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When the smallpox rash first appears, one must observe whether the color is flourishing or withered. Once noticed, if the lesions are coarse, plump, and sparse, a poor prognosis can be certain. If initially erupting like fine scales, densely packed, it indicates severity; if accompanied by fever and lesions emerging sequentially, although dense, there is still hope for rescue. If all lesions surge out at once with thin, raised red skin, even if sparse, not all may survive. If the white heads are fine like pustules, they will inevitably undergo internal attack after drying; if shaped like chirping red dots resembling erysipelas, they will surely dry up, wither, and become scorched and emaciated. If the trend is coarse and plump, but the apex remains non-red and ultimately sunken white, or if the head is sharp with thin skin showing periwinkle-like wrinkles, it indicates empty blisters (lack of pus). However, infants' muscle textures differ, so judgments cannot be made uniformly. Tender skin implies thin epidermis and unnatural redness; yellow and emaciated bodies result in brownish lesions; dark-skinned individuals have coarse skin, and colors appear grim. More favorable signs include lesions bursting with spirit, appearing like pearls or millet grains, with lustrous color and calm spirit. Taboo signs include profuse, red, dry eruptions spreading over the body, turning purple or scorched, with withered hair and shriveled skin. Even if emerging with heat simultaneously, fear that they are as dense as needle points. Even if emerging sequentially, shapes resembling silkworm eggs, bran, nodules, rashes, or scabies, lacking roots and bases, are highly contraindicated. Violating these conditions is termed incurable. If mixed with macules like mosquito bites, more malignant than snakebites, or resembling snail-shell clouds/lightning, this stage is slightly more salvageable. But do not assume safety immediately. A few spots appearing before fever, commonly called "reporting smallpox," followed by prolonged fever without further eruption, should be viewed as carbuncles. Hard masses appearing before sores are named "foolish toxins" and will definitely arise; sores appearing before hard masses are named "ghost swellings" and are difficult to heal. Avoidance of smallpox in hidden areas predicts misfortune in eyelids, lips, and ribs. Stagnation in vital areas portends ill omens in the tongue, throat, chest, and back. Favorable cases tolerate many lesions; unfavorable ones fear even a single point. Cold carbuncles appearing first obscure other sores; thief smallpox prevents other lesions from filling with fluid. Accurate identification requires urgent puncture. If interior symptoms are unbalanced, though toxin exits, it remains inside; regulate to calm the body. If heat exists but toxin is on the surface, treat accordingly. For toxins inside, promote muscular dispersion and add detoxification; for toxins outside, tonify and disperse, prioritizing stabilizing the exterior. If interior and exterior symptoms are balanced, no excessive treatment is needed.

The course of smallpox lasts only fourteen days. From the appearance of spots until the seventh day, it resembles flower buds opening. Its qi grows daily strong; after seven days, qi converges and flowers fade. Therefore, medication should be taken continuously day and night before the seventh day, without indulgence, facilitating blister formation through continuous toxin-fire action. Treatment after seven days is futile. Smallpox toxin in blood and qi is like chaff in rice. Only when blood and qi are sufficient and circulation rapid, like sifting rice continuously, does chaff separate and gather into a ball. Thus, sufficient and circulating blood and qi prevent toxin stagnation in Ying and Wei, allowing timely suppuration and crusting without damaging flesh. It merely collects red toxic vapors from skin and flesh into the follicles. Wise physicians administer blood- and qi-tonifying herbs immediately after spot appearance to aid movement and expulsion. Alas! Ignoring this principle and using only toxic substances to induce smallpox is flawed. Using toxicity to combat toxicity rarely prevails universally. Although smallpox emerges, the function of pus formation and crusting cannot be achieved by toxic substances. With deficient Ying and Wei, using harsh toxic dispersants harms the center and exterior. Though toxin floats outward, the interior is hollow; if medicinal power slackens, toxin hides internally, making rescue impossible.

If lesions surge out after several days of fever, inquire if there was intermittent fever previously. If yes, judge according to delayed timing. If no prior fever, but current fever coincides with immediate eruption, this indicates deficient exterior qi and abundant toxic vapors. Heat in Ying and weakness in Wei lead to loose pores, or toxic impact causes collapse where Wei qi fails to constrain externally, resulting in sudden eruption. Treatment should prioritize interior support and detoxification, followed by exterior-strengthening agents to prevent itching and ulceration. However, eruptions occurring after five to six days of fever require examining causes for internal injury or external contraction. Prolonged heat from these causes sinks into the Kidney, combining with accumulated smallpox toxin, causing delayed eruption, which cannot be judged by standard timelines. Without these two causes, persistent long-term heat indicates Spleen qi deficiency failing to expel toxin, leading to lingering toxin in organs. Few initial spots increasing daily indicate internal toxin retention due to weak interior qi unable to push it out. Use interior-supporting agents first to accelerate eruption, then tonify the middle and detoxify to avoid sinking and inverted crusting. Some constitutions are naturally robust with thick skin and dense flesh, hindering toxin release. Others are naturally weak, susceptible to wind-cold, causing pore closure and stagnant blood/qi, preventing expected eruption. These must be treated differently. If eruption persists despite treatment, toxin is obstructed in the San Jiao, leading to complications soon. For abdominal distension, constipation, restlessness, high fever, and rapid pulse, mild purgation is indicated. If spots are faintly visible within the skin, cold has been expelled to the exterior, and purgation is contraindicated.

Uniform smallpox qi leads to rapid eruption. Uniform exterior qi ensures free Wei qi flow; uniform interior qi ensures unobstructed Ying qi flow. Thus, beyond releasing the exterior, promoting qi movement in both interior and exterior is common. Eruption should be gentle, like spring growth, ensuring smooth blood and qi flow for easy emergence, swelling, suppuration, and crusting. Excessive heat consumes qi via vigorous fire, weakening it further. Excessive cold causes qi stagnation, also hindering flow. Dense lesions like needle points should be analyzed by meridian regions: forehead corresponds to Heart, face to Stomach, abdomen and limbs to Spleen, flanks to Liver, eyes to Lungs, lower body to Kidneys, shoulders and back to Bladder. Address symptoms urgently to clear interior obstruction for subsequent tonification. Abundant smallpox means abundant toxin, requiring detoxification, but insufficient blood/qi circulation necessitates simultaneous major tonification to aid pus/blood formation. Sufficient blood and qi transform and carry toxin, controlling it regardless of density, except when blocking vital meridians.

Observing smallpox, some start dense then sparse, indicating mixed rashes/macules. Initially, red spots are indistinguishable; during elevation, only smallpox remains, appearing dense then sparse. Others start sparse then dense, indicating favorable or unfavorable courses. Text states mild cases erupt in three to four waves of varying sizes, appearing sparse then gradually dense—this is favorable smallpox, auspicious. Initial observation shows only 3-5 vague spots on face/chest with swollen/hard bases; upon elevation, they surge together, appearing sparse then extremely dense—this is unfavorable smallpox, ominous. Sequential eruption indicates sufficient righteous qi constraining light toxic vapors. Simultaneous eruption indicates deficient exterior and abundant toxin, unable to constrain, leading to chaotic eruption. The Spleen binds externally; Spleen deficiency leads to rupture. Qi expands internally; Lung governs Qi, Lung deficiency hinders elevation. Blood nourishes bases; Liver governs Blood, Liver deficiency fails to moisten. Water/Wood sources relate to Kidney governing water; Kidney deficiency causes dryness, blackening, and sinking. Itch and pain relate to Heart; Heart governs Fire. Excess Fire causes pain; deficient Fire causes itch.