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Appendix: Conditions after the scabbing of smallpox.

Xu Zhongguang stated: In one case, after the pustules were full of fluid, the scabs suddenly turned purple-black. This was caused by exposure to foul and turbid qi. It was treated with Shiquan Dabu Tang (Decoction for Ten-Absentee Tonification) plus Muxiang (Aucklandiae Radix), resulting in a cure.
In another case, during the scabbing phase, the scabs were thick, dry, and black, accompanied by fever and cough. This was due to wind-cold invading the lungs. It was cured with Mahuang Tang (Ephedra Decoction) inducing slight sweating.
In a third case, the scabs were thin like bran, adhering to the skin without falling off, accompanied by lethargy and internal heat. This was due to spleen deficiency and blood insufficiency. It was treated with Tiaopi Yangrong Tang (Spleen-Regulating and Nutritive-Vessel-Nourishing Decoction).
In a fourth case, the scabs were dry, black, and adhering to the skin, with fever, irritability, thirst, and restless sleep. Someone treated it as Qi and Blood deficiency with heavy tonification. On the forty-seventh day, the patient died in a state of emaciation.
In a fifth case, presenting similarly, treatment with Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) plus Lianqiao (Forsythiae Fructus) and Niubangzi (Arctii Fructus) gradually reduced the fire, causing all pustules to flatten, scabs to fall off, and recovery to ensue. This was due to excessive toxic fire. As the classics state, "When fire is excessive, water dries up," which applies here.
In a sixth case, the scabs were thick, dry, black, and adhering, with fever, irritability, thirst, delirium, and restless sleep. This was Yin deficiency with hyperactive fire. It was treated with Siwu Tang (Four Substances Decoction) combined with Shengmai San (Generate the Pulse Powder) plus Suanzaoren (Ziziphi Spinosae Semen).
In a seventh case, the pustular fluid was clear, and the scabs were thin like bran. This indicated insufficient righteous Qi failing to resolve the toxin completely. It was treated with Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Shanyao (Dioscoreae Rhizoma). The patient recovered when abscesses formed and suppurated at both Quchi (LI11) acupoints.
In an eighth case, the scabs were pale white like bran, with loose stools and poor appetite. This was deficiency of Middle Qi. It was cured with Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder) plus Roudoukou (Myristicae Semen) and Chencangmi (aged rice).
A nine-year-old child presented with uniform, protruding smallpox. By the ninth day, the pustules were full, but the child could eat yet had loose stools. Relying on the favorable course, the family overfed the child, leading to abdominal distension and pain, stagnation of pustular fluid, and dull color. After using digestive herbs, bowel movements normalized, and the child felt comfortable. However, the pustules did not mature because although the food was digested, the righteous Qi was injured. Treatment should have been to regulate the spleen and tonify Qi to assist in fluid generation and scab formation. Ignoring this advice, by the fourteenth day, the condition deteriorated into inverted scabbing (reversion), with fluid turning back to water. Only then was Qi-tonifying therapy attempted, but it was ineffective; the child died of wheezing and distension.
In a case where, on the tenth or eleventh day, the head and face were about to scab but the pus/fluid was insufficient, it was due to Qi deficiency failing to push the toxin outward. Urgent treatment with Muxiang San (Aucklandia Powder) plus Huangqi (Astragali Radix) and Chantui (Cicadae Perioaterium) resulted in a cure.
In a case on the twelfth or thirteenth day, the upper body had scabbed, but the lower body remained grayish-white and unfull, with a warm head and cold feet. Treatment with Muxiang San plus Fuzi (Aconiti Lateralis Radix Praeparata) decocted with wine led to recovery.
In a case on the fourteenth or fifteenth day, the whole body had scabbed fully, except the soles of the feet which were not scorched, accompanied by chills and teeth grinding. Treatment with Shiquan Dabu Tang plus Fuzi resulted in a cure.
In a case on the fifteenth or sixteenth day, despite sufficient pustules, scabbing failed to occur, accompanied by chills and teeth grinding. This indicated insufficiency, treated with warming and tonifying methods.
In a case where the pustule tops were prominent and bases spread, indicating excess Yang-fire and intense stomach heat, one dose of Baihu Tang (White Tiger Decoction) resulted in a cure.
In a case where all scabs had fallen off, a single pustule on the forehead ulcerated and failed to heal. After twenty-eight days (four cycles of seven days), it became itchy, ruptured with foul pus, and the patient died with hoarseness and mental confusion.
In another case where all scabs had fallen off, a single pustule on the head failed to heal. On the twenty-eighth day, severe itching occurred, discharging maggots amounting to a cupful. The patient also died with hoarseness and mental confusion.
Wan Mizhai treated the eldest daughter of the Hu family, who had dense smallpox that failed to scab after the pus stage. She usually had spleen deficiency and poor appetite, and refused decoctions. Wan prescribed Yigong San (Yi-Gong's Powder) from Qian's school plus Muxiang and Qingpi (Citri Reticulatae Pericarpium), made into honey pills, taken with rice water. She recovered through regulation.
The son of the Hu family had dense smallpox that failed to scab after pus formation, gradually ulcerating. Since onset, he had not had a bowel movement. This was due to stagnant toxic heat preventing scab formation. The family wanted purgatives, but since the child was constitutionally weak, they feared purging. At that time, a sorcerer offered effective talisman water. The talisman was burned and ingested. Soon, abdominal borborygmus occurred, followed by watery diarrhea, which everyone praised. Thinking that long-term constipation must imply dry feces, the next day the ulcers worsened. A gallbladder enema method was used, expelling over thirty hard fecal pellets, size of bullet seeds. Everyone laughed, saying this method was even better. The scabs then retracted, but stopped at the waist because no further bowel movement occurred. Another gallbladder enema expelled fourteen more hard pellets. Thereafter, stools were loose, all scabs retracted, and the child recovered.
A child drank too much water due to thirst, damaging the spleen and stomach with dampness, preventing scabbing. Treatment with Sijunzi Tang (Four Gentlemen Decoction): Renshen (Ginseng Radix et Rhizoma) tonified the center, Baizhu (Atractylodis Macrocephalae Rhizoma) dried dampness, Fuling (Poria) leached out water, Gancao (Glycyrrhizae Radix et Rhizoma) resolved toxicity, Fangfeng (Saposhnikoviae Radix) overcame dampness in the skin/hair, Baizhi (Angelicae Dahuricae Radix) drove out water in muscles, Guizhi (Cinnamomi Ramulus) benefited joints and dispelled cold-water pathogen, and Sharen (Amomi Fructus) warmed the stomach and stopped thirst. Regulation led to safety.
A child with constipation had internal heat steaming and generating dampness, causing moist exudation preventing scab formation. Treatment with Danggui Shao (Radix Angelicae Sinensis caulis) and Shengdi (Rehmanniae Radix) to cool blood, Huren (Semen Persicae? Note: Text says Mahren likely Hemp Seed/Renziren contextually but text says Mahren/Ma Ren - Sesame/Hemp seed for moistening), Jiuhuang (Rhizoma Coptidis? No, text says Jiu Dahuang - Wine-processed Rheum Rhizome) to purge heat and open knots, and Sheng Gancao to harmonize the middle. Recovery followed successful defecation.
A child with incessant diarrhea and poor appetite suffered from interior deficiency failing to form scabs. Treatment with Chen's Yigong San combined with Roukou Wan (Nutmeg Pill) resulted in a cure.
The Cai family's son had dense smallpox with pus, failing to scab past the due date, with facial ulcers swelling and ulcerating, groaning constantly, choking on water, vomiting food, and unclear speech. Some said it was incurable. Observation showed facial ulcers swelling, entering the suppuration stage, throughout the body—not inverted scabbing. Choking/vomiting was due to swollen/hard lips impeding swallowing, not throat ulceration. Unclear speech was due to nasal congestion obstructing airflow, not aphonia. With toxins expressed externally and interior harmony restored, it was treatable. Treatment with Kushen (Sophorae Flavescentis Radix), Jiu Qin (Scutellariae Radix processed with wine), Niubangzi, Bajieli (Tribuli Fructus), Heshouwu (Polygoni Multiflori Radix), and Jingjie Sui (Schizonepetae Spica) ground into powder, bound with wine paste into pills, taken with Dan Zhuye (Lophatheri Herba) decoction. Regulation led to safety. A neighbor's child had identical symptoms and was deemed incurable. When asked why, the explanation was: 1. That child was overdue for scabbing; this child had not yet formed pus, so scabbing was inappropriate. 2. That child was swollen with solid pus/blood; this child had flat face, open eyes, peeling skin, and dry flesh. 3. That child had no ulcers in throat/tongue; this child had ulcerated throat/tongue, choking, and aphonia. That child secretly sought medicine from the Cai family, took it ineffectively, and died. (Xiong notes: How can pills be used if swallowing is difficult?)
The Hu family's thirteen-year-old daughter had dense smallpox. She was given heavy tonification with Renshen and Huangqi. After twenty days, she failed to scab past the due date and had already ulcerated, though inversion was avoided. Excessive warming/tonification had expelled interior pathogens but left exterior toxins unresolved. Immediate exterior-resolving treatment was needed to prevent skin/muscle rot. The family disagreed. Five days later, still no retraction. Treatment with Jingjie, Fangfeng, and Shengma (Cimicifugae Rhizoma) to resolve the exterior, Baizhi to erode pus and drain water, Lianqiao, Niubangzi, and Gancao to resolve stagnant heat-toxin. The lung governs skin/hair; due to Huangqi tonification, lung heat was severe. Given the summer fire season, Huangqin (Scutellariae Radix) was used to purge lung fire and seasonal heat. Regulation over one month led to safety.
Li Shi, wife of Lu Wenxue, had dense smallpox. Before pus formation, facial ulcers ruptured spontaneously, with swollen skin and accumulated pus emitting a foul odor. Overdue for scabbing, food intake decreased, and she choked on water with locked throat. The doctor said: The signs and symptoms are malignant; recovery is unlikely. Death within twenty-plus days.
A child developed a second layer of smallpox after the initial eruption, alarming the family. The doctor said: This is a good omen. Smallpox texts state mild cases erupt in three or four waves of varying sizes; severe cases erupt all at once. This was the mildest type, with no residual toxin, and the eruption was complete. It proved true.
The Wu family's three-year-old son had smallpox with excess toxin Qi but insufficient grain Qi (digestive energy), leading to poor appetite and failure to scab. Asked what medicine to take, the doctor said: No medicine can solve this. If he eats, he lives; if not, he dies. The next day, he desired food and ate a lot. The doctor said: Death is imminent. Explaining: Previously, desire to eat increased gradually, indicating recovery of stomach Qi. Now, sudden excessive eating indicates stomach failure and hyperactive fire, where evil fire destroys grain, known as "Chu Zhong" (Elimination of the Middle), from Shanghan Lun. Like a candle about to extinguish, it flares brightly before dying. Death is imminent. It proved true.
After a child's scabs fell off, the scabs did not detach. The doctor said: This is deficiency of the Spleen and Lung meridians. The lung governs skin/hair, the spleen governs muscles. Insufficient Qi makes scab detachment difficult. Treatment with Qian's Yigong San plus Huangqi and Guizhi resulted in a cure.
A child's entire body scabbed and shed, except the head and feet. The doctor said: This is a normal pattern, requiring no treatment. All Yang meridians converge at the head, making it Yang within Yang, called "Gu Yang" (Solitary Yang). All Yin meridians converge at the feet, making it Yin within Yin, called "Gua Yin" (Lonely Yin). Solitary Yang cannot generate; Lonely Yin cannot nurture. Thus, head wounds fail to close due to Solitary Yang lacking Yin. Foot wounds fail to close due to Lonely Yin lacking Yang. They will eventually heal naturally, though slowly. (This explanation is considered insufficiently accurate.)
After a child's scabs fell off, bumps appeared inside the scars causing itching. This was Wind-Heat. Treatment with Renshen Baidu San (Ginseng and Detoxification Powder) plus Jingjie and Fangfeng resulted in relief after one dose. Later patients with this condition were treated with Jingfang Baidu San plus Renshen orally, and washed externally with Shuiyang Tang (Water-Yang Decoction), all effective.
After a child's scabs fell off, scar swelling recurred as sores, lingering without healing. This was a smallpox toxin sore. Caused by scratching/picking, preventing natural shedding, injuring skin/muscle. Treatment with Kushen Wan (Sophora Pill) orally was effective.
After a child's scabs fell off, the scarred area was uneven. The doctor said: Smallpox patients must avoid ginger, lest scabbing be irregular and scars uneven. Inquiry confirmed this.
A Wang family girl's scabs fell off, leaving her body entirely white, lacking redness, crying day and night, with tidal fever, and refusal of milk/food. The doctor said: If not urgently treated, within one to two months or two to three years, she will develop malnutrition syndrome (Gan) and die. The family disagreed; she indeed died. Her son suffered similarly. He was given several doses of Shiquan Dabu Tang, then Sanhe Tang. Fever subsided, crying stopped, scar tissue turned red, and medication ceased. He was fully cured with Jiajian Babao Tang (Modified Eight-Treasures Decoction).
A child had shed scabs with no other complaints. A physician observed his eyes lacked spirit and had white opacity, stating: It is hopeless. The child died the next day. (From Guang Biji.)