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The aphorism states: Deficiency manifests as itching, excess manifests as pain; this is a general statement. The itching of smallpox varies in presentation. Some patients experience whole-body itching and incessant scratching immediately upon eruption. This occurs because the pathogenic factor desires to exit, but the skin pores are closed and dense, causing the fire pathogen to wander back and forth, resulting in itching. This is analogous to the body itching without sweat seen in Taiyang disease (disease of the Taiyang channel) in Shanghan (Cold Damage) syndrome. It can be treated with diaphoresis (sweating method) to relax the skin, open the pores, allow the pathogen to escape, and resolve the itching once the pustules erupt. This aligns with the principle "when fire is constrained, release it."

Some patients experience itching when the lesions are about to crust over. At this stage, pus has formed, the lesions are subsiding, the pathogen is dispersing, and the healthy qi is recovering. The Ying and Wei (nutritive and defensive) qi are harmonious and flowing smoothly, causing itching. This is analogous to the itching seen when carbuncles and furuncles are nearing cure. Medication is unnecessary; careful nursing is required to prevent scratching, which could lead to swelling and suppuration. This represents a favorable healing process ("beautiful sores").

Some patients experience itching during the rising, blistering, and suppurating stages. When blood has transformed into fluid, but the fluid has not yet fully become pus, and the toxin has not yet resolved, the whole body itches, and the patient scratches restlessly. This is an ominous sign. It is analogous to the sensation of insects crawling under the skin seen in Yangming channel disease in Shanghan syndrome. This is described as external attack by deficient wind and internal strength of the pathogen, where incessant itching is called "leaking wind." In such cases, one must observe whether the lesions are dry or moist and administer wind-dispelling herbs accordingly. Itching must cease for this to be considered a good omen. If itching is severe and unceasing, leading to lesion destruction, skin peeling, and re-depression of the toxin, it is called "itch-collapse" (Yang Ta), which is incurable. Generally, if lesions appear bright red and shiny upon eruption, or tender and watery upon rising, they are prone to subsequent itch-collapse.

In all cases of smallpox itching, one must carefully examine the color and shape. If lesions have been rising red and vibrant, lustrous, plump, and full, and suddenly become itchy, this is due to contact with foul qi. Internal administration of Shiquan Dabu Tang (Complete Excellent Tonifying Decoction) and external application of Yinchen fumigation method are indicated. For broken lesions, Bailong San (White Dragon Powder) should be applied. If lesions that were originally dry develop additional itching, this indicates excessive fire/toxin. If lesions originally contained water, had tender/thin skin, and now itch, this indicates warm-heat pathogen. Symptoms such as head shaking, neck twisting, limb movements, and mental confusion indicate a death prognosis.

For initial itching upon eruption, use a releasing method with Guizhi Gegen Tang (Cinnamon Twig and Pueraria Decoction) plus processed Mahuang (Ephedrae Herba) and Niubangzi (Arctii Fructus). For itching during the rising and suppurating stages, generally use Shiquan Dabu Tang (Complete Excellent Tonifying Decoction) plus Fangfeng (Saposhnikoviae Radix) and Niubangzi (Arctii Fructus). There are two patterns of itching during the rising stage: 1) Blood and qi deficiency, where itching is due to deficiency, treated with Shiquan Dabu Tang (Complete Excellent Tonifying Decoction); 2) Itching caused by failure to maintain a bland diet, treated with Chantui Gao (Cicada Slough Ointment).

If lesions are dry and itchy, nourish blood and moisten dryness using Siwu Tang (Four Substances Decoction) combined with Xiaofeng Huadu Tang (Wind-Dispersing and Toxin-Resolving Decoction) and Duoming Dan (Life-Snatching Pill), with external Yinchen fumigation. If lesions are moist and itchy, tonify qi and remove dampness using Sijunzi Tang (Four Gentlemen Decoction) combined with Xiaofeng Huadu Tang (Wind-Dispersing and Toxin-Resolving Decoction) and Duoming Dan (Life-Snatching Pill), with external Yinchen fumigation.

If mature lesions suddenly itch and are scratched open, this is due to Spleen and Stomach weakness failing to nourish muscles. Internal treatment: Sijunzi Tang (Four Gentlemen Decoction) plus Huangqi (Astragali Radix) and Guigui (Cinnamomi Cortex). External treatment: Baicao San (Decayed Grass Powder). If diarrhea causes Spleen/Stomach weakness leading to itch-collapse, use Chen's Muxiang San (Costus Powder) or Yigong San (Extraordinary Power Powder). If lesions are crusting but itch due to accidental breaking and fail to dry, apply Bailong San (White Dragon Powder).

Danxi's method: Differentiate deficiency and excess based on appearance and pulse. Excess presents with strong pulse and robust qi; deficiency presents with weak pulse and depleted qi. Excess itching has an urgent intensity; deficiency itching has a timid intensity. Treat deficiency itching with exterior-strengthening agents plus blood-cooling herbs; treat excess itching with small doses of Da Huang (Rhei Radix et Rhizoma) and other cold/cool herbs to purge accumulated feces. Cangzhou Weng's method: Focus on blood/qi deficiency, using Shibu Tuoli San (Ten-Ingredient Interior-Tonifying and Supporting Powder) and Muxiang San (Costus Powder) plus Dingxiang (Caryophylli Flos) and Guigui (Cinnamomi Cortex). Since the Stomach governs muscles, Sijunzi Tang (Four Gentlemen Decoction) plus Xiong (Ligustici Chuanxiong Rhizoma), Danggui (Angelicae Sinensis Radix), Muxiang (Aucklandiae Radix), and Zicao (Leonuri Herba) is particularly suitable. If the patient fails to keep dietary restrictions and eats toxic foods causing itching, use Erwu Tang (Two-Substance Decoction), Baihua Gao (Hundred Flowers Ointment), or Sijunzi Tang (Four Gentlemen Decoction) plus detoxifying herbs.

Chen's method: Itching with scratched lesions weeping pus/blood is due to blood/qi decline and muscle weakness. Use Muxiang San (Costus Powder) plus Dingxiang (Caryophylli Flos) and Rougui (Cinnamomi Cortex), and Baicao San (Decayed Grass Powder). Strictly avoid cow dung ash, as it causes foul-smelling scars.

Wenrenshi's method: Two patterns of itching: 1) Blood/qi deficiency (deficiency type), treated with Huoxue San (Invigorate Blood Powder) or Sijunzi Tang (Four Gentlemen Decoction) plus Huangqi (Astragali Radix) and Zhike (Aurantii Fructus). (Zuo Zhongshu uses Shiquan Dabu Tang [Complete Excellent Tonifying Decoction] and Shixuan Naituo San [Ten-Acupoint Interior-Supporting Powder]). 2) Itching from failure to eat bland food, treated with Chantui Yiwu Tang (Cicada Slough Single-Substance Decoction).

Wei's method: Use Baoyuan Tang (Protect Origin Decoction) with doubled Huangqi (Astragali Radix) and added Shaoyao (Paeoniae Radix). Some say for head/tail itch-collapse, add Niubangzi (Arctii Fructus), Baishaoyao (White Peony Root), and Heshouwu (Polygoni Multiflori Radix) to Baoyuan Tang. Heshouwu has red and white varieties (male/female); both should be used together for efficacy. Avoid iron. Wang Ruyan states: Pale, weak smallpox with itch-collapse indicates deficiency-cold; use Chen's method. Fever with vigorous eruption of red/purple lesions and dry itching indicates heat-toxin; use blood-cooling and detoxifying agents.

Xue's statement: All preceding conditions result from blood/qi weakness. Preventative care to harmonize blood/qi avoids these issues. Observe external signs: pale colors require Sijunzi-type formulas; red colors require Siwu-type formulas.

Yuan's statement: Itching with half-filled blisters can be stopped using Renshen (Ginseng Radix), Huangqi (Astragali Radix), Shaoyao (Paeoniae Radix), Shengma (Cimicifugae Rhizoma), and Fuzi (Aconiti Lateralis Radix Preparata). Avoid cold/dispersing herbs. Burning lesions adhering to skin are incurable. Empty-shell lotus-pod-like lesions with itching are incurable.

Shenling Naituo San (Ginseng and Atractylodes Interior-Supporting Powder): Treats interior deficiency itching, non-ulcerating lesions, and inverted crusting.
Ingredients: Renshen (Ginseng Radix), Huangqi (Astragali Radix, stir-fried), Danggui (Angelicae Sinensis Radix), Chuanxiong (Ligustici Chuanxiong Rhizoma), Houpo (Magnoliae Officinalis Cortex, ginger-processed), Fangfeng (Saposhnikoviae Radix) [each 5 fen], Jiegeng (Platycodonis Radix), Baizhi (Angelicae Dahuricae Radix), Guigui (Cinnamomi Cortex) [each 2 fen], Muxiang (Aucklandiae Radix), Gancao (Glycyrrhizae Radix et Rhizoma) [each 3 fen], Zicao (Leonuri Herba) [5 fen].
Preparation: Add a pinch of glutinous rice, decoct in water, and take appropriate amounts. Also suitable for chills, teeth grinding, thirst, and diarrhea.

Zicao Muxiang San (Leonurus and Costus Powder): Treats interior deficiency itch-collapse, black depression, and fever in smallpox.
Ingredients: Zicao (Leonuri Herba), Fuling (Poria), Gancao (Glycyrrhizae Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Muxiang (Aucklandiae Radix), Renshen (Ginseng Radix) [equal parts], Glutinous Rice.
Preparation: Coarsely powder. Take 3 qian per dose, decoct in water.

Xiaofeng Huadu Tang (Wind-Dispersing and Toxin-Resolving Decoction):
Ingredients: Fangfeng (Saposhnikoviae Radix), Huangqi (Astragali Radix), Baishaoyao (Paeoniae Radix Alba), Jingjie Sui (Schizonepetae Spica), Guizhi (Cinnamomi Ramulus), Niubangzi (Arctii Fructus), Shengma (Cimicifugae Rhizoma) [equal parts], Gancao (Glycyrrhizae Radix et Rhizoma) [half amount].
Preparation: Coarsely chop. Add 7 leaves of Bohe (Menthae Haplocalycis Herba), 1 cup of water, decoct to 0.7 cup, strain, and take warm at any time.

[Dan] treats itch-collapse where lesions do not cover.
Ingredients: Baizhu (Atractylodis Macrocephalae Rhizoma) [1.5 qian], Huangqi (Astragali Radix, honey-fried), Danggui (Angelicae Sinensis Radix), Chenpi (Citri Reticulatae Pericarpium) [each 5 fen], Gancao (Glycyrrhizae Radix et Rhizoma, lightly fried).
Preparation: Decoct in water, take warm.

Case Study: I treated a seven-year-old boy. During the pre-eruption phase, he had several episodes of dark-colored diarrhea. Lesions failed to rise from their bases. Three days later, itch-collapse occurred; scratching turned them black. He was thirsty. Bases resembled water blisters, lacked redness/luster, and did not rise. Appetite was poor. Pulse was floating, rapid, and forceful, but empty upon deep pressure. I used Renshen (Ginseng Radix), Huangqi (Astragali Radix), Danggui (Angelicae Sinensis Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Chenpi (Citri Reticulatae Pericarpium), and Roudoukou (Myristicae Semen) as sovereign herbs; Zhi Gancao (Prepared Licorice), Hezi (Terminalia Chebulae Fructus), and Rougui (Cinnamomi Cortex) as minister herbs. Decocted in water, taken with a little fine wine. Itching stopped immediately, appetite returned, bases became red/lustrous and rose. Cured after two doses.

Chan Hua San (Cicada Flower Powder): Treats whole-body itching and scratching in smallpox/rubeola, regardless of stage.
Ingredients: Chantui (Cicada Slough, heads/feet removed, washed, lightly fried) [1 liang], Digupi (Lygodii Radix, fried until black) [1 liang].
Preparation: Powder. Take 1 tea spoon with water/wine. Effective after 1-2 doses.

Erwu Tang (Two-Substance Decoction):
Ingredients: Chantui (Cicada Slough, clean) [21 pieces], Gancao (Glycyrrhizae Radix et Rhizoma, fried) [1 liang].
Preparation: Powder. Decoct in water, take frequently.

Hepi San (Box Spleen Powder): Used for sudden severe whole-body itching on days 8-9 of smallpox, the most urgent condition.
Ingredients: Chao Baizhu (Stir-fried Atractylodis Macrocephalae Rhizoma), Shaoyao (Paeoniae Radix), Sheng Dihuang (Rehmanniae Radix), Gancao (Glycyrrhizae Radix et Rhizoma), Shengma (Cimicifugae Rhizoma), Jingjie (Schizonepetae Herba), Fangfeng (Saposhnikoviae Radix), Chenpi (Citri Reticulatae Pericarpium), Dafupi (Arecae Pericarpium), Jiangcan (Bombyx Batryticatus), Chantui (Cicada Slough).
Preparation: Decoct in water.

Zhenze Tang (Zhenze Decoction):
Ingredients: Renshen (Ginseng Radix), Huangqi (Astragali Radix), Shaoyao (Paeoniae Radix), Sheng Dihuang (Rehmanniae Radix), Fangfeng (Saposhnikoviae Radix), Gancao (Glycyrrhizae Radix et Rhizoma).
Preparation: Decoct in water.

Tianyuan Erxian Dan (Heavenly Origin Two Immortals Pill):
Huntian Tang Ingredients: Renshen (Ginseng Radix, milk-soaked), Huangqi (Astragali Radix), Sheng Fuzi (Prepared Aconiti Lateralis Radix, flour-baked) [each 1 liang].
Preparation: Grind the four ingredients separately to fine powder, mix, and blend with white honey. Dosage by age: >10 years old = 1 qian; >15 years old = 2 qian. Follow with Zhenyuan Tang (Restore Origin Decoction) consecutively to stop itching.

Qixing San (Seven Star Powder):
Ingredients: Huangqi (Astragali Radix), Shaoyao (Paeoniae Radix) [each 2 qian], Renshen (Ginseng Radix), Guixin (Cinnamomi Ramulus) [each 1 qian], Black Carp (1 fish).
Preparation: Powder the first four ingredients, place inside the black carp, cook in Shengma (Cimicifugae Rhizoma) wine until done. Eat the fish and medicine with the itchy child. Upper jiao itch: eat head; Middle jiao itch: eat body; Lower jiao itch: eat tail. An empirical formula.

Bailong San (White Dragon Powder):
Preparation: Use dried yellow cow manure aged long in wind/dew. Burn to ash. Take the white center, powder it, wrap in thin silk, and dust onto lesions.

Bathing Method:
Ingredients: Frost-exposed Sangye (Mori Folium) [top grade], Sugeng (Perillae Caulis) [medium], Shengma (Cimicifugae Rhizoma) [top grade], Jingjie Sui (Schizonepetae Spica) [medium], Fangfeng (Saposhnikoviae Radix) [medium].
Preparation: Decoct vigorously, cool, and wipe the body.

For severe itching wanting to scratch: Lightly brush with bird feathers. Smoke with Xiacha (Fine Tea), Danggui (Angelicae Sinensis Radix), Huangqi (Astragali Radix), Xuanshen (Scrophulariae Radix). Or heat an iron tool, dip in strong vinegar, and smoke the room.

[Dan]: Mild cases: Mix Tuhua Shi (Calcitum) powder with light honey water, apply with chicken feather.

[Chen]: Unbearable itching leading to sores/weeping pus/blood: Use Baicao San (Decayed Grass Powder). Strictly avoid cow dung ash, as it causes foul scars (see Crusting Treatment).

For children with unbearable itching causing sores, or stubborn scabs: Apply high-quality white honey to lesions. Scabs fall easily, preventing purple/black scars.

Popular belief: After crusting, unresolved toxins cause scabies/lichen. Apply aged tallow for miraculous effect.

Another Formula: Sheep marrow applied to lesions is effective (see Scab Removal Section).

[Scratching Open] [Wan]: If mature pus-filled lesions are scratched open due to itching, they will only ulcerate further and fail to crust. If scratched before pus formation, itch-collapse and death are inevitable. [Yuan]: Why do some die from weeping pus after scratching, while others die from dry peeling?
Answer: Dry wood breaks naturally; dry soil cracks naturally. Empty smallpox blisters cause intense itching, making scratching difficult to resist. Scratching non-vital areas may allow survival; scratching vital areas (cheeks/nose bridge) leads to imminent death. Weeping pus seems to nourish blood/qi, yet death occurs. Fish thrive in water; birds nest in forests. Once the blister breaks and pus leaks, Yuan Qi (Original Qi) is exhausted. Exhausted Yuan Qi leads to death. Commentary: "Pus flow suggests life, but scratching wastes the 'gold' (vital essence). No matter how skilled the treatment, losing the 'gold' is heartbreaking." This analogy is apt.

Xie Chongxiao said: Nuwa mended the sky with five-colored stones; skin loss can be patched with medicinal paper. This statement is erroneous.

Treatment for scratched bleeding lesions: Heihu Dan (Black Tiger Pill). Verse: Silk gourd stem and sac skin, black gold from within, slow-roasted on new tile preserving nature, efficacy truly miraculous. When scratching brings evil wind, know the laughter of Master Wang Zhen. Schizonepeta, Saposhnikovia, Angelica dahurica, Astragalus, and Peony perform wondrous feats.

Note: Ancient methods used Baicao San, Buckwheat flour, Gege (Clam shell powder), or Wen Ge (Clam shell powder). None compare to the excellence of Heihu Dan.