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Warm hands and feet are a favorable sign in smallpox. If during the pustule formation stage, the hands and feet are hot and sweating, this indicates toxic heat stagnating internally, inevitably leading to obstruction of urination and defecation, with a deep, slippery, rapid, and frequent pulse. The treatment should focus on promoting the unblocking of these two passages. If there is cold extremities (coldness of the four limbs), this signifies impending collapse of Yang Qi and spleen-stomach deficiency, inevitably accompanied by incessant vomiting and diarrhea, with a deep, fine, minute, and weak pulse; urgent warming therapy is required. If the hands and feet become warm after taking medicine, it indicates survival; if they remain cold, it indicates death. If there is obstruction of urination and defecation, restlessness, delirium, abdominal distension, panting, thirst, a deep, slippery, and rapid pulse, and non-elevated lesions, this is "Yang Jue" caused by toxin sinking inward; heavy purgation to drain toxins is indicated.

During the pus-forming stage of smallpox, if there is coughing with sputum, or sputum mixed with pus and blood, throat discomfort, and reduced appetite, this is due to lung invasion by fire pathogen and insufficiency of body fluids, resulting in sticky phlegm. Since internal ulcers are also present, pus and blood mix. Treatment should primarily focus on clearing the lungs, resolving phlegm, and benefiting the throat. After scabbing falls off, the condition will naturally stabilize; do not recklessly use strong cooling agents.

The pus within smallpox lesions is formed by the steaming of blood in the body. Therefore, when lesions are dense and pus/blood are widespread, body fluids are consumed. The Heart governs blood; blood deficiency leads to an empty Heart residence, causing heart heat, emptiness, irritability, and insomnia. Zao Ren Tang (Semen Ziziphi Jujubae Decoction) is indicated. If Heart deficiency is severe, leading to excessive sleepiness, muttering in dreams as if speaking to others about strange matters, and being unrousable, An Shen Wan (Calming Spirit Pill) is indicated. However, if toxins attack causing mental confusion, loss of spirit and will, and incessant delirium, it is a critical condition (bad syndrome).

Grayish-white, itchy, and collapsed smallpox lesions indicate deficiency and weakness of Qi and Blood transforming into deficiency-cold. The Yang aspect is where Qi resides; the Yin aspect is where Blood resides. When Yang Qi is weak, it sinks into Yin; when Yin Blood is abundant, it invades Yang. Qi deficiency allows Blood to advance; Blood deficiency allows Qi to encroach. This is natural law. The itching and collapsing occur because Blood invades the Qi aspect. Blood has a salty taste, which irritates the skin and flesh, causing scratching, bleeding, and damage. The more deficient the Qi, the more severe the itching, inevitably leading to Qi collapse and lesion flattening. Treatment should use Bao Yuan Tang (Protect the Origin Decoction), doubling the dosage of Huangqi (Astragali Radix) to support the exterior, adding a small amount of Shaoyao (Paeoniae Radix Alba) to restrain Blood, and adjusting according to circumstances to stop itching. Furthermore, overconsumption of toxic foods may stir up Middle Qi, causing body fluids to move outward, forming vesicles or bullae. With extreme Qi deficiency failing to contain them, fluid leaks into muscle layers, becoming stagnant and unable to move forward or backward, causing incessant itching and skin penetration. Some resemble burns/blistering from boiling water, which is an untreatable condition. Generally, Qi deficiency manifests as numbness, itching, and sinking; Blood heat manifests as dryness, roughness, and pain. White lesions must turn gray; gray lesions must flatten, itch, and collapse. These result from Qi deficiency failing to cause elevation and Blood deficiency failing to provide luster. Thus, treatment focuses on greatly tonifying Qi and Blood. If there is internal heat, slightly add clearing, draining, and detoxifying herbs to activate Blood and move Qi, so white can turn red. If only Qi is tonified without nourishing Blood, Qi becomes drier and hotter, worsening itching and collapse. Therefore, some cases involve itching due to Qi losing its protective function; some due to Blood failing to nourish; some initial itching due to fire pathogens; some severe itching due to violent toxic vapors; some post-scab itching due to new Blood generation. Deficiency-cold itching is common, while excess-heat itching is occasional. If lesions that were previously red, vibrant, and full suddenly itch, it is likely triggered by foul air. Internal Shiquan Dabu Tang (Complete Great Tonifying Decoction) and external Artemisiae Scopariae fumigation are indicated. If lesions are originally dry and intensely itchy, Fire is severe. If lesions are watery, thin-skinned, and itchy, it is meridian heat. During elevation and pus formation, if itching is due to Qi/Blood deficiency and empty muscle layers, it is deficiency itching; Shiquan Dabu Tang modified is generally used. Symptoms vary, so treatments differ. Itching due to inability to eat bland food: use Chantui Gao (Cicada Slough Paste). Dry itching: nourish Blood and moisten dryness. Wet itching: nourish Qi and remove dampness. Excess patterns have forceful pulses and robust Qi; deficiency patterns have weak pulses and depleted Qi. Excess itching presents with high fever, red-purple dryness; deficiency itching presents with pale color, weak posture, and cool body. Treat Qi weakness/deficiency by nourishing and solidifying the exterior; treat Spleen/Stomach excess by clearing interior and detoxifying to stop itching. If mature lesions itch and are scratched open due to spleen-stomach weakness failing to nourish muscles, use Sijunzi Tang (Four Gentlemen Decoction) added with Huangqi and Guigui (Cinnamomi Cortex). If diarrhea causes spleen-stomach deficiency leading to itching/collapse, urgently administer Muxiang Yigong San (Costus Root and Mutual Attack Powder). If itching is due to toxic food, use Sijunzi Tang with detoxifying herbs. Lesions half-filled with pus that itch can still be treated. Lesions adhered to skin, empty shells like lotus pods, head shaking, neck twisting, limb movements, and coma are all fatal signs. Itching during pus formation is mostly ominous. One must observe the onset site, etiology, and clinical state to determine treatment and prognosis. Observing onset: If itching stops upon stroking and obeys commands, but facial itching is incessant with skin peeling and flesh drying, it is ominous. Observing etiology: If due to vomiting/diarrhea/poor appetite causing weak spleen/stomach and un-nourished Qi/Blood, it is deficiency itching; use warming tonification. If due to foul air stirring evil fire, it is sudden itching; use fumigation and resolution. If lesions are mature, pathogens cleared, Zheng Qi growing, Qi/Blood harmonious, and mild fire retreating causing gentle itching, it is a good sign requiring no medicine. Spontaneous itching without cause indicates bad smallpox destined for poor outcome. Observing state: If itching comes and goes, spirit is clear, patient does not scratch but desires touch, there is hope. If scratching is constant, spirit is dull, thrashing wildly, head shaking and neck twisting, death is certain; do not treat.