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After the heat toxin has penetrated for three days and the smallpox lesions begin to show their form, this is a normal occurrence and requires no comment. If the eruption exceeds the expected time limit without being complete, it is often due to qi obstruction; treatment must first distinguish between deficiency (Xu) and excess (Shi).

For several days, the lesions erupt with a steaming sensation but are uneven in distribution. One should decisively employ dispersing and releasing methods without hesitation. By adjusting herbs according to the formula and observing the lesion's progression, if the exterior and interior are harmonious, the original density of the lesions was sparse.

The eruption of smallpox generally requires uniform qi flow, and it is further advisable to maintain a gentle warmth like spring. Uniform qi leads to rapid eruption without stagnation; deviation towards heat or cold impedes qi movement.

The head and face are called the "noble head," and the throat is tight and narrow like a strategic pass. One must prevent the lesions from becoming too dense on the head and neck; if they lock the neck and cover the head, the prognosis is poor.

Lesions on the chest and face should ideally be sparse. Even if there are many on the hands and feet, there is no need to worry. However, if the entire body is extremely dense, one must fear that qi and blood cannot circulate throughout the whole body.

The initial appearance of the lesions is delicate and colorful, indicating tender and unfirm skin. If they melt and break, causing distress, but eventually fill with pus, it is a joyful omen.

When smallpox initially erupts, symptoms in the throat should be resolved. If there is throat bi (obstruction) or ulcers due to fierce toxic fire, one must fear later closure of the glottis, leading to hoarseness where treatment becomes futile.

If one fears the rash entering the eyes, ancient formulas have miraculous effects for vision. For eyes with excessive tearing and redness, urgently draining Heart and Liver heat prevents toxic attack on the eyes.

During the stage of smallpox development, one should not rigidly adhere to the number of days. The eruption should be gradual, and its development should also be gradual; this is called "moderate." If they all surge out at once, it causes flaccid swelling of the skin and flesh. If they all erupt simultaneously, this indicates deficiency of Exterior Qi, with toxins rushing out violently. Due to Exterior deficiency, they cannot consolidate, inevitably leading to itching, pain, and ulceration. Treatment urgently prioritizes rescuing the Exterior. If the lesions have fully erupted but fail to develop, this indicates Interior Qi deficiency, with toxins lingering and stagnating, unable to emerge, inevitably increasing irritability, abdominal fullness, and panting. This situation urgently prioritizes rescuing the Interior. However, smallpox develops in the muscles, governed by the Yangming Stomach Meridian. When Spleen Qi warms and Stomach Qi rises timely, there will be no risk of sinking or stagnation. It is like steaming in a basket; the goal is simply looseness.

Whenever smallpox develops, if the lesions are distinct and well-distributed, it signifies smooth Exterior and Interior, upward and downward discharge, and dissolution of toxins; this is a favorable (Shun) case. If lesions cluster together, with hard bases, resembling tumors that are red but not painful, nodules that are hard and immobile, or carbuncles that swell but do not suppurate, this indicates stagnant qi and blood that do not flow, ruined muscle tissue that does not transform, and accumulated toxins that do not resolve; this is an unfavorable (Ni) case. Within four to five days, death will occur due to itching and restlessness. Furthermore, if initially fine and dense, indistinct, and lacking defined granules, and upon development turning into large blisters filled with clear fluid and feeling empty/itchy, this indicates defensive qi failing to consolidate; this is an unfavorable case. Within two to three days, skin peels off, flesh dries, and death occurs from restlessness. All these are caused by malignant toxic qi and must be assessed during the emergence and development stages. Once suppuration is reached, these pathologies cease.

The emergence of smallpox relies primarily on the harmony of qi and blood. Sharp, round, and firm lesions indicate sufficient qi. Active and lustrous blood indicates sufficient blood. Red, active, yet flat and sunken lesions indicate blood has arrived but qi is insufficient. Round and solid but pale lesions indicate qi has arrived but blood is insufficient. Flat, collapsed, and gray-white lesions indicate both qi and blood are insufficient. Swollen, red, and bursting lesions indicate heat in both qi and blood. Upon reaching the development stage, lesions should be transparent and distinct, sharp, round, bright, strong, plump, and lustrous; this is superior. If the base spreads horizontally and the skin rises with water accumulation, this is secondary. If the apex does not rise and the base does not open, retaining the initial shape without new fluid generation, this is called incomplete development. If the constitution is originally robust, it likely involved wind-cold invasion, requiring exterior-releasing herbs. If the constitution is originally deficient, involving inability to eat or vomiting/diarrhea, tonifying Middle Qi while supporting the Exterior is appropriate. If after many days facing the sun, development remains incomplete, accompanied by irritability, crying, and aversion to heat, this indicates toxic heat in the Interior; urgently loosening the muscle layer, supporting internally while resolving external heat toxins, and guiding Heart fire downward is suitable. If delirium, hallucinations, and frequent manic shouting occur, this indicates accumulation of heat toxins in the Five Zang organs with exclusive dominance of Yang Qi and lack of Yin Qi to harmonize it; bowel movements will likely be difficult, requiring mild purgation to clear internal stagnation and facilitate external relief. If unconsciousness, abdominal distension, and panting occur, it is untreatable. In summary, during development, without haste or slowness, gradually growing sharp, round, distinct, bright, strong, firm, with red and active bases, indicates sufficient qi carrying blood through all lesions, naturally resulting in sharp, round, bright, and firm forms without needing medication. If red and active but flat with central depression, not sharp or round, tender color, thin skin, unable to become firm and thick, transforming into itching/collapse or stagnation/suppression, this is qi deficiency, requiring qi tonification. If lesion skin is thin and delicate, moist like dampness, this indicates qi cannot control blood, requiring qi tonification and blood cooling. If floating blisters rise emptily without fluid in the center, this indicates qi fails to transform blood and blood fails to attach to qi, transforming into itching/collapse or carbuncles; Shiquan Dabu Decoction (Ten Great Tonifying Decoction) modified is indicated. Progression from erythema to vesicles, to pustules, to scabs follows a natural order, which is auspicious. Reversal of this order, entirely due to dual deficiency of qi and blood and assault by evil fire, manifesting harm, or initial development showing white pus on the head regardless of location, is not a good omen, not limited to the lips.

On the third and fourth days, eruptions should be uniform down to the soles of the feet, indicating stability. If there is still a pattern of delayed eruption or hidden within the skin without appearing or developing, it is not due to wind-cold stagnation but rather internal deficiency and weakness. Therefore, before the fourth day, as toxins are just emerging, the body surface should be cool; after the fourth day, as toxins have stabilized, the body surface should be warm. Coolness harmonizes qi and blood, ensuring lustrous lesion color; warmth opens the interior, facilitating toxin transformation into pus. If the body is not warm at this stage, although not necessarily leading to watery lesions, smallpox growth will definitely be difficult. If fever persists or body pain continues, whether due to wind-cold pressure or summer-heat combination, without constipation, vexation, or panting, the pathology is in the Exterior, not the Interior. Ge Gen Tang (Kudzu Root Decoction) or similar muscle-loosening herbs should be used to release the exterior. Wait for exterior harmony so eruptions proceed smoothly, but avoid excessive sweating to preserve fluids.

By the fourth and fifth days, blood blisters should have formed, and development/swelling should logically follow. If large and coarse, with red bases and bright white apices, the potential for pus formation is established. If the redness is excessive, though appearing delicate and acceptable, if it persists for six days, it will inevitably end up as empty shells, with thin, flower-like skin bright as a lamp, containing only water inside. If the apex is sharp but the base is not red, pus formation will be insubstantial. Fierce heat toxins unresolved lead to purple or black colors. Obstructed and non-rising leads to sinking and collapse; stagnant and un-nourished leads to dryness, withering, green, or gray colors; weak and un-stirring leads to sluggishness or stopped pus formation. Flesh swells first while lesions do not rise, pus stagnates and does not flow; face becomes puffy while lesions recede, toxins are blocked and do not advance. If the body is not hot and lesions do not rise, forming ice-hard shapes, if redness does not change, warming can revive them. If qi and blood are weak and un-stirring, leading to sluggishness, if redness remains unchanged, tonification can generate life. Purple and dry/withered lesions require only blood-invigorating and muscle-loosening methods; strictly avoid warming with tonification to prevent stagnation. Although potent drugs can release and penetrate the muscle layer and are good prescriptions, for loose stools, warming and tonification should come first; for chronic diarrhea, assisting with lifting is key. This is the standard method for evaluating smallpox and the general principles of medication.