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[Discussion by Wan Quan] Doulai (severe sequelae of smallpox resembling leprosy or deep scarring) arises from the stagnation and depression of heat-toxin, deficiency of Qi and Blood, and deterioration of muscles. The Classics state: "When heat prevails, flesh rots," which is precisely this condition. *Zheng Lilun* states: "A pulse that is floating and large; floating indicates wind and deficiency, while large indicates strong Qi. When wind and Qi contend with each other, urticaria (skin rashes with redness, swelling, and itching) must form, causing body itching. This itching is named 'Xiefeng' (draining wind), and over time it develops into severe Lai disease. Those whose Qi and Blood are abundant have no external deficient wind and no internal strong pathogen, so they certainly will not suffer from this disease. Only those who are constitutionally deficient in Qi and Blood cannot nourish the body with Ying and Wei Qi, making them susceptible to the killing energy of heaven and earth. Deficient wind resides within the skin and flesh, compounded by the filth and toxin of smallpox/rash and the malignant qi of epidemics. These factors strike, burn, and scorch, flowing and spreading throughout, exiting through the pores. Consequently, the sores are originally dense, leaving no intact skin on the body; the itching is unbearable, muscles ulcerate, and thus Doulai forms. Urgently employ methods to greatly tonify Qi and Blood and clear heat-toxin, so that preservation may be sought. If one waits until the face decays and falls off, the nose collapses, lips rupture, eyes go blind, and limbs are maimed, even if death does not occur, the person becomes disabled. For cases where sores break and become Lai, administer Shiquan Dabu Decoction (for the sweating stage) combined with Kushen Pill externally applied Miecan Jiuku San (for the crusting stage).

Kushen Pill Formula:
Sophora Root (one tael), Tribulus Fruit (half tael), Sesame Seed (half tael), Burdock Fruit (half tael), Licorice Root (two qian half).
Grind all into powder. Mix with wine and flour to make pills. Take with Bamboo Leaf Decoction.

The Classics state: "Heat prevailing causes swelling." Generally, when toxin is vigorous, swelling occurs; when toxin is slight, there is no swelling. When all sores have erupted and reach the expected stage of rising, if the head and face gradually swell, this indicates heat-fire dispersing and gathering in the three Yang meridians, preparing to suppurate and bleed, hence the swelling of skin and flesh. If at the time of rising, the head and face do not swell, it must be that the sores are distinct and磊落 (clear/separate), the toxic gas is light and superficial; although suppuration occurs, the root does not occupy a large area, hence no swelling. This requires no treatment. If the sores are originally indistinct and do not swell upon rising, this indicates toxin hidden internally without immediate release; it cannot be judged as slight toxin. If rising involves swelling, with normal skin and flesh texture, sharp and round sore tips, and distinct grains, this is a favorable omen. If the skin color is bright red, the sore bases are clustered in strings, adherent and flat, or if the sore color is gray-white like a cake or tin surface, or if the sores are scorched purple and dry without fluid, these are all ominous omens. If the head and face swell prematurely before rising, this involves epidemic toxic qi, known as Datou Wen (Big Head Plague). If the cheeks and jaw swell prematurely, it is named Xiamu Wen (Toad Plague); it must be treated concurrently with epidemic qi, and prognosis is mostly poor with little hope. Generally, for swollen sores, until they dry, form pus, and crust, the toxin transforms and swelling subsides. Therefore, cases that should swell but do not, or should subside but do not, require careful vigilance.

For sores with swelling, facial edema, and closed eyes, urgently treat with detoxification, eye protection, and throat rescue simultaneously. Internally use Xiaodu Huaban Decoction (for the rising stage); externally apply Shenying Ointment (see Manifestation stage) to protect the eyes. For swollen sores, strictly prevent itching. The center of the face must not suffer any damage. If itching leads to breaking, the trend of 'sand collapse' (ulceration spreading like collapsing sand) becomes irreversible; pathogenic qi sinks inward, true Qi leaks outward, swelling subsides, and death ensues. However, if broken areas refill with pus, subsided areas swell again, diet remains normal, and bowel/bladder functions regulate themselves, misfortune turns to fortune. Use Shiquan Dabu Decoction (sweating stage) and Kushen Pill (Doulai stage) combined for treatment. If sore color is gray-white and face swells like a tin cake, observe the patient's Zang-Fu organs. If they can eat, stool is regular, urine is long/profuse, and there are no other complaints, prognosis is mostly good. If they cannot eat, vomiting and diarrhea occur together, or itching arises, prognosis is mostly bad.

If head/face or cheeks/jaws swell prematurely, this is due to seasonal epidemic toxicity; treat primarily with Qianghuo Jiuku Decoction.

Qianghuo Jiuku Decoction (See Rising Stage)