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When the smallpox pustules begin to rise, one must observe their roots (gen ke). If the pustules are red, plump, and the blood and qi are harmonious, it is an auspicious sign; if they are dry, withered, or present as cyanotic-purple spots, nourishing the blood is urgently required, and time must not be wasted.

If the sides of the pustules are raised while the center is depressed, it indicates deficiency of stomach qi and failure of the toxin to vent smoothly; if the skin is white externally but has a black spot in the center, this is named "Ghost Pox" (Gui Dou), and urgent attack therapy is required.

If the center of the pustule is convex and the margins are flat, whether the exterior is black or the interior is red, treat them under the same principle: this is due to excess pathogenic factors obstructing the exterior; resolve the exterior to allow the pathogen to disperse and regulate the qi and blood.

It is most praiseworthy when the erupted pustules are distinct and clear; if three or five adhere together, it is unfavorable; if they blur into a single mass, one must guard against the recurrence of itching.

Rashes on the head and face generally belong to Yang patterns; their ascending and floating growth corresponds to Yang qi. Slight, gradual swelling with red and lustrous pustules is a good sign; sudden severe swelling with flat-topped pustules requires prevention of complications.

At the initial stage of rising, before serum appears, if the color of the sores on the lips turns scorched yellow early, this is a malignant symptom unrecognized by many; waiting until the crusting stage will bring disaster.

If water content appears before the shape is fixed, or if serum is present at the very beginning of rising, rushing to crust before pus is formed will make the patient unable to withstand the condition, potentially leading to death.

If the rising pustules are uniformly smooth like tin foil, accompanied by edema and altered facial features, good appetite is a favorable sign; reduced diet and qi deficiency indicate a ominous prognosis.

Heat intensity varies, requiring different treatments. Ancients compared it to a steamer, but failing to recognize the depth of the pathogen leads to inappropriate treatment.

Swelling during the rising phase is unusual; however, swelling first appearing on the head and face is unfavorable, as it signifies the dispersion of essence from the five zang organs, with toxic fire raging and soul departing.

By the sixth or seventh day, in favorable cases, the serum flow is more than half complete, while weak pustules only then show separation of light. Those with heavy toxins and obstruction will inevitably become dry and retracted; those with vigorous qi will be full and glorious. If the head and face have serum while the limbs have not yet risen, do not panic; if legs blister while the face and forehead are scorched and dry, do not rejoice prematurely. One should fear upward choking of the toxin, worry about loss of voice, and dread rapid breathing; rapid breathing may lead to abdominal distension. Insufficient food intake may cause visceral deficiency and internal collapse; excessive fluid intake may lead to diarrhea and confusion. Improper management can reverse the situation instantly. With intense heat, thirst, and irritability, one must no longer diagnose based on excess syndromes; if loose stools occur, treat as deficiency. Black, purple, and dry conditions require urgent attacking methods for potential survival; qi deficiency and collapse require warming tonification for potential recovery. White pustules lacking spirit are difficult to cure even if the base is red; skin that does not rise and detaches from the root is hard to regenerate even if the feet are red; pale, collapsed, and dried-out conditions imply no internal serum; thin, tender, and bright-red skin implies thin serum even if present. Violating these four principles leads to itching by the eighth or ninth day. If accompanied by high fever burning the body, lack of itching ensures dryness; purple dryness indicates imminent fatality with coagulated blood traces, though rare recovery into serum is possible. Crusting purple within three days allows for reversal; crusting purple after seven days makes rescue difficult. Once serum flows and is more than half complete, it is too early to converge; sudden uniform darkening is anciently called "Reverse Crusting" (Dao Ye); do not mistake it for normal scabbing. Proper attacking therapy may still revive the patient; lateral blood spots and subsequent serum formation allow latent toxins to dissipate. Rapid breathing with abdominal distension indicates approaching death; loss of voice with vomiting and hiccupping indicates exhaustion of yang qi.

For heart-related smallpox, three days after appearance, the pustules begin to swell, gradually nourish pus, and finally crust. Initially, they are small, red, and appear as a dot of blood. Upon rising, they become round, red and white, indicating blood transforming into water. During pus nourishment, they become large and firm, red and yellow, indicating water transforming into pus. During crusting, they become large and soft, red and black, termed "Cang La," representing ripe pus ready to crust, like a ripe fruit where the outer skin softens and inner flesh rots before solidifying. If after ten days, during the expected pus and crusting stage, the shape is flat and depressed, color red-purple, exterior not plump, and interior lacking pus, this is named "Raw Pox" (Sheng Dou), where blood arrives but qi does not, constituting a reverse collapse; death from abdominal distension, panting, and confusion occurs within three days.

One asks: From which meridian does the smallpox serum originate, and through which is it collected? This is like the illumination of the sun and moon, or the source of rivers and seas. Smallpox originates in the Kidney and hides in the Kidney; Heaven generates Water, and the Kidney resides there. The Kidney governs bone marrow, which is where the smallpox toxin hides. Thus, serum begins from the Water of Heaven One. Since Liver (Yi) and Kidney (Gui) share the same source, supported by Ying blood, the root lies in the Kidney. Heart governs respect, Liver ensures smooth flow, Lung protects and nourishes, and Spleen stores and hides. Water and Fire assist each other to achieve success, relying on Earth to form substance. Therefore, smallpox eventually turns yellow, the true color of Yangming Earth. Thus, toxin hides in Kidney, vibrates in Yangming, and finally returns to storage via transforming Earth. Without serum, toxin does not transform; insufficient serum means toxin is not exhausted. Toxin hiding in Kidney relies on Kidney to complete it; upper transformation of toxin relies on Spleen to collect it. Thus, although serum comes from Liver blood, it truly depends on True Water (True Yin). Although serum collection relies on Spleen Earth, it truly borrows from True Fire (True Yang). The logic of serum is thus clear.