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Three days after the appearance of spots. Life and death are decided at this time. Making a judgment here is what qualifies one as a high-level practitioner. The key point lies in the face. The face is the head of all convergences (of Yang meridians). Among them, the Tian Ting (Forehead) and Yin Tang (Glabella) are the most critical parts of the face. The Tian Ting is the handle for observing smallpox, because it is where the Yuan Shen (Primordial Spirit, i.e., Yuan Qi/Essential Qi) returns. Yuan Shen is Yuan Qi. For children developing smallpox, it boils down to three characters: Qi (Vital Energy), Blood, and Toxin. Qi and Blood are governed by Yuan Qi. If Yuan Qi overcomes the toxin, the lesions will open and fall according to schedule; if the toxin overcomes Yuan Qi, it will attack internally and peel externally. Since the toxin has already prevailed, how can we expect Yuan Qi to regain dominance? Therefore, if spots appear first, rise first, penetrate first, and crust first in these areas, being dense and itchy, miserable and dark, they are all signs of death. The toxin emanating from deficiency is indeed true.

Whenever the spots are distinct and scattered, palpable with resistance, and lustrous and moist, appearing first below the eyes while body heat gradually subsides, it is an auspicious sign. "Distinct and scattered with resistance" means sparse yet spirited. "Lustrous and moist" refers to having color/luster. If spots appear later in the Tian Ting area, it indicates that Yuan Qi is solidified. The opposite is adverse.

When smallpox first emerges, those appearing in clusters of three or five will likely become dense later; those appearing singly will be sparse. The depth of the toxin can be anticipated from this.

Form belongs to Qi, color belongs to Blood. Both can verify auspiciousness or inauspiciousness, and decide life or death. Why do people only speak of Blood and neglect Qi? Because Qi is formless and hard to know, while Blood has color and is easy to see. Thus, within three days of spot appearance, if the color resembles pig liver, it is fatal; if it resembles red rice grains, it is fatal; if it resembles washed old red cloth, the color is too heavy [and fatal]. Although there may be dozens of spots on the face, if they have spirit and luster, the patient can still be saved. Do not worry about bad form, but worry about lack of spirit; do not worry about bad color, but worry about lack of luster. Spirit manifests as protruding and distinct; luster manifests as moist and bright. Even among severe smallpox cases, seeing one or two reddish, fresh, and lovely spots indicates that although the prognosis is ominous, it turns auspicious because Yuan Qi still exists. Generally speaking, as long as there are a few pleasing and lovely spots above the eyebrows, which are not琐碎 (trivial/cluttered) nor slanted, even if the whole body is densely covered and various complications arise, death will ultimately be avoided. The term "pleasing to the eye" is difficult to fully express with words and brushes; it must be understood intuitively by students.

If the scalp is scorched and the facial color is purple upon spot appearance, it indicates blazing toxin in the Blood aspect. Treat with Mantianqiu Decoction. Dry lips and tongue coating indicate obvious heat; if yellow coating arises, treat with Qianlima Decoction. Generally, although scorched and purple colors indicate blood heat, it may not necessarily stem from internal heat. Examine the tongue to ensure appropriate medication.

If spots appear white like water droplets, the condition is severe. If they are sparse and not dense, and the person usually has a sallow complexion accompanied by poor eruption of spots, it means Qi arrives but Blood does not. One should administer methods to scatter fire. If the spirit is not calm internally, and spots increase daily, becoming pointed and painful with a sub-form (sharp protrusion), the toxin is too excessive, and it is feared that medicine cannot cure it. If spots are white, not red, one should not immediately treat as deficiency. If white without spirit, with pale lips and tongue, or vomiting/diarrhea, it is a deficiency syndrome. If white but rising with color, and lips/tongue are crimson red, it is not deficiency; it is a hidden-fire smallpox. After three days, it will gradually turn red-purple. Treating it as deficiency would cause significant error. If the feet are cold upon spot appearance, there is no need to worry; this is because Qi has not yet descended.

Two days after spot appearance, if stool remains constipated and there is no tongue coating, it is known as dry Blood, not toxin stagnation. Urgently perform clearing and resolving treatments using Zhike (Fructus Aurantii) and Xuanmingfen (Natrii Sulfas). Fear that during the pus-formation stage, sore throat and diarrhea may occur leading to failure to erupt. In the formula, Danggui (Radix Angelicae Sinensis) and Chuanxiong (Rhizoma Chuanxiong) should be doubled.

At initial appearance, if spots vary in size, with colored dots resembling prickly heat, it is called "Jia Zhen" (Smallpox complicated by Rash). Treat with Jiuku Dan. Another type consists of tiny,琐碎 (trivial) red dots faintly appearing between muscles, called "Jia Sha" (Smallpox complicated by Sand-pox). Treatment is the same as above. This applies to smallpox cases as well, but such complications must present with positive smallpox spots that are pleasing and lovely; otherwise, they are just smallpox. Experts should distinguish carefully.

There are cases where a few smallpox spots emerge, but rashes cover the whole body, round and clean, sparse and clear, with fresh red color, disappearing completely after two days. All physicians were astonished. I said it is rash, not smallpox. Smallpox disappearance must involve confusion and irritability, whereas this case was quiet, and the main smallpox spots remained. Hence I knew it was rash. Treated with a mild agent, it gradually healed. It was difficult to distinguish before disappearance.

Body heat upon spot appearance indicates toxin is not exhausted. However, the pathogen differs: some have external constriction by cold, others have internal depression of heat-toxin. Both require dispersal; Jiuku Dan is the treatment. If internal depression presents with yellow coating, add Qianlima Decoction. If color gradually becomes scorched purple, spots remain hidden, and body heat is intense, or skin is swollen and shiny, add Saichunlei Decoction to vent.

Spontaneous sweating upon spot appearance can lead to survival or death. Zhu Danxi stated that spontaneous sweating is harmless, referring to cases with good form and color. If sweating occurs and form/color deteriorate daily, death is certain; this must be distinguished. However, when treating symptoms, do not worry about this. If it is a deficiency syndrome, observe the tongue for medication.

Whenever smallpox fails to erupt quickly, one must consider the season for treatment. In winter, cold constrains; use Saichunlei Decoction. In summer, heat constrains; use Mantianqiu Decoction. However, there are also differences between deficiency and excess. If lips and tongue are moist with no coating, treat as deficiency.

One type: Spots are white, poorly erupted, lips and tongue are pale, with vomiting/diarrhea, abdominal distension, spontaneous sweating, cold limbs, and timid spirit. This is exterior-interior deficiency. Treat according to deficiency principles.

Another type: Spots appear on the navel or around the anus in clusters. These are all severe conditions.

Erupting a few spots followed by several on the Shan Gen (root of nose) is severe. Voice changing immediately upon eruption, becoming hoarse or aphonic, is especially severe.

Erupting a few spots, then face and eyes becoming bright like claws, with foul breath rushing out, leads to rapid death. Later, macules will appear, leading to death from hematemesis.

Spots appearing first above the eyebrows or on both temples, protruding brightly, then disappearing shortly after, is "Fu Dou" (Endowed Smallpox), which is fatal.

Another type appears lovely initially, with thin, bright skin, growing large in one or two days. This is "Wei Zhi Er Zhi" (Arriving before its time), caused by epidemic qi. Later, itching and collapse will occur, leading to death. Mistaking this for a favorable course invites the accusation of medical homicide.

For patients with unresolved sores/toxins, or newly healed sores, who develop smallpox spots now, the condition is severe. This is Yang Toxin. But if the sores are not dry and red, although severe, it will not be fatal. "Treatable when possible, fatal when impossible" refers to dangerous syndromes. As for spots resembling snake skin, silkworm eggs, mosquito bites, flea marks, scalds, burns, blue-black macules, body feeling like beaten, macules, swollen lips, foul odor, neck swelling, head swelling, waist gap (no spots on waist), rootlessness, powder-white color like dead bones, chest fullness with panting, bleeding from seven orifices, oblique gaze like orange peel, abnormal form/color with convulsions/raving, and unceasing lower back/abdominal pain—can these be treated? No.

Regarding "waist gap" and rootlessness: it must be that the form and color of all spots are poor. If the form and color are round and lustrous, what harm is there if there are no spots on the waist and legs?