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Zhao Zhongshulang, aged twenty, contracted smallpox. Zhu [Danxi] examined him on the fourth day. The facial skin was oily and glossy; from the depression of the throat down to Jiwei (CV15) below the chest, it resembled a layer of saliva membrane in infants, presenting as a sheet of red mottling, moist and shiny extending to the front of both axillae, while the neck and abdomen showed distinct, spreading lesions. Zhu said: "This is 'Oily Light Syndrome', indicating a massive leakage of Primordial Yang. The red mottling on the chest resides in the area of Huagai (the Lung), which is a dangerous condition with adverse signs." After medication, by the fifth day, the oily gloss on the face had subsided, and the lesions showed signs of filling with pus. The red mottling on the chest all rose like millet grains, taking on a pus-like color, except for the purple patches on the back which remained. There was a slight coating on the tongue. Other physicians decided to use strong purgatives such as Xiaoshi (Mirabilite) and Dahuang (Rhubarb). Zhu said: "Since the Primordial Yang has already leaked out through the face, we can only heavily use moistening herbs; we must not use Xiaoshi or Dahuang to attack." He prescribed Danggui (Angelica Sinensis Root) five to seven qian, one dose, assisted by Zhiqiao (Aurantii Fructus) and other blood-cooling herbs. During the period of minor filling on days five or six, another physician used Renshen (Ginseng), Huangqi (Astragalus), Rougui (Cinnamon Bark), and Lujiao Jiao (Deer Antler Glue). In the afternoon, the patient became comatose and delirious, his teeth chattering so loudly that it could be heard through the ears, persisting through days seven and eight. Zhu continued using four doses of Da Qingliang (Great Cooling) formula. By the ninth day, the pus seemed to be abundantly formed, and the teeth-chattering symptoms subsided slightly. The patient felt his eye sockets were slightly sunken and his spirit somewhat fatigued. A small amount of Renshen (five fen) was added to the cooling formula to support Yuan Qi (Primordial Qi). His eyes no longer closed completely and tears flowed; his nostrils were no longer blocked and nasal discharge appeared. The face gradually took on an aged appearance, while the red base on the chest formed bags of pus, and similar bags formed on both arms and legs. On the night of the eleventh day, he suddenly experienced extreme thirst, drinking thirteen or fourteen bowls of tea continuously; this was the body's attempt to draw water to save itself. Mild clearing and tonifying methods were used, and by the twelfth day, the symptoms gradually stabilized. Renshen was then removed, and solely blood-nourishing and fire-clearing herbs were used to support him until recovery on the seventeenth or eighteenth day. This person had recently married, so his Yuan Qi was inevitably depleted; thus, slight tonification was included in the cooling formula. On the eighth or ninth day, sudden bleeding occurred at the root of the scrotum, about one cup. Zhu said: "This bleeding can substitute for venting the toxin," and indeed it happened as predicted. If it were a deteriorating case, this blood loss would further deplete Kidney Yuan, making survival impossible.

Zhu Yingwo treated his cousin, aged forty, who suffered from smallpox. On the second day, examination revealed facial edema, white spots forming sheets, and the entire body covered with fine purple spots resembling measles. Zhu said: "The life or death of this case depends on whether the 'biao' (surface indicators) open up. If they open, there is life; if not, it is critical." He urgently prescribed Xijiao Yin (Rhino Horn Drink) combined with blood-breaking and qi-moving herbs, administered in large doses, three times daily. By the fourth day, the Tian Ting (Forehead) and Di Jiao (Chin/Jaw corners) suddenly cleared up like scattered stars, except for the two zygomatic areas which remained unopened. Upon lifting the body to inspect, the areas were also clear, but the purple discoloration was too severe, and the area below the waist was flat and collapsed like moles. Although there was some vitality, the patient was still on the brink of death. Zhu urgently used Dahuang (Rhubarb) to purge, keeping the dosage of Xijiao (Rhino Horn) unchanged from the original prescription. The stool passed was merely loose and not fully cleared. Because the patient had a history of hemoptysis and was constitutionally weak, he could not withstand heavy depletion; therefore, Jiu Shu Dahuang (Wine-processed Rhubarb) was used gently to cleanse. On the fifth day, the purgation was more profuse, resembling millet grains. On the sixth morning, the zygomatic areas suddenly cleared like scattered stars, and the body lesions spread openly. The face showed signs of turning white and producing fluid. By the seventh day, the momentum was full, and pus arrived. Dahuang and Xijiao were stopped, and only blood-cooling and fire-clearing agents were used. However, the chest, back, and arms remained dry, stagnant, purple, and scorched without movement. Zhu urgently administered Xijiao (four to five qian). Suddenly, the lesions on the chest and wrists raised their peaks and released white fluid, with roots resembling pomegranates, bright red and lovely. Zhu said: "By the ninth day, pus will surely arrive." He continued using Xijiao. In the afternoon, pus arrived, and by the tenth day, the entire body was filled with fluid. Soon, on the twelfth day, the crusts formed. There were no hard scabs on the body; instead, ruptured pus was seen. Unruptured ones formed blisters, and ruptured ones exposed red flesh, causing great fear in the patient. Zhu said: "The pus is about seventy to eighty percent complete, and the red roots have all transformed; this is 'waking the pus' for crusting." By the sixteenth or seventeenth day, the forehead developed pox-like scars with renewed pus formation, and the chest also showed this. The originally ruptured areas formed crusts. Pox on the forehead produced maggots on the sixth day, and the broken scrotal sacs also had maggots; the pus was foul-smelling and rotting, indicating slight vitality that could be treated. However, the Spleen and Stomach were weak, and mouth/tongue ulcers indicated residual toxins not yet cleared. Until the nineteenth day, only cooling herbs were used to support the patient. Initially, this case was judged as abnormal blood heat, and tonification was contraindicated. However, the patient was usually weak, suggesting otherwise. Subsequent use of cooling herbs brought peace, but stopping Xijiao caused high fever. On the third day, he went mad; Niuhuang (Calculus Bovis) and Hupo (Amber) calmed him. Stopping Xijiao on the sixth day caused unrest. Reusing Xijiao heavily on the seventh/eighth day restored calm. Taking Shaoyao (Peony) and Baizhu (Atractylodes) lightly on the seventeenth/eighteenth day caused unrest again. Moreover, from the waist down to the shins, the color remained purple-dark on days seventeen/eighteen, and the skin of the filled pustules had wrinkles and folds. This smallpox was difficult to treat to this extent. In major dangerous cases, it is unheard of to fill with pus when the eyes do not close and the nose does not seal. Before the ninth day, the eyes were closed for only one day, and the nose did not seal. How could he fill with eighty percent pus? Ultimately, he did not form crusts but woke the pus which ruptured; the eyes re-closed slightly, and the nose sealed significantly. On the night of the eighteenth day, due to anger, he had slight epistaxis on the nineteenth day; this was negligence in care. He defecated six or seven times day and night, spirit was unrefreshed, food intake decreased, and urination occurred seven or eight times per night. Reluctantly, Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) was given, with Renshen (Ginseng) up to several qian, to restore vitality. Using tonification after clearing is the correct method. After passing the twenty-day mark, he desired food slightly. After Chen hour (7-9 AM), stool was soft strips; after Wu hour (1-3 PM), food intake increased slightly. Zhu urgently removed Shengma (Cimicifuga) and Chaihu (Bupleurum) from Buzhong Yiqi Tang, combined it with Bazhen (Eight Treasures) ingredients, kept Huanglian (Coptis) unchanged, and reduced Renshen to three or four fen to nourish blood, preventing Qi from floating and transforming into fire; this is the subtle principle of balancing Yin and Yang. Due to fatigue lying down from the seventh/eighth day, unable to extend, and knees/feet too weak to walk, before being helped up, he suddenly felt able to sit and move, demonstrating the efficacy of guiding herbs. On the night of the twenty-fourth day, he first had chills, then fever, resembling malaria, for four nights, intermittent. Since the smallpox erupted in June, it inevitably involved damp-heat from summer heat. On the afternoon of the fifth day, sweat flowed to the abdomen. Zhu said: "Summer heat is resolved; there will be no fever tonight." Indeed. Actually, over these few days, Xiaochaihu Tang (Minor Bupleurum Decoction) plus Renshen, Tiandong (Asparagus Root), Zhimu (Anemarrhena), Wuweizi (Schisandra), occasionally Xiangru (Elsholtzia), allowed him to recover.

Commentary: This smallpox appeared on the second day of the sixth lunar month. By mid-July, I traveled south, instructing: "The original smallpox was very critical. At this time, thigh muscles are wasted, food intake is low, and Yuan Qi has not recovered. One must rest and nourish for over a year to sleep peacefully." After fifty days apart, returning home in early September, I exclaimed in shock: "Why has my brother wasted away to this state?" I urgently left the bedroom to prepare medicine and food, hoping to prolong life. Alas, I traveled far again. The patient did not relax household duties nor put down books. Suddenly, he died in the middle of the night. Generally, when smallpox reaches a critical danger, poor care afterwards leads to failure to survive. After recovery, having sexual intercourse within one hundred days—how could one avoid bedchamber matters? Thus, the hurdle of one hundred and twenty days could not be escaped. (Original commentary.)

Zhu Yingwo treated a woman surnamed Zheng. The initial spots on the face were not dense, with only a small red patch under the chin. By the fourth day, the face was soft and flaccid, the body covered with Dan (erysipelas/mottling) containing tiny points. Zhu said: "This Dan cannot recede; later it will pour out clear fluid, and definitely peel externally. Although doctors used Renshen and Huangqi, the face did not turn white. From the chin to the body, the skin rolled and ruptured throughout. She died on the ninth day. This was the most cruel type of Dan syndrome."

A son of a fellow student, aged thirty-something, had smallpox. One physician examined the surface indicators and deemed it extremely smooth, requiring no medication. A family physician considered it very dangerous. The master believed the first physician and not the family doctor. After five days of treatment, Zhu was consulted. Examination showed no distinction between root and peak on the face, no distinction between lesion bases, a pale white color, and oily gloss. Furthermore, the mouth was open and unclosable, lips did not cover teeth; this was a critical condition. The basis for judgment was that facial spots were sparse and countable, few on the chest, and sparse on the neck. Inspecting limbs, amidst clusters were Dan patches. Dan on the anterior aspect of both arms extended from Qugu (SP12) up and down, about 3-4 cun long, 1 cun wide. Dan on the anterior aspect of both thighs started from the gluteal crease down to the calf, about 2 chi long. The back resembled a thoroughly red felt strip. Fortunately, the posterior aspects of arms and thighs still had spots, though not dense. Regarding color: face pale white, neck/chest spots white, roots not red. Inside the Dan, fine points piled like millet; outside the Dan, a sheet of purple ground. Even spots on the posterior aspect had a purple halo around each point. Carefully observing this shape and color, one might wish to die. However, the mistress was a relative of Zhu, and strongly detained him. Two or three days prior, the patient had small blood blisters on the tongue, which flattened after sucking. Inquiry revealed constipation for several days, and the whole body was purple. Temporarily using Dahuang to purge two or three times, followed by Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) combined with Huangqin (Scutellaria) and Huanglian (Coptis), yielded immediate results. By the ninth day, pus arrived on the face, neck, and chest, and was visible on the back and limbs, with Dan areas looking like white water. The master became even more convinced it was a smooth case. On the eleventh day, pus in Dan areas formed bags, suddenly ruptured and flowed, shedding the skin. The face and chest formed thick crusts. That day, porridge induced vomiting of phlegm and water; food intake was low and difficult. Zhu and the family doctor discussed a Spleen-supporting formula. The patient planned to drink milk, hiring a wet nurse and a female attendant, mimicking infant sucking. The master thought this a wonderful technique. At sunset, he muttered deliriously for a sentence or two; worse at midnight. Urine contained blood drops. On the twelfth morning, he was comatose and delirious but responsive to questioning, though spirit was exhausted. Due to constipation, hoping bowel movement might stop delirium, honey suppositories failed. Heavy Danggui was added to the Spleen-tonifying formula, resulting in slight loose stool and bloody stool, frightening the master. Zhu was away, unaware why urine contained blood. Detailed inquiry revealed the patient loved lust. A friend slept with him. Before sucking milk, the patient said, "It feels good, but I fear semen loss." When the mistress visited, she ordered a maid to serve at the foot of the bed. The friend sat separately, peeking through a wall gap. Seeing the mistress leave, the patient asked who it was. The maid answered. He pushed aside the covers and embraced the maid with both hands. Thus, during the young woman's milk-sucking, he likely had thoughts, and essence transformed into blood, hence the situation. Thinking carefully: porridge induced vomiting, little food entered, honey suppositories failed, moistening herbs were useless. This is Guan Ge (Obstruction and Regurgitation) in smallpox; Qi and Blood circulation has ceased, how can success be expected? Blood heat causes Dan; Dan beauty causes peeling. This severe peeling is rare. Usually, as facial swelling recedes, eyes open. Here, washing eyes opened them, but upper eyelids drooped and tightly closed. Looking at the black pupil, it seemed bright yet dim; this is also a sign of Spirit departing. The patient drank pre-rain fine tea incessantly, ignoring prohibitions. Later vomiting porridge was likely due to tea. After parting, I heard his tongue was short for two days, critically ill. Then he gradually resumed eating. The family doctor continued cooling agents. By the eighteenth day, appetite increased greatly, suggesting gradual recovery. Reflecting on this case: few spots on face, neck, chest; even inside arms/thighs, there were spots. Back like red felt; outside arms/thighs, seamless Dan. Never have I seen such disparity in density between Yin and Yang aspects. Internal symptoms: vomiting/regurgitation above, obstruction/blood loss below, coma, short tongue. External peeling was severe. This is a case where death outweighs life; survival is a miracle. Reflecting on survival: finally, the face was sparse with pus. Even with limbs and back so severely affected, preservation occurred near death. Ancients said smallpox relies entirely on the front; truly so. By the nineteenth day, I heard his left eye flowed with pus, eyeball protruding. If the right eye was blocked, it would fail. Generally, external peeling does not lead to internal attack; internal attack is rare. Survival in this case was one in a thousand or two.

Zhu Danxi treated a man, aged twenty-three. Smallpox had erupted for six days. Tongue was covered in black; a black ding (carbuncle) was inside the tip of the tongue, size of a round eye kernel. Facial spots were clear, body distribution even, foot color not yet purple-dark. Zhu urgently ground 2-3 qian of raw Xijiao (Rhino Horn), added to Huanglian Jiedu Tang (Coptis Detoxification Decoction), plus Shigao (Gypsum), Zhuye (Bamboo Leaf), Dengxincao (Juncus Effusus). Large doses, three times daily. Blackness on tongue completely receded, ding disappeared and flattened, tongue became red and moist as normal, diet improved. By the eighth day, front face pus was 50-60%, chest/back pus arrived. Zhu returned due to a relative's urgent smallpox case, leaving the patient to another doctor. On the night of the twelfth day, restlessness and muttering began. By the thirteenth day, urinary and fecal incontinence suddenly appeared. On the fourteenth day, Zhu was summoned again. Examination showed inverted crusts, fragmented like furnace ash gray, lying stiffly like a corpse, speaking to himself, hands scattering, chest/back pus clear, wrists to arms soft and spiritless, lesions denser than before. Swollen legs and thin arms made lesions appear dense because they fell. Zhu refused to treat. Later, I heard the other doctor, seeing incontinence, gave 3 qian of Renshen; seeing delirium, gave 3 qian of Xijiao. This doctor was frantic, unknown to the master. The patient died on the sixteenth day. Although this was medical incompetence, it was actually a Ding-type smallpox, never so cruel before. Thus, deep latent poison, one medical error, can cost a life.

Zhu Danxi treated an old man, feverish and drowsy, pulse large and seemingly rapid. He prescribed Renshen, Huangqi, Danggui, Baizhu, Chenpi. Large doses for twenty doses, then smallpox erupted. Another twenty doses, pustules formed, no intact skin on body. Another sixty doses, he recovered.