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[Background Information]
Book: Yanfang Xinbian (New Collection of Verified Prescriptions)
Author: Bao Xiang'ao
Dynasty: Qing
Chapter: Methods for Regulation and Treatment within a Few Days After Pox Eruption is Complete, During the Swelling and Suppuration Phase
Category: Formula

After two days of pox eruption, when the lesions are fully erupted, the body temperature is mild, spirit is clear, lesions are pointed, round, lustrous, with red and vibrant roots, sparse on the head and back, diet is normal, and urination and defecation are unobstructed, this is a favorable prognosis (Shun Hou). Medication is not necessary; simply regulate diet, avoid wind and cold, and prevent foul odors.

Within three days after the pox is fully erupted, the time is critical, and the morphology, color, and symptoms require careful observation. Good pox rely entirely on thick and full pus; at least six or seven parts pus are needed to ensure safety. Once the pox is fully erupted, the morphology and color are evident, and whether pus will form and be sufficient can be predicted in advance. Favorable cases naturally have sufficient pus and require no medication. Unfavorable cases will likely lack pus or have scanty, thin pus. It is urgent to observe morphology and color within these three days, differentiate deficiency, excess, cold, and heat, and use medication to regulate treatment to promote suppuration; there is still time. If this opportunity is missed, many cases become untreatable due to delay and fail to suppurate. The life or death of pox depends on the presence or absence of pus: presence means survival, absence means death. Pus allows toxins to dissipate externally, leading to survival; lack of pus causes toxins to attack internally, leading to death. Therefore, thick pus with thick scabs is superior; insufficient pus with thin scabs is secondary; the worst is generalized vesicles. However, if vesicles account for seven or eight parts with two or three parts of thin pus interspersed, survival is possible. The worst case is dense, confluent lesions without distinct grains. If there is pus under the skin, or if they are dense and ulcerating with wet pus discharge, survival is still possible. Only dry, pus-less lesions, or those with thin pus less than two or three parts, will inevitably die from itching and collapse, with no hope of recovery. Thus, regulating and promoting suppuration after complete eruption is as urgent as saving someone from drowning or extinguishing a fire; it cannot be delayed.

When Qi and Blood flow smoothly, toxins transform into pus. Failure to form pus has two causes: First, excessive toxin-fire causes blood dryness and coagulation, preventing transformation into pus. Lesions appear dry, red-purple, or scorched-black, indicating intense toxin and blood stasis. Urgently use Qingdu Huoxue Tang (Clear Toxin and Invigorate Blood Decoction); if accompanied by irritability and thirst, remove Renshen (Ginseng Radix) and Gancao (Licorice Root), and add Maidong (Ophiopogon Tuber) and Huafen (Trichosanthes Root) 8 fen. Second, Yuanqi (Primal Qi) deficiency causes blood coldness and contraction, also preventing pus formation. Lesions appear pale white, not pointed or round, with no red halo at the root, indicating Qi deficiency and blood retraction. Urgently use Shenguilurong Tang (Ginseng, Angelica, and Deer Antler Decoction) or Qianjin Neituo San (Thousand-Gold Internal Support Powder). Severe cases may see lesions turn red and vibrant after one or two doses. For lethargy during the pus-forming stage, cold extremities, and poor appetite, add Muxiang (Aucklandia Root) and Dingxiang (Clove) 5 fen, Guanzi Gui (Cinnamon Bark) 5 fen. For chills and teeth grinding, add Guanzi Gui 3 fen and Zhifuzi (Prepared Aconite Root) 8 fen. For diarrhea, remove Danggui (Angelica Sinensis), add Shenqu (Massa Medicata Fermentata), Baizhu (Atractylodes Macrocephala Rhizome), Jiubaishao (Wine-processed White Peony Root), and Fuling (Poria) 8 fen, Muxiang 3 fen, Dingxiang 3 fen, and separately administer Shenshu San (Ginseng and Atractylodes Powder). No formula is more excellent for stopping diarrhea and supporting pus formation. Deer antler (Lurong) has potent blood-nourishing effects, differing from herbal medicines. Since Lurong may be unavailable, Qianjin Neituo San is recorded as an alternative, with the same modification rules.

Failure to treat after complete eruption leads to stagnant pus and the onset of "Five Collapses" (Wu Xian): White Collapse, Gray Collapse, Purple Collapse, Black Collapse, and Blood Collapse. Dense, red-purple lesions with depressed tops indicate Purple Collapse. If severe, it turns into Black Collapse. This is caused by intense heat-toxin closing Qi mechanism and congealing Blood. Use Qingdu Huoxue Tang; if accompanied by irritability and thirst, remove Renshen and Gancao, add Maidong and Huafen 8 fen. At the Purple Collapse stage, one or two doses usually cause immediate elevation of lesions with miraculous effect. By the time it becomes Black Collapse, toxin penetration is deep; even with treatment, eight or nine out of ten cases die.

Dense lesions that are pale white, with no red halo at the root and depressed tops indicate White Collapse. If severe, it turns into Gray Collapse. This is caused by Qi and Blood deficiency, failing to transform toxins into pus. Use Shenguilurong Tang or Qianjin Neituo San, with modifications as described above.

Another type presents with bright red lesions or bleeding without pus formation. This indicates Qi failing to control Blood, causing Blood to overflow and occupy Qi's position. See the previous discussion on Qi and Blood. Greatly tonify Qi using Shenqi Tang (Ginseng and Astragalus Decoction). After administration, lesions turn white and form pus. Otherwise, persistent bleeding leads to Qi deficiency and Blood Collapse. Treatment remains the same. Blood Collapse resembles Purple Collapse but is pale rather than purple. Purple Collapse is Heat-type, with coarse breathing and fever. Blood Collapse is Deficiency-type, with weak breath and cool body; differentiation is crucial. He Xiqiu’s discussion on Five Collapses was vague; Guan Tongjing clarified it.

For those suffering from Five Collapses, treatments are listed above. Cases where lesions are not depressed but lack luster, or where Qi deficiency results in less than three or four parts of pus, or where pus is clear and thin, or where pus fails to fill even after two to three days, are difficult to heal. Use Shenguilurong Tang to promote sufficient pus, or Qianjin Neituo San. If pus is insufficient, Chicken Comb Blood Wine may be used. Take a large rooster aged three to four years, warm one cup of good wine, prick the comb to let blood drip into the wine, mix well, warm again, and drink. Temporary dryness and pain after ingestion are acceptable; do not kill the chicken.

Another scenario involves dense pox with intense toxin-fire, yet deficient Yuanqi, weak Qi and Blood, and depleted essence, failing to control fire. This leads to deficient fire steaming upward, causing sore throat or epistaxis. Warm tonification is poorly tolerated, preventing pus and scab formation. This is common in older individuals with long-term indulgence and depleted Qi and Blood, making it very difficult to treat. Contemporary physicians often see heat signs and indiscriminately use cooling formulas like Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction). They fail to realize that these symptoms arise because Qi and Blood cannot overcome toxins. Using pure cold herbs further depletes Qi and Blood and allows toxins to run rampant, leaving no hope for survival. Such cases are rarely curable and pitiable. We now specially formulate Shenmai Qingbu Tang (Ginseng and Ophiopogon Clearing and Tonifying Decoction); frequent administration ensures safety.

Between five to six days and seven to eight days after eruption, if pus does not form, use Shenguilurong Tang to support. Use raw Huangqi (Astragalus Root) without modifications. If pus does not rise, there is no hope. If four or five parts of pus exist, survival is possible.

During the suppuration phase, vomiting and diarrhea occur with varying symptoms. There are two types of vomiting and two types of diarrhea.

Vomiting sour/bitter sounds with relief afterward indicates toxin-fire rising. Lesions are red-purple. Use Lianzhi Erchen Tang (Scutellaria, Gardenia, and Two-Chen Decoction) slowly; stop after vomiting ceases. Do not use Erchen Tang lightly; Longgu (Dragon Bone) or Huoxiang (Patchouli) may be used instead.

Vomiting without sound, non-acid/non-bitter, followed by fatigue and loss of appetite indicates damaged Stomach Qi. Lesions are pale white. Use Shensha Hewei San (Ginseng and Amomum Harmonizing Stomach Powder), see previous Fever section.

Diarrhea with yellow, foul stool and dark, scanty urine indicates toxin dispersion. Lesions are red-purple. Use Jiawei Siling San (Modified Four-Poria Powder), taken before meals.

Diarrhea with slippery, clear, white stool indicates deficiency-cold. Lesions are pale white. Use Shenshu San, taken warm before meals, or mixed with rice gruel. Alternatively, remove Baizhu and add Chishizhi (Halloysitum Rubrum) and Gusuibu (Drynaria Rhizome) to stop diarrhea. For persistent deficiency-slippage unresponsive to previous remedies, combine with Qiwei Doukou Wan (Seven-Ingredient Cardamom Pill). These pills/powders should be prepared in advance by families treating pox to prevent deficiency-slippage. Sudden persistent diarrhea during swelling/scabbing stages is critical. If decoctions and Yigong San (Yi Gong Powder) fail, only these pills/powders work. For heat-toxin diarrhea, Jiawei Siling San stops it in one or two doses.

During swelling/suppuration, constipation for six to seven days with irritability and pain indicates intense toxin and blockage. Use previous Qingdu Hexue Tang, remove Renshen and Gancao, add Huainiu Xi (Achyranthes Root) 2 qian, raw honey half cup, Zicao (Arnebia Root) and Danggui doubled. If still blocked, add Jiu Da Huang (Wine-processed Rhubarb) for mild purgation. If still blocked, insert pig bile into the anus. Never use Xiaoyan (Mirabilite) or Da Huang for purgation, as post-purgation complications are dangerous.

During suppuration, cool body with continuous sweating requires Guiqi Tang (Angelica and Astragalus Decoction). If phlegm is present, use Baifuzi (Typhonii Rhizoma), ground in hot water. Do not use Erchen Tang, as it dries Yangming, leaving isolated Yang without Yin, preventing transformation. It is safe to use during the scabbing stage.