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Thirst is caused by toxic heat attacking and rushing, leading to stomach fire flaring upward, resulting in severe thirst in the mouth. Internal ulceration refers to the rotting of the epigastrium, piercing through the chest and back leading to death; there is no tragedy more cruel than this. Various medical texts attribute this to external invasion of wind-cold, with tight pores (skin and hair follicles) causing blockage and obstruction. Yang Qi carries the toxic fire inward, attacking and causing ulceration. If there is no severe thirst but symptoms of aversion to cold are present, Shengma Gegen Tang (Ephedra Root and Pueraria Decoction) added with Qianghuo (Notopterygii Rhizoma et Radix), Fangfeng (Saposhnikoviae Radix), Chuanxiong (Ligustici Chuanxiong Rhizoma), and Baizhi (Angelicae Dahuricae Radix) should be used to disperse wind-cold. If thirst is observed, one must not shrink back out of fear of dispersing; merely using herbs like Maidong (Ophiopogonis Tuber) and Wuweizi (Schisandrae Fructus) to stop thirst would be like a cup of water trying to extinguish a bonfire on a cartload of firewood—how could it suffice? For mild thirst, Liuyi San (Six-One Powder); for severe thirst, a large dose of Baihu Tang (White Tiger Decoction). If accompanied by constipation, use one dose of Liangge San (Cooling the Diaphragm Powder) to ensure the thirst stops, thereby avoiding major disaster. How can one sit idly by and watch people die? If thirst after the eruption of smallpox is not severe, Baoyuan Tang (Preserve the Origin Decoction) added with Maidong, Wuweizi, and Tianfen (Tianhua Fen/Trichosanthis Radix), or Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder) may be used. White tongue and mouth, with gray pustules on the chest, are precursors indicating internal ulceration.

Heat in the Heart Meridian causes irritability. This is because the heat of the smallpox toxin accumulates in the heart, leading to irritability, crying out, mental confusion, and delirious speech. Jiedu Tang (Detoxification Decoction) and Chencha Liuyi San (Cinnabar Six-One Powder) should be used to promote clear urination and defecation, allowing the fire to dissipate naturally. For irritability caused by pain and itching, treat according to the syndrome. Irritability after the resolution of smallpox indicates deficiency with residual toxins; the primary treatment is to greatly tonify Qi and Blood, while simultaneously resolving residual toxins.

This syndrome arises from heat-toxin blockage impairing Metal (Lungs), or wind-pathogen entering due to deficiency. Treatment involves detoxification or dispersion, temporarily adding herbs to stop coughing and clear phlegm, such as Sangbai Pi (Morus Alba Bark), Xingren (Prunus Armeniaca Seed), Zhike (Aurantii Fructus Immaturus), Jiegeng (Platycodon Root), Qianhu (Peucedani Radix), Beimu (Fritillariae Bulbus), Chenpi (Citri Reticulatae Pericarpium), and Fuling (Poria). Banxia (Pinelliae Rhizoma) and Nanting (Arisaematis Rhizoma Preparatum) are contraindicated. If medication induces immediate coughing and vomiting upon entry, it indicates heat-toxin stagnating in the Lungs and Stomach; treat according to the syndrome.

Maculae (spots) are the remnants of blood. They appear as dots without heads, granular like ink drops or insect bites. However, pustules emerge following the organs, moving rapidly. If heat-toxin is excessive, surplus blood in the pustules mixes with toxin floating upward, erupting as maculae driven by the heat of the smallpox toxin. Once the pustules have fully risen, the interior must be deficient. Interior deficiency allows maculae to resolve internally; if they do not resolve, the fire-pathogen should be dispersed. Herbs for cooling blood, invigorating blood, and detoxifying include Xuanshen Shengma Tang (Scrophularia and Cimicifugae Decoction) added with Huangqin (Scutellariae Radix), Huanglian (Coptidis Rhizoma), Honghua (Carthami Flos - stir-fried with wine), Danpi (Moutan Cortex), Jingjie (Schizonepetae Spica), Danggui (Angelicae Sinensis Radix), Chuanxiong, and Baishao (Paeoniae Radix Alba). In the early stage, exterior dispersion is appropriate; subsequently, resolution and benefit are needed. If the maculae recede and blood returns to normal, tonification should be applied, while guarding against collapse and sinking. However, smallpox complicated by maculae is a critical and ominous sign; only one or two out of ten may survive. Purple maculae lead to death within three days; green or black maculae within an hour; maculae resembling brocade patterns lead to death in six days.