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When the smallpox (or variola) reaches the stage of pustule formation, the latent toxins and the body's essence are forced to the exterior by heat. Therefore, at orifices such as the eyes and nose, body fluids accumulate, leading to "sealing and blocking" (Fengsai, accumulation of fluid causing obstruction). However, this must occur after swelling and pus formation; this is the normal presentation. Thus, if sealing occurs on the third or fourth day, it is unfavorable, indicating that the toxin has not yet reached the exterior and pathogenic fire is flaring upward. If sealing occurs after the fifth day, it is favorable, indicating that Qi and blood are充盈 (full) and essence is not leaking out. If the sealed area is smooth and lustrous like glue or fat, it is auspicious. If it appears dry and black like coal, it indicates dryness and withering of the Zang-Fu organs and depletion of body fluids. If it flows like pus, it indicates internal burning by toxic heat and leakage of essence, which are ominous signs. If sealing occurs but opens up on the sixth or seventh day, one must guard against the possibility that the toxin remains uneliminated and attacks inwardly, which would be even more critical. This exception does not apply to cases with sparse lesions.

The shoulder and back are areas connected to the Five Zang Organs. They should ideally be sparse, red, and vibrant, and must avoid being dense, scorched, and purplish. Since infants often lie supine, the lesions on the shoulders, buttocks, and back are prone to friction from turning over. If the lesions are healthy, they will naturally be firm, thick, and durable; otherwise, scabbing (Shouye) may be delayed, leading to rupture and ulceration. The most undesirable presentation is when lesions resemble burns from hot water or fire, with skin peeling off, or when lesions spontaneously rupture and discharge clear fluid, becoming dry, black, and scorched, accompanied by red, scattered, and spiritless eyes. Cases where there is no pus, with flat, scorched, and purplish lesions, are incurable.

At the initial stage, if the skin is dry, it indicates closed pores (Couli) and blocked body fluids; treatment should focus on dispersing the exterior to promote eruption. If lesions appear dry, rough, and lacking luster upon emergence, it indicates deficiency of Ying-Blood, exacerbated by wind dominance and fire burning, leading to further dryness; treatment should focus on cooling the blood and nourishing blood. If lesions become dry during the swelling phase or just before maturation, it indicates insufficient Ying-Blood and further loss due to pus formation, failing to irrigate the skin and hair follicles and regulate the meridians; treatment relies solely on tonification.

The *Classic* states: "Excessive heat causes flesh to rot." Therefore, foul-smelling lesions are invariably caused by fire forcing toxins outward. However, many patients survive because the toxin is transformed and discharged via the Yangming channel. If the lesions are foul-smelling, black, rotten, and pitted, accompanied by a lack of spirit in the eyes, it indicates exhaustion of Yuan-Qi and is a fatal sign. Conversely, if lesions are foul-smelling but red and vibrant, with flowing pus and blood; foul-smelling but not dry or itchy; foul-smelling but not spreading into painful toxic areas; foul-smelling but the sac does not completely detach; foul-smelling but skin and flesh are not black and rotten; foul-smelling but without bad breath in the mouth; foul-smelling but not rotting down to the tendons; foul-smelling but with steaming body heat, clear voice, and ability to eat—these are all signs of survival. Treatment requires burning mugwort (Aiye) and shepherd's purse (Yuansui) to dispel foul odors, wiping the affected areas with decoctions of Cimicifugae Rhizoma (Shengma) and Perillae Folium (Zisu), maintaining cleanliness of clothes and bedding, and internally administering herbs that lift and tonify. If lesions on the crown, hypochondrium, chest, neck, and axilla are four-sided rotten, foul, black, and deep enough to expose bone and tendon, it is inevitably fatal. If foul odor appears before pus formation and toxin transformation, it indicates pathogenic fire acting unchecked and premature leakage of Wei-Qi, leading inevitably to Yang exhaustion and Yin depletion.