficacy of care and nurturing. How can it be judged merely by physique! Thus, if the smallpox follows correct meridians, presents with sparse and clear lesions, aligns with favorable seasonal rhythms, and receives appropriate care, even if the toxin is originally shallow, a thin person with solid Yuan Qi will certainly not be harmed. Even a thin person with weak Yuan Qi may survive. However, if the smallpox invades incorrect meridians, presents with dense spots, occurs during adverse seasons, involves improper management, and carries a strong toxic constitution, then an obese person with deficient blood and qi will surely suffer misfortune. Even an obese person with abundant blood and qi may die. Furthermore, lean and dark-skinned individuals have firm bones and hard muscles, with qi secured internally and bone surpassing muscle; they tend to have auspicious outcomes with smallpox. Fat and fair-skinned individuals have fragile bones and loose muscles, with qi floating externally and muscle surpassing bone; they tend to have ominous outcomes with smallpox. This is because the Kidneys govern bones, and smallpox is considered a toxin of the Kidneys.

One who does not understand deficiency and excess cannot be a competent physician. The Classics state: Do not reinforce excess, and do not deplete deficiency. Therefore, the distinction between deficiency and excess must be clearly understood. The Classics state: First, measure the fatness or leanness of the body to regulate the deficiency or excess of qi. This distinguishes deficiency and excess through physical form. It also states: Abundant food intake leads to abundant qi; deficient food intake leads to deficient qi. This distinguishes deficiency and excess through diet. It further states: A surging pulse indicates abundant blood; a weak pulse indicates deficient blood. This distinguishes deficiency and excess through pulse diagnosis. It also states: When pathogenic factors are abundant, it manifests as excess; when essential qi is depleted, it manifests as deficiency. This distinguishes deficiency and excess through the relationship between pathogens and healthy qi. Generally, excess refers to the abundance of pathogenic factors, while deficiency refers to the insufficiency of healthy qi. The Classics state: Wherever pathogenic factors gather, healthy qi must be deficient. If they remain and do not depart, the disease manifests as excess. It is also said: Death from the five excess conditions results from the abundance of pathogenic factors. Death from the five deficiency conditions results from the insufficiency of healthy qi. In cases of smallpox, if the patient has a robust and healthy physique, good appetite, surging and forceful pulses across all six positions, no prior illnesses, normal bowel movements, and red, lustrous lesions, this indicates that both exterior and interior healthy qi are solid; medication is unnecessary. If the patient is emaciated, frequently ill, has reduced appetite, weak and faint pulses across all six positions, frequent vomiting and diarrhea, and pale, tender lesions, this indicates that both exterior and interior healthy qi are deficient; treatment should employ warming and tonifying methods. If the lesion progression is too vigorous, with severe swelling, pain, distension, persistent high fever, restlessness, thirst, drowsiness, and constipation of urine and stool, this indicates that both exterior and interior pathogenic factors are excessive; treatment should employ cooling and purgative methods. If the lesions are originally dense, red, and vibrant, yet accompanied by vomiting, diarrhea, and inability to eat, this indicates exterior excess and interior deficiency; detoxifying herbs should be added to tonic decoctions. If the lesions are pale white, fail to fully erupt, accompanied by constipation of urine and stool, yet the patient drinks heavily and eats voraciously, this indicates interior excess and exterior deficiency; ascending and diffusing herbs should be added to exterior-resolving and promoting formulas. Generally, pain indicates excess; however, pain from sores is due to excess pathogenic factors, requiring blood-invigorating methods to resolve stagnation. But if the pain is like knife-cutting, accompanied by mental confusion and loud crying, do not treat. Generally, itching indicates deficiency; however, itching from sores is due to deficient healthy qi, requiring qi-tonifying methods to dry dampness. But if scratching is incessant, with skin breakdown and peeling, do not treat. Grayish-white color indicates qi deficiency; Ren Shen (Ginseng Radix et Rhizoma) is most effective. Dryness indicates blood deficiency; Dang Gui (Angelicae Sinensis Radix) and Chuan Xiong (Ligusticum Chuanxiong Rhizoma) are most suitable. Deficiency is treated by tonification, excess by purgation; cease treatment once the illness is addressed, without exceeding the prescribed limits; this is the balance of treatment. If one tonifies when there is actual excess, it is an error of over-tonification. If one purges when there is actual deficiency, healthy qi becomes further depleted, potentially leading to vomiting, diarrhea, or cold extremities and reversal; these are errors of over-purgation. The Classics state: Do not aid the pathogen, do not lose the healthy qi, thereby cutting short human life—this is what is meant!