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When the first blood spot appears, its color and form are not yet distinct; this is a manifestation of Yin. Blood initially carries the pathogenic toxin upward, exiting through orifices, without yet being constrained by Yang, yet its physical structure is established. Subsequently, changes occur as Yang begins to intersect; Yin Qi can position itself and control the lower aspect. Thus, Qi manifests internally, while Blood circulates externally. Internally, there is a slight whitish hue, while externally it remains pale red. However, since the momentum of abundant Blood has not subsided, this belongs to the phenomenon of slight Yang. Further transformation occurs as Qi becomes dominant internally, restraining Blood to transform toxins. When Qi is harmonious and Blood adheres, the hierarchy is correct, and the root becomes round and integrated. The whiteness inside gradually enlarges, while the pale red outside gradually thins, representing the phenomenon of slight Yin. In further evolution, Blood retracts and Qi becomes sufficient; toxins transform into pus. With Blood fully充盈 (filled) inside, it becomes round and firm. White turns yellow, and the red halo transforms into Blood. Both toxin and Blood momentum descend, representing the phenomenon of Pure Yang. Nevertheless, this toxin, despite differences in size, sparsity, and density, shares a common nature across thousands of shapes. Its varied manifestations constitute its "emotion" (dynamic state). Nature arises from Yin and Yang, while emotion can be transformed. Can nature be altered by human effort? Therefore, treatment must adapt to these changes. At the initial stage of Yin-Yang intersection, when Yang meets Yin and the summer-skin-like appearance is indistinct, unless one is a sage physician who understands deficiency, excess, cold, and heat, one should not lightly administer purgatives, lest drug properties cause chaos and disrupt the mechanism of Qi-Blood intersection. If Qi positions itself and Blood returns to its place, each following its natural course, what medication is needed? Only if deviation occurs is treatment appropriate. Harmonizing the purple stagnation of Qi and Blood achieves the wonder of intersection, naturally expelling toxins successfully without fault.

(For details not covered herein, please refer to the General Discussion on Key Points of Smallpox.)

Rashes originate from Heart Heat, while macules arise from Stomach Heat. Macules are the surplus of Blood, characterized by colored spots without granular heads. Generally, variola (smallpox) erupts from the Zang-Fu organs with rapid momentum. In cases of severe Blood Heat and toxin abundance, Blood exceeds while Qi fails to defend; Qi is sparse and deficient, unable to densely network the vessels. This excessive Blood allows the floating fire of the San Jiao (Triple Burner) to erupt as macules, thus carrying toxins upward. However, once the variola toxin is fully expressed, internal deficiency inevitably follows. Internal deficiency causes macules to resolve from within. If they do not resolve, light agents should be used to disperse Fire pathogens, combined with herbs that invigorate Blood and detoxify. Initially, exterior-releasing methods are mostly used; later, resolving and promoting methods are suitable. Once macules recede and Blood adheres, tonifying medicines should be immediately administered to prevent damage and sinking complications. However, macules that are crimson like fire indicate stagnant toxins unable to diffuse. Cases where scabs form and then re-erupt indicate residual toxins with intense heat, boiling the flesh, causing macules to ulcerate. Antidotal measures are required, and ulcerated areas should be treated with Shengji San (Flesh-Regenerating Powder). Red macules are easy to resolve; purple macules are slightly difficult. Blue and black macules indicate extreme toxicity and heat, which are incurable. If sores appear and macules recede, it is auspicious. If macules recede and sores appear firm, it is also auspicious. Otherwise, skin maceration and itching of sores may occur. If red macules form knots resembling locust trees, with swollen and hard flesh, it is called Danliu (Red Tumor). Its toxicity is most fierce; often, sores have not yet formed, but ulceration occurs here first, making it largely incurable. In summary, macules and rashes must be made to recede, allowing variola to manifest alone for the best outcome. Otherwise, both Qi and Blood will be doubly depleted, and all Zang-Fu organs will become diseased.