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(Added in the Ding Chou year of Guangxu 3)

The onset of smallpox has a distant origin. Some say it began in the Zhou Dynasty, others in the Han Dynasty, but it ultimately does not transcend the principle of yin and yang mingling to generate essence (Yinyun Huachun). When the father's essence and mother's form combine to create the fetus, the innate pathogenic fire lies dormant within the zang-fu organs. Occasionally, upon sensing changes in the heavenly climate, it is vented forth. Hence, it is called "Tianxing" (Seasonal Epidemic).

The arrival of Tianxing epidemics causes parents' hearts to tremble with fear. Why? Because of the high number of premature deaths. Our predecessors, endowed with great wisdom, invented the method of variolation. They would store pure, firm, and thick scabs from smallpox pustules, grind them into powder, and during times when the epidemic had not yet started, amidst gentle winds and sweet rains, select infants free from diseases such as sores, scabies, or malnutrition. Using a paper tube to hold the scab powder, they would blow it into the infant's nostrils, or use a silver hairpin to extract fresh pus and place it inside the nose. This allowed the qi to penetrate into the lungs, where similar elements attract each other, thereby inducing the eruption of the disease. Since the heavenly climate was favorable and the body healthy, and because this approach avoided digging a well only after one was thirsty (metaphor for acting before the crisis), treating the condition before it arose, and being cautious before symptoms appeared, constantly vigilant and thorough in every detail, nine out of ten children survived. The method was excellent. However, it could not guarantee absolute perfection. This is because the lungs open into the nose; the lungs are the canopy of the five zang and six fu organs, covering them and receiving all vessels. Once the qi is stimulated, the fire of all five zang and six fu organs erupts simultaneously. The depth of toxicity varies, and the density of pustules differs. Occasional imbalance leads to occasional untreatable cases; this is not the fault of the variolation method itself.

Humans do not grow from empty mulberry pods; thus, contracting smallpox is inevitable. Yet, the greatest virtue of Heaven and Earth is life. By maintaining Taihe (Great Harmony), Heaven silently wishes for all people under heaven to attain benevolence and longevity. What sin have these infants committed that Heaven should deliberately inflict such a disease to cause their death? Why are there many deaths and few survivors during smallpox epidemics? This is not a special disaster sent by Heaven. It is the same seasonal epidemic, but some individuals have inherent constitutional deficiency and encounter pestilential qi, while others suffer from illness and meet with calamity. Thus, crises lie hidden before the rash appears, and death follows immediately upon eruption. When the root is first undermined, collapse follows naturally; this is a common principle of affairs, nothing strange about it. But this accounts for only one or two out of ten. Heaven's benevolence ensures this is not frequent. Four or five out of ten recover without treatment or medication; two or three out of ten recover with slight treatment; yet four or five out of ten deteriorate due to improper treatment, causing infants to suffer劫 (calamity). This is not an overly harsh argument. Let us discuss this calmly: observing the peak of smallpox epidemics, those who are ignorant, greedy for profit, pretentious, treat human lives as grass, and remain unaware of their sins—let us not speak of them. Even those who achieve superficial success through trial and error, gaining fame as emerging talents, merely follow tradition like cattle passing before eyes. They rigidly adhere to transmitted teachings, unable to adapt to individual patients, nor flexible enough to change according to circumstances. Finding someone who reads thousands of volumes, sees clearly like the Qin mirror, uses methods without being bound by them, treats people without being trapped by them, and achieves maximum benefit through flexibility and divine understanding—is rare, though not non-existent. It is indeed difficult. This is why one cannot see the whole leopard, nor fully comprehend the secret formulas. Overuse of cold herbs suppresses the vigorous eruption mechanism, driving toxicity inward; overuse of tonics violates the prohibition against reinforcing excess (Shi Shi), trapping pathogens internally. Even using toxicity to combat toxicity, if misused, causes skin ulceration, akin to inviting thieves into the house. Reckless prescribing damages the fundamental root. Wandering aimlessly across fields and losing strategic opportunities, the consequences of such abuses lead to unnecessary deaths, missed chances for survival, disfigured faces, and suffering filling streets and alleys. Alas, what a calamity! This is what Jia Yi referred to as worthy of tears and bitter weeping. Yet, practitioners make mistakes repeatedly, still believing themselves correct, blaming Heaven, and attributing outcomes to fate. Does Heaven bear responsibility? Does Fate bear responsibility? The vast Heaven and the ignorant masses, how can they stop this ignorance...

In the tenth year of Jiaqing, Dutch ships carrying smallpox seeds and their physician Kina arrived from Luzon to Guangdong via sea route to perform variolation on humans. According to their records: Dr. Kina, pitying the high mortality of smallpox, noticed that families raising livestock did not contract the disease. Upon examining blue blisters on cows, he suspected they were related to smallpox. He extracted the fluid, used a small knife to lift the skin between the arms of children, inserted the cowpox fluid, and subsequently developed a single pock. By circulating this fluid through successive inoculations, he achieved 100% success with permanent immunity. However, reviewing their books reveals only illustrations of the technique, lacking explanation of its origin. Initially, people found it different from nasal insufflation and deemed it strange, not realizing it was not strange at all, but rather that the foreigners had not yet elucidated the underlying rationale.

The Western method is similar to nasal insufflation but more ingenious. Why? Nasal insufflation introduces the agent via the Lungs; arm inoculation also introduces it via the Lungs. However, nasal insufflation stirs up fire in all five zang and six fu organs, potentially resulting in numerous pustules. Arm inoculation targets a specific point in the middle of the arms, associated with the Sanjiao (Triple Burner), where there is slight movement. The skin and hair belong to the Lungs, while the transmission of fluid and harmonization of blood involve the Heart. As stated in the *Neijing*: "All pain and sores belong to the Heart." Smallpox is innate pathogenic fire residing in the Heart. Their ingenuity lies in direct access, isolating this single point of heart fire without disturbing other meridians. Producing only one pock ensures complete efficacy. Why use cowpox? Cows belong to the Earth element; toxicity dissolves upon contact with Earth. Borrowing the Earth nature of cows neutralizes the Fire toxicity of smallpox. Wealthy families now donate funds to preserve this strain, truly spreading nectar of Bodhi throughout the world. Preserving the strain is good, but if lost, separated by oceans, how can it be transported instantly? I believe medicine relies on intent. Cowpox can infect humans; human smallpox can infect cows. During an epidemic, selecting pure, firm scabs, grinding them into powder, and inoculating healthy young cows mirrors human nasal variolation. Obtaining cowpox from cows allows subsequent human inoculation, which seems feasible. However, during inoculation, one must mark the slightly moving spot between the arms, corresponding to the Sanjiao acupoint. Gently lift the thin epidermis with a slanted blade without breaking the membrane beneath to avoid bleeding. This layer between skin and flesh is what the *Neijing* calls "fenrou" (divided flesh). If the needle is not placed precisely at this moving spot, but deviates left or right, away from the Sanjiao point, it fails to extract the innate heart fire. Pustules may not appear, or if they do, they recur. This is not a flaw in the method, but an error in execution.

Fearing that future generations might transmit errors, compounding minor deviations into major failures, leading to recurrence, and then dismissing the method as absurd, thereby betraying the compassionate intention of saving lives, I deem it a great pity. Therefore, disregarding my own limitations, I detail this method here. May even humble insights be considered. With steady hands like holding a tiger during acupuncture, and precise acupoint selection down to the finest hairs, every movement honors Heaven's generative will, and every needle fulfills the hopes of parents. May天花 (smallpox) rain fall gently, ensuring no plants are broken in vain. May clouds of compassion cover the earth, granting safety to children. Without wasting wealth or labor, simple and easy, achieving perfection in every attempt, the method is supreme, the art most benevolent. I pray that gentlemen and virtuous people strengthen their faith and spread this widely, cultivating merit and attaining longevity together. Is this not joyful? Written on the Duanwu Festival of the 20th year of Jiaqing at Xiao You Qing Xu Jing She, Huang Anhuai of Nanhai.