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[Wan] The human body is fundamentally based on Ying (Nutritive Qi) and Wei (Defensive Qi). Wei Qi, which is Yang Qi, controls the opening and closing of the cou li (interstices/skin pores) and drives the pivotal mechanisms of the body. Ying Blood, which is Yin Blood, fills the Zang-Fu organs and irrigates the limbs. Therefore, when Qi is deficient, the Shen (Spirit/Mental activity) mechanism ceases; when Blood is deficient, the source of transformation is cut off. These two cannot be allowed to dominate excessively. The toxin of smallpox originates from the fluids of the five Zang organs and, following the meridians and specific locations, directly invades Ying and Wei to emerge. Observing the eruption: if the vesicles are firm and dense, and the pustule sacs are full and long, this indicates sufficient Qi. If the roots and buds are red, vibrant, lustrous, and moist, this indicates sufficient Blood. Once Qi and Blood are sufficient, the smallpox will erupt and crust over easily, requiring no treatment, to avoid the error of "reinforcing an excess" (making an excess condition worse). If the lesions are flat, depressed, tender, and thin, it is a disease of Qi; if dry, purple, and black, it is a disease of Blood. One must identify the cause and treat it, not allowing negligence to lead to regret. However, the Spleen and Stomach are the "parents" of Qi and Blood; the Heart and Kidney are the "mothers"; the Liver and Lung are the "residences." The Spleen receives water and grain; its fierce Qi enters the Kidney to transform into Qi. The Kidney stores this in the Lung to form Wei Qi, which warms the muscles and skin, fills the hair and pores, thickens the interstices, and governs opening and closing. If Wei Qi is deficient, the sores will not erupt; the toxin takes advantage of Qi deficiency to enter the Lung. If the Lung is affected, the smallpox becomes sunken and hidden, eventually returning to the Kidney. The Spleen receives water and grain; its essence Qi enters the Heart to transform into Blood. The Heart stores this in the Liver to form Ying Blood, which flows through the nine orifices, pours into the six Fu channels, and gathers in the hundred vessels. If Ying Blood is deficient, the sores lack luster; the toxin takes advantage of Blood deficiency to enter the Liver. If the Liver is affected, itching occurs, eventually returning to the Heart. In treating such cases, Qi diseases are treated by regulating Qi, Blood diseases by regulating Blood. Cold conditions are warmed, Heat conditions are cleared, Deficiency conditions are tonified, and Excess conditions are purged. Nevertheless, regulation of the Spleen and Stomach remains primary and must not be violated.

[Wan] One who does not understand the differentiation of Deficiency and Excess cannot be a physician. The Classics state: Do not make Deficiency more deficient, do not make Excess more excessive. The distinction between Deficiency and Excess must be known. The Classics state: First measure the patient's body shape (fat or thin) to regulate the Deficiency or Excess of Qi. This distinguishes Deficiency/Excess by body shape. It also states: Abundant food intake leads to abundant Qi; scant food intake leads to scant Qi. This distinguishes Deficiency/Excess by diet. It also states: An Excess pulse indicates Excess Blood; a Deficient pulse indicates Deficient Blood. This distinguishes Deficiency/Excess by pulse. It also states: When pathogenic factors are abundant, it is Excess; when essential Qi is depleted, it is Deficiency. This distinguishes Deficiency/Excess by the relationship between Pathogen and Righteous Qi. Generally, Excess refers to Pathogenic Excess, and Deficiency refers to Righteous Qi Deficiency. The Classics state: Where pathogenic factors gather, Righteous Qi must be deficient; if they remain and do not depart, the disease manifests as Excess. It is also said: Death from Five Excesses refers to Excess of Pathogenic factors; death from Five Deficiencies refers to Deficiency of Righteous Qi. (This applies to general diagnosis). In smallpox cases, if the patient is physically robust, eats well, has a洪大 (Surging) and forceful pulse in all six positions, has no prior illness, normal stool, and red/rosy lesions, this indicates both Exterior and Interior Righteous Qi are Excess; medication is unnecessary. If the patient is emaciated and weak, suffers from frequent illnesses, has reduced appetite, a faint and weak pulse in all six positions, frequent vomiting and diarrhea, and pale/tender lesions, this indicates both Exterior and Interior Righteous Qi are Deficient; Chen's method of Warming and Tonifying may be used. If the eruption is too vigorous, with severe swelling, pain, distension, persistent high fever, restlessness, thirst, drowsiness, and constipation of urine and stool, this indicates both Exterior and Interior Pathogenic factors are Excess; Qian's method of Cooling and Purging may be used. If the eruption is originally dense, red, and vibrant, but accompanied by vomiting, diarrhea, and inability to eat, this indicates Exterior Excess and Interior Deficiency; add detoxifying herbs to tonifying decoctions. If the lesions are pale white, fail to erupt fully, accompanied by constipation, yet the patient drinks heavily and eats greedily, this indicates Interior Excess and Exterior Deficiency; add diaphoretic/herbs promoting eruption to resolving/detoxifying formulas. Furthermore, pain in sores indicates Pathogenic Excess; activate Blood to resolve stagnation. If pain is like knife-cutting, with extreme restlessness and screaming, do not treat. Itching indicates Righteous Qi Deficiency; tonify Qi to dry Dampness. If scratching is incessant with skin peeling and ulceration, do not treat. Gray-white color indicates Qi Deficiency; Ren Shen (Ginseng Root) is most effective. Dryness indicates Blood Deficiency; Dang Gui (Angelica Sinensis Root) and Chuan Xiong (Ligusticum Chuanxiong Rhizome) should be used generously. Deficiency requires tonification, Excess requires purging; stop when the disease is addressed, without exceeding proper limits; this is the balance of treatment. If an Excess condition is wrongly tonified, toxins become more rampant, leading to ulceration, carbuncles, eye diseases, throat sores, or hemorrhage—all due to excessive tonification. If a Deficiency condition is wrongly purged, Righteous Qi becomes further depleted, leading to vomiting, diarrhea, or cold extremities—all due to excessive purging. The Classics say: Do not invite pathogens, do not lose Righteous Qi, thereby shortening life. This is what is meant.

[Weng] Qi has the function of generating Blood, but Blood has no function of benefiting Qi. Therefore, Qi must not be deficient; if deficient, Yang energy will be insufficient, and the round outline of the smallpox vesicles will not form. Blood must not be excessive; if excessive, Yin will invade Yang positions, and the disaster of inverted/collapsed smallpox will occur immediately. Thus, smallpox presents differences in Qi and Blood Deficiency and Excess. Generally, Cold indicates Deficiency, Heat indicates Excess. Qi Deficiency requires Warming and Tonifying; Qi Excess with Heat requires Cooling; Blood Deficiency requires Tonifying Blood; Blood Heat requires Detoxifying. One must aim for the harmony of Qi and Blood, neither excessive nor insufficient. What constitutes Qi and Blood Deficiency/Excess? For instance, excess Qi leads to vesicles; excess Blood leads to [blistering/pustulation]. Insufficient Qi leads to depression and failure to rise; insufficient Blood leads to lack of pus and toxin attachment. Pale white lesions, soft tops that do not resist touch, and failure to swell indicate Qi Deficiency; Bao Yuan Tang (Preserve Origin Decoction) is highly suitable, with doubled Jiu Chao Huang Qi (Wine-fried Astragalus Root), Rou Gui (Cinnamon Bark), Chuan Xiong, Ding Xiang (Clove), Ren Ru (Human Milk), and good wine. Roots that are not red, or red but scattered, turning white upon touch, with lesions standing like goosebumps, dry and dull, indicate Blood Deficiency; Bao Yuan Tang plus Chuan Xiong, Dang Gui, Jiu Xi Hong Hua (Wine-rinsed Carthamus Flower), and Shan Zha (Hawthorn Fruit) to eliminate the stagnating effect of Ren Shen and Huang Qi, followed by Mu Xiang (Aucklandia Root) to move stagnant Qi, so Blood becomes active. Huang Qi should be used only after all smallpox have erupted. Hot herbs should be used only when toxins are completely resolved, and treatment should be adjusted according to Qi and Blood Deficiency/Excess, ensuring efficacy. For blood tonification, Di Huang (Rehmannia Root) is used at the beginning and end; Jiang Zhi (Ginger-processed) is used to prevent blood stagnation; Shao Yao (Peony Root) is avoided due to its sour-cold nature damaging Stomach Qi, or if used, must be Jiu Chao (wine-fried).

[Discussion on Nursing Deficiency Patterns] Smallpox treatment focuses on Yuan Qi (Original Qi). If Yuan Qi is substantial, toxins are easily expelled and transformed. Therefore, skilled practitioners preserve Yuan Qi before it becomes weak, preventing depletion. The methods are: first, strengthen the cou li and consolidate the muscle surface; second, regulate diet and protect the Spleen Earth. If the exterior is solid, there is no fear of external collapse; if the Spleen Earth is solid, there is no fear of internal sinking. With the tonifying power of Ren Shen and Huang Qi, Yuan Qi naturally becomes substantial, making it easy for smallpox to form pus, preventing complications, and ensuring smooth crusting. Therefore, cold and purgative herbs like Da Huang (Rhubarb Root), Hua Shi (Talcum), Che Qian Zi (Plantago Seed), Sheng Di Huang (Rehmannia Root), Niu Bang Zi (Arctium Fruit), Zi Cao (Arnebia Root), Zhi Ke (Bitter Orange Fruit), etc., are forbidden, as their purgative and lubricating nature damages the Spleen and Stomach. Damage to Spleen/Stomach causes Yuan Qi to sink, leading to Qi collapse and internal attack, resulting in death—a certainty caused by the medicine itself. Lubricating and dispersing herbs like Niu Bang Zi, Ren Ya (Human Teeth), Chan Tui (Cicada Slough), Ma Huang (Ephedra Stem), Ge Gen (Kudzu Root), Sheng Ma (Cimicifuga Rhizome), Zi Cao, Jie Geng (Platycodon Root), Qiang Huo (Notopterygium Rhizome), Fang Feng (Saposhnikovia Root), Jing Jie (Schizonepeta Spike) are forbidden, as excessive dispersion causes Exterior Deficiency. Once the Exterior is deficient, Yuan Qi dissipates outward, leading to collapse, itching, and skin shedding, causing death. Who is to blame?

[Tonifying Qi but Not Blood in Deficiency Patterns] In weak smallpox patterns, mental fatigue and cyanotic-pale complexion occur because insufficient Qi causes fatigue, and un-nourished Blood causes cyanosis. Why treat Deficiency by tonifying Qi but not Blood? Qi has spirit but no form; tonifying it is easy to fill. Blood has form but no spirit; tonifying it yields slow results. Moreover, Qi is Yang and Blood is Yin; Yin follows Yang, Blood follows Qi. Thus, tonifying Qi makes it abundant, and Blood naturally follows and becomes abundant. Additionally, blood-tonifying agents like Dang Gui and Sheng Di Huang are moistening and laxative; excessive use may cause loose stools. However, in some deficiency smallpox cases with white, collapsed, un-nourished lesions, Dang Gui and Shao Yao may be reluctantly used. In cases of floating Deficiency Fire with numerous red spots resembling Blood Heat, Zi Cao, Hong Hua, and Sheng Di Huang may be reluctantly used for cooling and activating Blood. All should be wine-fried to counteract their laxative nature; using wine helps reach the Exterior. This achieves the subtlety of ascending and reaching the Exterior within blood tonification and activation, avoiding intestinal lubrication and diarrhea.

[Differentiating Inevitable Bad Outcomes of Deficiency Patterns] In Qi-deficient smallpox, initial symptoms include lingering fever, alternating hot and cold, flaccid skin, mental fatigue, cyanotic-pale face, reduced appetite, alternating cold/hot extremities, vomiting, loose stools. Lesions appear faintly, lacking vigor, pale red, thin-skinned. Over 3-4 days, they emerge unevenly, hard to grow. By 5-6 days, hard to form pus. Reduced food intake leads to Qi exhaustion; food stagnation leads to diarrhea. By 7-8 days, collapse, gray-white color, failure to rise, spontaneous sweating, slight thirst, or abdominal distension, wheezing, thirst, diarrhea, collapse, itching, restlessness, teeth grinding, chills, warm head/cold feet—these are inevitable outcomes. Therefore, at the onset of Qi-deficient smallpox, do not use Shen Su Yin (Ginseng and Schizonepeta Decoction), Ren Shen Bai Du San (Ginseng and Detoxifying Powder), Huang Lian Jie Du Tang (Coptis Detoxifying Decoction), Sheng Ma Ge Gen Tang (Cimicifuga and Kudzu Decoction), or Zi Cao San Dou Yin (Arnebia and Three Beans Decoction). Use Shen Qi Yin (Ginseng and Astragalus Decoction). Avoid patterns with rough breathing and dry skin lacking luster. Use Si Jun Zi Tang (Four Gentlemen Decoction) minus Ren Shen, plus small amounts of Jie Geng and Chuan Xiong, Fu Pi (Tangerine Peel), combining tonification with mild ascending methods. Once lesions are complete, heavily use Ren Shen and Huang Qi. By days 8-9, if no other ominous signs, proceed normally. If tops are depressed, gray-white, failing to rise, with clear pus, spontaneous sweating, slight thirst, add Rou Gui to major tonifying decoctions. For collapse, gray-white, abdominal distension, diarrhea, use Mu Xiang San (Aucklandia Powder). For collapse, itching, restlessness, abdominal distension, thirst, diarrhea, wheezing, warm head/cold feet, chills, teeth grinding, urgently administer Yi Gong San (Extraordinary Success Powder).

[Deficiency Pattern Transforming into Excess] In Qi-deficient smallpox, if parents observe taboos, medications are correct, and care is appropriate, Yuan Qi becomes substantial, cou li solid, Spleen/Stomach strong, diet normal, urination/defecation regular. However, excessive tonification, especially heavy use of Ren Shen/Huang Qi after pus formation, may cause abdominal distension and wheezing; use Zhi Ke Tang (Bitter Orange Decoction). Misuse of Wu Ling San (Five Ingredient Powder with Poria) or Tong Cao (Tetrapanax Pith) in excess may cause constipation; use Kuan Zhong San (Broad Middle Powder). Constipation with thirst: Mai Men Dong Tang (Ophiopogon Decoction). Overuse of Xin Re (Pungent-Hot) herbs like Ding Xiang and Rou Gui may cause sore throat, swelling, restlessness, and closed thirst; use Zi Yin Run Zao Tang (Nourish Yin and Moisten Dryness Decoction). Wheezing, distension, constipation, restlessness, thirst, sore throat resemble Excess, but Qi-deficiency transforming into Excess is not true Excess; it is a mistake of shallow disease treated with deep/heavy medication. Careful adjustment is needed, not purgation. Over-purging depletes newly generated Qi, leading to collapse.

[Deficiency Pattern Resembling Excess] Qi-deficient smallpox, due to raw/cold food or improper care, damages Spleen/Stomach, causing diarrhea. Fluids sink, Deficiency Fire rises, causing thirst. Yuan Qi sinks, Deficiency Yang surges upward, lower Qi fails to continue, causing wheezing. Thirst and wheezing are Excess patterns, but arising after diarrhea, they result from sudden fluid loss (thirst) and Qi deficiency (wheezing). How could true Heat-thirst or Qi-surging-wheezing arise after diarrhea? Treat thirst with Shen Ling Bai Zhu San plus Mu Xiang. Persistent thirst and diarrhea: Yi Gong San. Wheezing: Ren Shen Ding Chuan Tang or Du Shen Xing Ren Tang. Wheezing, thirst, diarrhea: Mu Xiang Yi Gong San. Restlessness, distension, internal attacking toxin, eyes closed, talking in delirium (Shi Zhi/Loss of Will): Mistaking this for Excess is foolish.

[Excess Pattern Resembling Deficiency] High fever, straight hair, dry skin, restless sleep, red cheeks/red eyes, rough breathing, restlessness/thirst, abdominal distension, constipation, wheezing—all are Excess. This is due to severe Heat and heavy toxins causing obstruction. Vomiting may appear as Deficiency, but it is actually Heat-toxin trapped inside, unable to vent, forcing upward rebellion. The Classics state: All rebellious attacks belong to Fire. Alternatively, cold invasion or irregular diet damages Wind-Cold, trapping internal Heat, causing rejection/vomiting. For trapped toxins, ascending and dispersing is best. For rejection vomiting, guide downward using Zhu Ling (Polyporus), Ze Xie (Alisma), Ju Pi (Tangerine Peel). Diarrhea accompanying these resembles Deficiency, but is due to郁盛 (Stagnant-Abundant) Heat-Toxin baking the Spleen/Stomach, preventing external release, causing toxins to sink and exit via orifices ("Heat-Toxin pouring downward"). Ancient saying: Diarrhea before eruption indicates survival; diarrhea after eruption indicates death. Treatment: Ascend and disperse to bring toxins to the Exterior; once toxins are resolved externally, internal diarrhea stops. If combined with food stagnation, add digestive herbs (mild) or follow the path (severe). Lack of appetite resembles Internal Deficiency, but in Yu Re (Stagnant Heat) patterns, toxins are trapped internally, unable to reach the skin, causing constipation, blocked cou li, Heat-Toxin obstruction, distension, and anorexia. Treatment: Ascend and disperse to allow Heat to vent, harmonizing Zang-Fu and restoring appetite. Mistakenly using Xin Re (Pungent-Hot) herbs like Ding Xiang, Rou Gui, Ban Xia for vomiting/diarrhea/anorexia uses Heat to attack Heat, worsening symptoms. Using Bu (Tonifying) herbs like Ren Shen, Huang Qi, Fu Ling, Bai Zhu for distension/anorexia allows Pathogens to be tonified and flourish; one dose can kill. Physicians must be cautious. Long Gu (Dragon Bone), Dou Kou (Cardamom) stop diarrhea; Shen Qu, Mai Ya, Sha Ren aid digestion—but none are suitable for obstructed Heat-anorexia. Future practitioners take note.

[Heat Pattern Transforming into Deficiency] Blood-Heat smallpox requires Cooling and Dispersing, not harsh Bitter-Cold. Overuse of Cold agents like Sheng Ma, Huang Qin, Huang Lian, and laxatives damages Spleen/Stomach internally and freezes muscles externally. Mild damage reduces appetite and causes loose stools; severe damage causes profuse watery diarrhea, leading to Cold-Deficiency. Frozen muscles prevent Heat vaporization, close cou li, prevent smallpox from swelling, erupting, or forming pus, leading to hidden collapse. This is Heat transforming into Deficiency. Once Deficiency is identified, treat as Deficiency. Ren Shen, Huang Qi, Ding Xiang, Rou Gui are not contraindicated. After day 5-6, Mu Xiang Yi Gong San is appropriate. Judgment depends on careful syndrome differentiation.

[Obstructed Heat Transforming into Deficiency] Severe toxin obstruction requires ascending/dispersing as primary, aided by Cooling/Detoxifying. Stop when balanced. Excessive dispersion empties the Exterior, depletes Yuan Qi, leading to clear fluid penetration, empty shells, itching/collapse/shedding, or non-healing ulcers. These signs indicate Exterior Deficiency. Once Exterior is deficient, Yuan Qi leaks, internal Qi cannot guard itself. Minor dietary errors (cold/raw food) cause diarrhea; persistent diarrhea leads to Cold-Deficiency, Qi collapse, restlessness, chills, etc. Once Deficiency is known, treat as Deficiency. Ren Shen, Huang Qi, Bai Zhu, Ding Xiang, Rou Gui, Gan Jiang, Fu Zi are not contraindicated. After day 6-7, even Mu Xiang Yi Gong San should be administered urgently. Adjust based on observation.

[Differentiating Use of Yi Gong San for Obstructed Heat] Excess-Heat obstruction often uses Cold herbs, causing frozen diarrhea, or excessive dispersion, causing Exterior Deficiency. If frozen/hard, use mild herbs; Ginger/Cinnamon heat is acceptable. After diarrhea, Heat dissipates, True Qi becomes deficient; use tonics. Qi Deficiency implies Cold; if Cold-Deficiency is clear, use Warming-Tonics. Thus, although initial eruption shows Blood-Heat obstruction, by days 3-4, if the body is no longer hot and skin is cold, and lesions do not grow, mild warming agents like Guan Gui (Cinnamon), Gan Jiang, Chuan Xiong are necessary to warm internal Qi, harmonizing external Qi. After diarrhea, the interior is definitely deficient. Even with distension, restlessness, thirst, wheezing, it is not Excess-Heat, but Internal Deficiency with hidden collapse and internal attacking toxins. Therefore, Excess-Heat cases with diarrhea on days 7-8-9 are treated as Deficiency. If Mu Xiang Yi Gong indications exist, prioritize this formula. Without frozen/hard signs, do not mistakenly use warming agents. Without diarrhea, do not mistakenly use Mu Xiang Yi Gong San. Collapse, inverted crusting, dryness without freezing/diarrhea are usually due to internal attacking Heat-Toxin; treat with Bai Xiang Dan or Zhu Wei Dan.