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(When the pustules) subside, if there is obstruction in the Middle Jiao (Middle Burner), belching with a sour and putrid odor, abdominal fullness and distension, and slow or unsmooth eruption of the pox, this is an Excess condition in the Interior. It is urgent to employ methods of digestion and promotion to allow the Qi mechanism to be open and smooth. The general principles for treating various syndromes listed above can be extrapolated to cover other situations.

Nie Jiwu stated: Three days after the initial appearance of smallpox, when the lesions have fully erupted, if the body temperature is moderate, the spirit is clear, the individual pustules are pointed, round, lustrous, with red and vibrant roots, sparse distribution on the chest and back, normal appetite, and unobstructed urination and defecation, this is a favorable prognosis (Shun Hou). Medication is not necessary; one should merely regulate diet, avoid wind and cold, and prevent foul odors. The three days following the complete eruption of the pox are critically important, and the color, shape, and symptoms require careful observation. Good pox rely entirely on being filled with pus; at minimum, they must have 60-70% pus content to ensure safety. Once the pox have fully erupted, their color and shape are obvious, and whether pus will form and whether it will be sufficient can be predicted. Except for the aforementioned favorable cases where pus naturally fills adequately—requiring no medication—if the course is unfavorable, there will likely be no pus later, or the pus will be scanty and thin. Within these three days, one must observe the color and shape, differentiate between Cold, Heat, Excess, and Deficiency, and administer medication to promote pus formation; this is still timely. If treatment is delayed beyond this period, many cases become untreatable and fail to form pus. The life or death of the pox depends on the presence or absence of pus: with pus, the toxin disperses outward, leading to survival; without pus, the toxin remains internal and attacks the organs, leading to death. Therefore, cases where pus is fully formed and the scab is thick are superior; those where pus is incomplete but the scab is thin are secondary. Inferior cases present with water-filled vesicles all over the body; however, if 70-80% are water-filled and 20-30% contain pus, survival is still possible. The worst cases are those where lesions are dense and merge into a single mass; even if there is pus under the skin or the dense lesions ulcerate with wet discharge, there is a slight hope for survival. Only cases that are dry, devoid of pus, or have very thin pus (less than 20-30%) will inevitably die from itching and collapse, with no hope of recovery. Thus, treating and promoting pus formation after complete eruption is as urgent as rescuing someone from drowning or putting out a fire. When Qi and Blood flow smoothly, toxins transform into pus. Failure to form pus has two causes: excessive Fire-Toxin causes blood to dry and coagulate, preventing transformation into pus; weak Yuan Qi causes blood to become cold and contract, also preventing transformation into pus. Therefore, pox that are red-purple, dry, or scorched-black indicate excessive Fire-Toxin and blood coagulation, which will not form pus. It is urgent to use Qing Du Huo Xue Tang (Clear Toxin and Invigorate Blood Decoction). (Treats Zi Xian/Purple Depression; the pox will turn around after one or two doses. During the pus-filling stage, if there is constipation for six to seven days, this formula is also used. During the swelling stage, add Dang Gui (Angelicae Sinensis Radix), Zicao Rong (Arnebiae Radix et Rhizoma), Qian Hu (Peucedani Radix), Niubangzi (Arctii Fructus), Mutong (Akebiae Caulis), Sheng Di Huang (Rehmanniae Radix), Sheng Bai Shao (Paeoniae Radix Alba), Lian Qiao (Forsythiae Fructus), Jie Geng (Platycodonis Radix), Huang Lian (Coptidis Rhizoma), Huang Qin (Scutellariae Radix), Gan Cao (Glycyrrhizae Radix et Rhizoma), Zha Rou (Crataegi Fructus), Ren Shen (Ginseng Radix et Rhizoma), and Sheng Huang Qi (Astragali Radix); decoct and take. For patients with irritability and thirst, remove Ren Shen and add Mai Dong (Ophiopogonis Radix) and Tian Hua Fen (Trichosanthis Radix).) Pox that are pale white, not pointed or round, and lack red halos at the roots indicate Qi deficiency and blood contraction, which will not form pus. It is urgent to use Shen Gui Lu Rong Tang (Ginseng, Angelica, and Deer Antler Decoction). (Treats Bai Xian/White Depression and Hui Xian/Grey Depression; for pox that are not smooth, with Qi deficiency and thin pus, or where pus formation takes two to three days without filling, this formula can be used to support the pox. Use Lu Rong (Cervi Cornu Pantotrichum) prepared with honey, Nen Mian Huang Qi (Astragali Radix), Dang Gui Shen (Angelicae Sinensis Radix), Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma), Ren Shen (Ginseng Radix et Rhizoma), and three Long Yan Rou (Longan Aril); decoct together and take warm with a cup of good wine. For children who can drink alcohol, decoct the medicine strongly and mix half with wine. For mild weakness, one or two doses will turn the pox red and active. For fatigue, cold extremities, and poor appetite, add Mu Xiang (Aucklandiae Radix), Ding Xiang (Caryophylli Flos), and Guan Gui (Cinnamomi Cortex). For chills and teeth grinding, further add Guan Gui and Fu Zi (Aconiti Lateralis Radix Praeparata). For diarrhea, remove Dang Gui and add flour-fried Bai Zhu (Atractylodis Macrocephalae Rhizoma), wine-fried Bai Shao (Paeoniae Radix Alba), Bai Fu Ling (Poria), Mu Xiang, Ding Xiang, and Guan Gui; additionally use Shen Zhu San (Ginseng and Atractylodes Powder) to stop diarrhea. This is the best formula for supporting pus formation because Lu Rong has strong blood-nourishing power, different from herbal tonics. However, since Lu Rong may be unavailable, Qian Jin Nei Tuo San (Thousand Gold Internal Support Powder) is recorded as an alternative: double the dose of Ren Shen, Dang Gui Shen, Mi Zhi Huang Qi, Bai Shao, Chuan Xiong (Chuanxiong Rhizoma), Guan Gui, Zhi Cao (Prepared Licorice), Shan Zha Rou (Crataegi Fructus), Nan Mu Xiang (Costi Radix), Fang Feng (Saposhnikoviae Radix), Bai Zhi (Angelicae Dahuricae Radix), Hou Po (Magnoliae Officinalis Cortex), and three Long Yan Rou; decoct together and take with good wine. Dosage adjustments follow the same method as above. Some use human milk to mix with the medicine; while this aligns with the principle of promoting pus, human milk is cooling in nature and is contraindicated for those with weak Spleen-Stomach and loose stools, especially those with diarrhea.) If treatment is neglected after complete eruption, the fluid will not circulate, leading to the Five Depressions (Wu Xian). The Five Depressions are: White Depression, Grey Depression, Purple Depression, Black Depression, and Blood Depression. Dense, red-purple pox with depressed tops are called Purple Depression. Severe cases turn into Black Depression. This is caused by excessive Heat-Toxin obstructing Qi and coagulating Blood, leading to depression. Treat with Qing Du Huo Xue Tang, using the same modification principles. At the stage of Purple Depression, one or two doses will rapidly raise the pox with miraculous effect; however, once it becomes Black Depression, the toxin has penetrated deeply, and even with this formula, eight or nine out of ten cases will not survive. Dense pox that are pale white, lack red halos at the roots, and have depressed tops are called White Depression. Severe cases turn into Grey Depression. This is due to Qi and Blood deficiency and Cold, failing to transform toxins into fluid, causing depression. Treat with Shen Gui Lu Rong Tang or Qian Jin Nei Tuo San, with similar modifications. Another type of pox presents with red heads turning into blood blisters without forming fluid; this is Qi deficiency failing to control Blood, causing Blood to overflow and occupy the Qi position. Treat with Shen Qi Tang (Ginseng and Astragalus Decoction) to greatly tonify Qi. (Ren Shen, Zhi Huang Qi, Zhi Gan Cao, Guan Gui decocted and taken warm; taking this will turn the pox white and form fluid.) If Blood Depression is untreated, Qi becomes increasingly deficient. Treatment remains the same. Blood Depression resembles Purple Depression but is pale rather than purple. Purple Depression belongs to Heat, with coarse breathing and fever; Blood Depression belongs to Deficiency, with shortness of breath and cool body. These must be distinguished clearly. He Xiqiu’s discussion on the Five Depressions is vague and unclear; Guan Xiang’s commentary is particularly erroneous and detestable. Two to three days after complete eruption, if Heat-Toxin transforms into pus, gradually filling the lesions, with smooth, moist tops, moderate body temperature, ability to eat, clear urine, and bowel movements every two to three days, this is a favorable prognosis. No medication is needed; simply regulate diet, protect against wind and cold, and avoid foul odors.

For cases involving the Five Depressions, see treatments above. For cases where the top is not depressed but the pox are not smooth, or Qi deficiency results in less than 30-40% fluid, or fluid is thin and clear, or pus formation takes two to three days without filling, it will be difficult to form scabs. Use Shen Gui Lu Rong Tang to promote adequate fluid formation. (Without proper roots, fluid cannot fill; insufficient fluid prevents scabbing; focus on observing fluid at this stage.)

Shao Shi stated: Three days after eruption, the pox should gradually swell. Red, expanded roots and bright, lustrous tops indicate survival. If, during swelling, the entire body and scalp depress, with eyes like needle holes that are purple-black, it indicates death. If, during swelling, the waist and abdomen hurt intermittently, roots resemble mosquito bites with no improvement, it indicates death. If the top is depressed during swelling, tonifying Qi and Blood medicines can save the patient. If thirst persists during swelling, Tui Huo Hui Sheng Dan (Fire-Reducing Life-Restoring Pill) can save the patient. If the pox turn black and depressed during swelling, accompanied by stifling restlessness, coma, and rapid breathing, it indicates death. If hematuria occurs during swelling, with purple, dry, and non-elevating tops, it indicates death. If both hematochezia and hematuria occur during swelling, with prolonged diarrhea, Qi exhaustion, and withered pox, it indicates death. If abdominal distension and inability to eat occur during swelling, it indicates death. (If food intake is slightly maintained, quickly treat with anti-distension medicines.) If a pox starts as a small dot and grows to the size of a mung bean, it indicates the stage after swelling, preparing for pus formation; "swelling" is the time just before pus filling. When swelling and pus filling occur, the pox enlarge, narrowing the airway, causing sore throat, which heals spontaneously. If the color is like white liquid during swelling, it indicates death. (Do not treat this as Cold-Deficiency; it is due to excessive Toxin and Qi stagnation.) If, during swelling, six or seven fine grains form clumps, with one flat, wide, and tilted grain among them, it indicates death. If a pore appears on the pox during swelling, neither black nor white, called "Moth-Eaten Pox," it is due to loose interstices leaking Yuan Qi; neglect leads to凶险 (danger). (Use Bao Yuan Tang plus Ding Xiang and Rou Gui; the pore will close, and the pox will rise.)

Xi Taishun stated: After five or six days, blood packets form the pox, which should be large and coarse. The top should be bright and white, so red roots and white tops indicate the trend of fluid circulation. If the redness is excessive, appearing charming but remaining empty shells after six days, with thin, shiny skin like a lamp containing water, and a pointed top with non-red roots, fluid circulation is insubstantial. Thus, unresolved Heat-Toxin leads to Purple or Black colors; blocked pox lead to Depression or Collapse; dull luster leads to Dryness or Withering, Green or Grey colors; weak form leads to slow progression or stagnant fluid. If flesh swells first but pox do not rise, fluid stagnates; if the face is puffy but pox recede, Toxin is blocked. Therefore, distinguish medications based on Excess/Deficiency and Cold/Heat, Exterior/Interior and Severity. Tonification and Purging, Warming and Cooling should facilitate Qi-Blood intersection. Abundant Qi makes the top round; adherent Blood secures the root. With a round top and secure root, success is achieved. During the Qi-Blood intersection phase, if the head is pointed, skin thin and shiny like a lamp, with no red halo, it will later result in thin skin and clear fluid. By day eight or nine, itching will occur; teeth grinding and scratching without pus will lead to death by day twelve. If the top is depressed and does not rise, with a prickly heat appearance and purple, scattered, collapsed roots, Qi and Blood are stagnated by Fire-Toxin, lacking luster. Internal signs include thirst, delirium, teeth grinding, chills, and obvious external Excess-Heat. Treatment requires cooling and detoxifying,酌情 (judiciously) purging, using strong Heart-cooling and Blood-breaking agents continuously to clarify Qi and Blood, providing a path to life. For cases with grey-white, weak forms, texts state grey-white indicates Deficiency. One must carefully examine external signs: blue-pale face, emaciation, loose stools, vomiting milk. Tonification is primary, using large doses of Ren Shen, Huang Qi, Mu Xiang, Ding Xiang, and Rou Gui to salvage one in ten. All above conditions must clearly distinguish Excess/Deficiency and Cold/Heat before administering medicine; otherwise, fake pearls may pass for real ones, and inferior stones may be mistaken for jade.