Library

In the late autumn of Yichou year (1865), I reviewed and proofread the printed edition of *Yanfang Xinbian* (New Compilation of Verified Prescriptions), correcting erroneous characters. Mr. Chen Shaohai from our county presented me with a volume titled *Douzheng Cihang* (Compassionate Navigation for Smallpox). Initially, I thought that the discussion on treating smallpox in *Xinbian · Pediatrics* was already quite detailed, so it seemed unnecessary to add more. Subsequently, I flipped through that book and found that it was written by Mr. Ouyang Tiaolv from the Ming Dynasty and later edited and polished by Mr. Guo Kunshan. The discussions on syndrome differentiation and prescription selection were consistent with the principles in *Xinbian*. From fever to the appearance of pustules, filling with pus, and scabbing, based on the symptoms presented, one can distinguish between favorable and unfavorable courses by observing complexion and form, listening to voice and breath, and palpating pulses, while assessing cold, heat, deficiency, and excess. For each symptom, the appropriate prescription is listed immediately after, making it clear at a glance. Even those unfamiliar with medicine can consult the volume to differentiate syndromes and select prescriptions accordingly; it is indeed a compassionate guide for emergency rescue in hasty situations. Therefore, I appended it to the "Supplement" volume, hoping it would serve as an aid to widely benefit sentient beings. Recorded by Li Dong of Ziyang in mid-winter of Yichou year, Tongzhi 4th Year.

There have been many physicians treating smallpox. Liu Hejian used exclusively cooling and purgative herbs, causing significant harm due to this bias. As for Qian Zhongyang, his prescriptions also focused mainly on detoxification but relied heavily on cooling herbs and rarely on warming and tonifying ones. Zhang Jiegu and Wang Haicang both revered this approach. Their intent was based on the statement in *Neijing* (The Inner Canon) that "all sores and ulcers belong to Heart Fire," thus using cooling herbs to drain Heart Fire. Later, Chen Wenzhong created prescriptions to vigorously correct this bias, specifically advocating warming and tonifying. Whenever smallpox was about to appear or had just appeared, he exclusively used Twelve-Ingredient Yigong San (Twelve-Ingredient Extraordinary Efficacy Powder), focusing his intent on the Taiyin channel. Since Hand-Taiyin Lung governs skin and hair, and Foot-Taiyin Spleen governs muscles, the Lung channel dislikes cold, and Spleen earth dislikes dampness. Therefore, he used Dingxiang (Caryophylli Flos, Clove) and Guigui (Cinnamomi Ramulus, Cinnamon Twig) to treat Lung cold, and Baizhu (Atractylodis Rhizoma, Atractylodes), Fuzi (Aconiti Lateralis Radix Praeparata, Prepared Aconite Root), and Banxia (Pinelliae Rhizoma, Pinellia) to treat Spleen dampness. If this prescription is used appropriately, its efficacy is indeed great. However, if used indiscriminately without distinguishing cold, heat, deficiency, or excess, it suits deficiency-cold but not excess-heat, revealing its biased harm. Zhu Danxi explained this correctly. When Danxi formulated his theories, he corrected Chen's bias while adopting Qian's strengths, emphasizing detoxification, harmonizing the middle, and stabilizing the exterior, considering this appropriate. The world adopted it, and for centuries no one questioned its errors. However, I believe that while Danxi offered many brilliant insights for other diseases, his treatment of smallpox was rash and incomplete, perhaps a rare oversight. Correcting Chen's bias, he dared not lightly use Muxiang (Aucklandiae Radix, Aucklandia), Guizhi (Cinnamomi Ramulus, Cinnamon Twig), and Fuzi (Aconiti Lateralis Radix Praeparata, Prepared Aconite Root), seemingly giving up eating because of choking. Adopting Qian's strengths, he insisted on using Huangqin (Scutellariae Radix, Scutellaria), Lianzi (Coptidis Rhizoma, Coptis - *Note: Text says 'Lianzi' but context implies Huanglian/Coptis or similar bitter cold herb, likely typo for Huanglian or referring to seeds, but standard term for detox is Huanglian. Given context 'Qin, Lian', it refers to Huangqin and Huanglian*), and Niuzi (Arctii Fructus, Arctium) to control the strength of tonics like Renshen (Ginseng Radix, Ginseng), Baizhu (Atractylodis Rhizoma, Atractylodes), and Fuzi (Aconiti Lateralis Radix Praeparata, Prepared Aconite Root). This is like appointing generals but restraining them from within, or relying on troops but monitoring them from outside. His error also lay in rigidly adhering to the *Neijing* saying "all sores belong to Heart Fire" without fully penetrating its logic. One should not know that although smallpox belongs to Heart Fire, it differs from other sores. The toxin of various sores, when initially erupting and not yet formed, can be resolved with medication to heal. Once formed but not yet suppurated, it can also be dispersed with medication to heal. Smallpox toxin originates from the five zang organs and must rely on blood and qi to transport it to the skin, transform it into pus, and consolidate it into scabs to complete the cure. Can it heal merely by dispersion? Can it heal before suppuration? Thus, treating various sores focuses on detoxification; early detoxification leads to mild disease. If detoxification fails... Detoxifying herbs often damage Stomach Qi. Ignoring the depletion of blood and qi to rush towards detoxification is like rushing to kill enemies without considering the strength of one's own troops.

Generally, toxins have some that must be resolved and some that cannot be. If a child has strong constitution, good Stomach Qi, and normal appetite, their blood and qi are naturally vigorous, naturally transporting toxins to succeed; such smallpox cases are mostly favorable throughout, requiring no detoxification. If their constitution is inherently weak, Spleen and Stomach are weak, appetite is poor during eruption, accompanied by thirst or diarrhea, abdominal distension, cold hands and feet, shortness of breath, loss of voice, slow eruption, non-vibrant roots, white color with depressed tops, failure to fill with pus when expected, or failure to scab when expected, these are all due to blood and qi's inability to transport toxins; in these cases, detoxification is contraindicated. One should rapidly use warming and tonifying herbs to support Stomach Qi and assist blood and qi. If Renshen (Ginseng Radix, Ginseng), [Missing Character], Danggui (Angelicae Sinensis Radix, Angelica), and Baizhu (Atractylodis Rhizoma, Atractylodes) are insufficient, adding Muxiang (Aucklandiae Radix, Aucklandia), Dingxiang (Caryophylli Flos, Clove), Guizhi (Cinnamomi Ramulus, Cinnamon Twig), and Fuzi (Aconiti Lateralis Radix Praeparata, Prepared Aconite Root) as assistants is not excessive. Why mix in Niuzi (Arctii Fructus, Arctium), Huangqin (Scutellariae Radix, Scutellaria), and Huanglian (Coptidis Rhizoma, Coptis) to inhibit the power of warming tonics and damage blood and qi? This is where Danxi failed to fully grasp the subtleties. Danxi also taught using Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) to resolve smallpox toxins. Later generations followed this, losing the original intent, using it out of habit, thinking it miraculous without knowing its harm. The Heart primarily governs blood; the reason the Heart can govern blood is because it belongs to Fire. Smallpox belongs to Heart Fire, which precisely utilizes Heart Fire to circulate the body's qi and blood to achieve success. How can it be drained away? Blood in the human body flows when warm and stagnates when cold. Xijiao Dihuang Tang cools the Heart channel and drains Heart Fire. Once the Heart channel is cooled and Heart Fire drained, the blood in the entire body will stagnate and fail to flow. How can it then transform toxins into pus and scabs? Thus, internal attack complications arise, leading to death; drugs that drain Heart Fire actually kill the patient, though people do not realize it, and physicians remain unaware. Truly lamentable! I propose that after smallpox appears and before scabs form, all cooling-heart drugs like Xijiao (Rhinocerotis Cornu, Rhino Horn - *Note: Modern practice uses substitutes, but text specifies Xijiao*) and Dihuang (Rehmanniae Radix, Rehmannia) should be strictly prohibited. They may be used after scabbing to resolve residual toxins. Someone asked: If so, can toxins never be resolved before consolidation? I said: Why not? If both blood/qi and toxins are vigorous, the pulse will be surging and rapid. Or if purple-black upon initial appearance, or dense red-purple after eruption, accompanied by internal restlessness, dry mouth/thirst, red scanty urine, and constipation, this belongs to excess-heat. One should rapidly use cooling agents to detoxify. If constipation persists,适量 (moderate amount) of Jiuhuang (Rhhei Radix et Rhizoma, Rhubarb fried with wine) can be added to mildly promote bowel movement. If toxins are abundant but blood/qi are not yet vigorous, focus on detoxification while simultaneously invigorating blood and nourishing qi; Renshen (Ginseng Radix, Ginseng), [Missing Character], Danggui (Angelicae Sinensis Radix, Angelica), and Baishao (Paeoniae Radix Alba, White Peony Root) should not be abandoned. During clinical practice, careful examination is required.

Recent prescriptions for smallpox mostly follow Huang Xiqiu. His book consistently distinguishes between favorable, unfavorable, and dangerous syndromes. He stated that favorable syndromes require no medication. Dangerous syndromes should be treated with Baoyuan Tang (Preserve Origin Decoction), which is still reasonable. However, stating that unfavorable syndromes are untreatable and treatment is futile teaches people to stand by and wait for death, which is extremely unkind. This is convenient for vulgar physicians seeking profit but contrary to the art of saving lives. Medicine is a benevolent art; sages use it to assist what creation cannot achieve, valuing the ability to support the perilous, rescue the distressed, and revive the dead. If one treats only easy cases and abandons difficult ones, what is the purpose of being a physician? Only vulgar physicians seek profit and fear damaging their reputation; seeing unfavorable cases, they shirk responsibility and abandon patients, fearing they might gain nothing but incur the name of misdiagnosis. If one is a benevolent gentleman, one should strive for life amidst death; how could one bear to watch them die without treatment? Thus, Huang Xiqiu's words benefit vulgar physicians but do not save the world. Moreover, the unfavorable syndromes he points out are numerous, especially in dense cases. Examples include fever with palpitations, vomiting, and diarrhea; eruption starting first at Sikong, Yintang, or Tianting areas; no halo around roots upon initial appearance; white/gray depressed color after eruption; blister formation; itching and collapse; failure to progress to pus stage when expected; or chattering teeth and chills before scabs fall off. These are all what he calls unfavorable and untreatable. I have treated many such cases successfully. Why claim treatment is useless and warn against it? Only cases appearing like silkworm eggs, turning purple-black and dry after eruption, failing to fill with pus, are mostly incurable. Yet, even knowing they may not survive, I cannot bear to sit idly by without treating them.