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When the smallpox lesions first appear, if the heads are scorched and blackish, or red-purple, dull and obscure, accompanied by delirium, mania, persistent high fever, irritability, thirst, and desire to drink water, this indicates that the toxin is in the Blood level, constituting a syndrome of excessive blood heat and toxicity. The treatment should urgently focus on cooling the blood, resolving toxicity, and expelling pathogens from the exterior while supporting the interior (Tuo). If there is constipation, mild purgation should be employed to clear and resolve, lifting and supporting the toxins. If not treated urgently, it will progress to black sinking (Hei Xian), which is incurable.

If the lesions first appear white with thin, shiny skin, and only the root area shows a faint line of redness, this indicates that the toxin is stagnant in the Qi level, constituting a syndrome of Qi deficiency and insufficiency. Treatment should urgently focus on tonifying Qi and regulating the Ying (Nutritive) level. If not treated urgently, it will later lead to itching and collapse, resulting in death. Among newly appearing smallpox lesions, there are only these two syndromes: blood heat and Qi deficiency. At this stage, urgent treatment is essential. One must wait until the color turns from white to vibrant red, from black to pale red, the roots become bright and moist, the crusts become firm, appetite returns, and bowel and bladder functions normalize. Then, the stages of swelling, suppuration, and scabbing will proceed smoothly without further complications.

If the distribution is even over the body but dense specifically in the throat, it is named "Chanting Throat" (Chan Hou). Urgent treatment should focus on clearing the Lungs and benefiting the throat to prevent choking on fluids and inability to eat around the eighth or ninth day. If fever persists from the initial appearance of spots until the end, it indicates excessive toxic qi. Clearing and resolving methods should be used throughout. If fever persists after two or three days of eruption due to blood depletion causing a lack of red halo at the roots, use Dang Gui Huo Xue San (Angelica Sinensis Blood-Activating Powder) with added Jiu Chao Huang Qin and Huang Lian (Alcohol-fried Scutellariae Radix and Coptidis Rhizoma).

If lesions are dense on the chest upon initial eruption, urgently apply detoxification and fire-clearing methods. As the raised marks increase, accompanied by macules, dry purple lesions that do not rise, feel flat to the touch, with fever and coarse breathing, urgently clear the Stomach, transform macules, and support the exterior. If lesions initially appear gray-white, depressed and non-rising, or rising but flat, with non-vibrant roots, cool body, and quiet demeanor, this is a Deficient-Cold syndrome. If the body is cool, lesions are gray-white, appetite is lost, or there is vomiting, abdominal distension, counterflow of cold qi, watery diarrhea, and cold extremities, this is a Pure Yin syndrome; treatment requires significant warming and tonification.

Lesions appearing first on the fingertips are called "Gan Jia Dou" (Liver Nail Smallpox) and are treatable. Lesions appearing first in the anus are called "Lan Men Dou" (Gate of Intestines Smallpox) and are treatable. Lesions appearing first along the eye margins are called "Cuan Yan Dou" (Gathering Eyes Smallpox) and are treatable. Lesions appearing first on both sides of the genitals are called "Nang Yan Dou" (Sac Eye Smallpox) and are treatable. Lesions appearing first at the two corners of the head are called "Ri Yue Jiao Dou" (Sun-Moon Corner Smallpox) and are treatable. If a few appear on the head, with one being extremely large and deeply ulcerated, it is named "Niao Du Dou" (Urine Toxin Smallpox). It should be urgently punctured and sealed with a mixture of Hong Zhi (Vermilion/Red Lac) and fine Zhen Zhu powder. The seal must remain until pus forms and toxins resolve; otherwise, it will re-aggregate into a cavity, draining Qi and Blood, making other lesions difficult to grow.

If the eruption is dense but the roots are naturally sparse, without clumping, and the color is not dry red, it is treatable despite the quantity. If the base is established but the top has not risen and the skin is not loose, urgently apply permeating and supporting methods. If there are white lesions resembling flour, with bases and tops but soft and plump, strongly tonify Qi and Blood. If lesions are white with red flesh, it is indeed Qi deficiency failing to constrain Blood, but also due to Heat wandering on the exterior; thus, cooling the blood to clear exterior heat is appropriate. Avoid formulas containing Dang Gui (Angelicae Sinensis Radix) and Chuan Xiong (Ligustici Chuanxiong Rhizoma) that ascend and disperse. If lesions are black inside and white outside, the toxin is internal; use Jie Du Tang (Detoxification Decoction) to clear the interior. If white inside and black outside, the toxin is external; use Sheng Ma Tang (Cimicifugae Decoction) to scatter the exterior.

After complete eruption, if fever is severe, Qi is stagnant, and skin/muscles are swollen and bright, the toxin is internal; urgently apply internal support. Delay leads to internal attack and death. If caused by summer heat steaming, leading to irritability, thirst, and poor eruption, use Ren Shen Bai Hu Tang (Ginseng White Tiger Decoction) modified. If invaded by cold qi in various months, causing gooseflesh, nasal congestion, heavy voice, cough, and poor eruption, use Shen Su Yin (Ginseng Perilla Drink) modified. If triggered by pathogenic contact causing poor eruption, use Shi Xuan San (Ten Acupoints Powder) modified, externally burning Ru Xiang (Frankincense) and Yuan Su (Coriander) to repel the pathogen. If caused by prior labor and weak Yuan Qi leading to poor eruption, use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) as the main formula. If caused by vomiting/diarrhea, stomach deficiency, and anorexia leading to poor eruption, use Li Zhong Tang (Regulate the Middle Decoction) as the main formula.

Constipation with thirst and poor eruption indicates internal Excess Heat. Normal stool with thirst and poor eruption indicates internal Deficient Heat. Normal stool without thirst and poor eruption indicates internal Deficient Cold; distinguish carefully. One to two days after seeing the raised marks, if there is sore throat, red eyes, and swollen lips, it indicates hyperactive Fire in the Liver, Lungs, and Stomach. If the lesion color shows intersection of Qi and Blood, urgent clearing and resolving will cure it. If the color is dull, dark, and dry red, Qi and Blood have separated; nosebleeds will occur within seven to eight days, and it is incurable. Some lesions resemble gray peach kernels, large and plump. If hard to the touch, they may turn vibrant and red, indicating they are still treatable.