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For patients with **Biao Xu (Exterior Deficiency)**, the smallpox rash is easy to erupt but difficult to crust over; for those with **Biao Shi (Exterior Excess)**, the rash is difficult to erupt but easy to resolve. If **Li Shi (Interior Excess)** is present, the eruption is rapid and the condition is mild; if **Li Xu (Interior Deficiency)** is present, the eruption is delayed and the condition is severe. If Biao Shi coexists with Li Xu, the rash may sink inward or invert (collapse); if Li Shi coexists with Biao Xu, the eruption is slow and resolution is delayed, manifesting as ashen-white, non-red rashes that spread out but do not elevate, lack luster, erupt slowly, have dark sunken tops, and red roots that are not red. These are all signs of **Biao Han (Exterior Cold)** combined with deficiency. If urination and defecation are clear and smooth, the body is not cold, hands, feet, and breath from mouth and nose are all cold without thirst, appetite is low, lips are white, nasal discharge is clear, and food is undigested, these are signs of **Li Han (Interior Cold)** combined with deficiency. This is a syndrome of **Biao Li Xu Han (Exterior and Interior Deficiency-Cold)**. One should urgently warm the Spleen and Stomach, tonify Qi and Blood, and use herbs such as Renshen (Ginseng), Siwu Tang (Four Substance Decoction), Muxiang (Aucklandia Root), and Rougui (Cinnamon Bark) to assist in pus formation and crusting. However, for Biao Xu, treatment focuses on tonification, with blood tonification secondary. Since blood carries toxins to the exterior, it must be constrained by Qi. If Qi does not control the blood, the blood will flood and fail to attach to the toxin, leading immediately to the danger of sinking inward and attacking internally. For Li Xu, while tonifying blood, one should also tonify Qi. If Qi is tonified, the Spleen and Stomach become strong, Wei Qi flows smoothly, and the rash naturally rises, eliminating the worry of sinking inward later. Since blood is tonified, Qi circulates, sending toxins out completely without stagnation, eliminating the worry of itching and collapse later. However, within Qi tonification, Qi-moving herbs should be added to prevent Qi stagnation; within Blood tonification, Blood-activating herbs should be added to prevent Blood stasis, because for Blood to flow without stagnation, it relies on the movement of Qi. If the rash is red-purple, dry, and stagnant, or black-sunken and scorched, these are signs of **Biao Re (Exterior Heat)** and Excess. If there is constipation, dark and scanty urine, fever, dry nose, hot breath, dry lips, irritability, and thirst, these are signs of **Li Re (Interior Heat)** and Excess. This is a syndrome of **Biao Li Shi Re (Exterior and Interior Excess-Heat)**. One should urgently cool the Blood and resolve toxicity, using Huadu Tang (Toxin Resolving Decoction) and herbs like Honghua (Safflower), Zicao (Arnebia Root), Shengdi (Rehmannia Root), Chantui (Cicada Slough), Huanglian (Coptis Rhizome), and Jingjie (Schizonepeta). For Biao Re, cooling and releasing the exterior is primary, with promoting diuresis secondary. For Li Re, resolving toxicity is primary, with cooling secondary. If before the second or third day, heat-toxin is severe, mild purgation is acceptable. Cooling Blood prevents redness and purple discoloration; resolving toxicity prevents blackening and sinking. If Biao Xu is not tonified, it becomes external peeling; if Li Xu is not tonified, it becomes internal attack. Over-tonification of Biao Shi prevents crusting; over-tonification of Li Shi causes carbuncles and sores. However, there are cases that appear deficient but are actually excess, and vice versa. For example, if the rash does not rise and color is not red and vibrant, it appears deficient; but if accompanied by irritability, thirst, fever, and difficulty in urination and defecation, it should be treated as excess. Thus, smallpox symptoms change unpredictably; if the color changes, treatment must adapt and not be rigid.

The eruption of smallpox originates in the Interior and manifests in the Exterior, so the Excess/Deficiency and Cold/Heat of the Exterior and Interior must be distinguished. There is Deficiency with Cold, and Deficiency without Cold, but never Cold without Deficiency, which is crucial to know. The Spleen governs muscles, and the Lung governs skin and hair. Symptoms such as aversion to cold, spontaneous sweating, aversion to wind, alternating chills and fever, blue-white face, lethargy, desire to sleep, loose muscles, cold hands and feet, cool and quiet body, weak spirit, gray-white rash, sinking/inversion, itching/collapse, failure to rise, lack of luster, non-red roots, and body trembling with cold, combined with a floating, fine, and deficient pulse, indicate Spleen weakness and Lung deficiency, constituting Biao Xu Han (Exterior Deficiency-Cold). Treatment should warm and tonify the Exterior. If spirit is sluggish, milk/food indigestion, poor appetite, diarrhea causing thirst, abdominal distension and shortness of breath, green stool, clear urine, cold extremities, pale lips/face, desire to drink but little intake, body trembling, cold feet above knees, gray-white cold rash, mental fatigue, cold breath, rash failing to rise, and a deep, fine, slow pulse, this is Li Xu Han (Interior Deficiency-Cold). Treatment should warm and tonify the Interior. If there is high fever, intermittent fever like fan-blowing, firm rash, pain in head/back muscles, yellow eyes, nasal congestion, dry/scorched-purple rash unable to rise, body burning with red-purple surge, dry/itchy rash, tongue coating, red face/lips, scorched hair/dry skin, hot extremities, and a floating, rapid, large, and excess pulse, this is swelling-heat and Lung excess, constituting Biao Shi Re (Exterior Excess-Heat). Treatment should disperse the Exterior and remove heat; strictly avoid herbs that close the pores. If diet is normal, excretion is normal, spirit is bright, and rash rises harmoniously, this is a balanced state of Interior Excess, requiring no treatment. If there is steaming fever, scalding hands/feet, short dark urine, constipation, scorched-purple rash, preference for cool places, hot breath/thirst, dry tongue with panting, palpitations, irritability, phlegm obstruction, cough with rough breathing, vomiting/diarrhea with extreme thirst, urinary/fecal retention, purple-red lips, delirium, chest fullness, abdominal distension, even bleeding from upper/lower orifices, and a deep, solid, rapid pulse, this is excessive Interior Excess-Heat. It will consume Yin-Blood. Treatment should urgently activate and cool Blood, resolve heat, and detoxify; strictly avoid tonifying herbs like Renshen (Ginseng) and Baizhu (Atractylodes Macrocephala Rhizome) that aid the Spleen and tonify Qi. However, if from day one to ten of eruption, fever persists but spirit is clear, diet is normal, stool is yellow/thick, urine is clear, rash is lustrous, plump, with red roots, easy to erupt and crust, this is Biao Li Shi Re (Exterior and Interior Excess-Heat). Although there is heat, it causes no damage. If urine is dark/scanty, mild purgation is urgent, as excess heat-toxin risks triggering convulsions. Initially, Biao Xu allows easy, neat eruption; thus, Su Ye (Perilla Leaf) and Gegen (Pueraria Root) open the pores. After eruption, Biao Shi facilitates rising and resolving, preventing inversion/collapse; thus, Renshen (Ginseng) and Huangqi (Astragalus Root) fortify the muscle-exterior. During the rising phase, Huangqi should be more than Renshen to prioritize exterior tonification over middle jiao. During crusting, Renshen should be more than Huangqi to prioritize middle jiao over exterior. Since the face/head is primary, adding Chuanxiong (Ligusticum Rhizome) and Fangfeng (Saposhnikovia Root) guides the medicine upward. This discusses only the Excess/Deficiency of righteous Qi. If rash is sparse, spirit calm, color pleasant, rising/crusting on schedule, symptoms normal, this is Deficiency of Toxin; follow nature without treating. If rash is dense, swollen red-purple, body burning/painful/wailing, this is Excess of Toxin; treat with detoxifying herbs according to symptoms. Danxi said: Tonify the deficient, reduce the excess, warm the cold, clear the heat. These four are the essentials of smallpox treatment. At initial fever, urgent dispersal is needed until exterior heat subsides. After eruption, adjust warmth/coolness, resolve heat/toxin, regulate Qi/Blood, harmonize Ying and Wei, avoid wind-cold, abstain from sex, regulate diet, avoid foul odors, and auspicious results will follow.