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The two elbows and two knees are referred to as the "Four Passes" (Sì Guān). This is because the Twelve Yuan-Source points of the Zang-Fu organs originate from the Four Passes; therefore, the variola lesions at these sites are of utmost importance. Although the lesions on the rest of the body may appear favorable, if variations occur at the elbows and knees, the lesions throughout the entire body will also change and fail to suppurate and form pus. Why is this? Because if the joints become obstructed and Qi circulation is impeded, all three hundred and sixty-five acupoints will be closed. Thus, if there are "Thief Lesions" (Zéi Dòu, referring to aberrant or malignant lesions) at the Four Passes that present with purple coloration and depression, they must be immediately pricked, the foul blood sucked out, and sealed with medicinal paste. Otherwise, all lesions will undergo pathological transformation. Some regard the four limbs as soldiers and infantry, belonging to humble categories, and thus neglect them. If one seeks to verify the safety or danger of a disease through pulse diagnosis, why focus solely on the three positions (Cun, Guan, Chi) of both wrists and the Chongyang, Taixi, and Taichong pulses of both feet?

When variola first erupts, it originates in the Kidney, transmits to the Liver on the second day, to the Heart on the third day, to the Spleen on the fourth day, to the Lung on the fifth day, and the Lung transmits back to the Kidney, completing a cycle. This process takes approximately thirteen shichen (two-hour periods), shifting meridians every two ke (forty-eight minutes); thus, five and a half days constitute one full cycle. For individuals who have not previously had variola, eruption may occur close to five and a half days, then eleven days, then sixteen and a half days, then twenty-two days, and finally twenty-seven and a half days. One should observe their complexion and morphology, examine the ear patterns, detail various signs, and palpate the heat intensity to determine the timing. This transmission sequence of Kidney, Liver, Heart, Spleen, and Lung follows the principle of mutual generation (Shēng). Others propose the sequence of Kidney, Heart, Spleen, Liver, and Lung, following the principle of mutual restriction generating harmony (Kè zhōng xiāng chéng), as the Spleen resides in the center of the four viscera.

In males, a yellowish complexion; in females, a reddish complexion; accompanied by rapid breathing, increased aversion to cold, neck stiffness, hot breath, and frequent yawning—this indicates Cold Damage (Shāng Hán), do not misidentify it. Reddish and dry cheeks; frequent sneezing; coldness in all four limbs combined with palpitations; coolness at the tip of the nose, tips of the ears, and the coccyx; red threads behind the ears—these are indications of variola.

Any sudden swelling like an egg in forbidden areas, black-purple in color, accompanied by asthma: [Mortal sign].
Any passage of bright red blood, or blood resembling the color of a dead chicken's liver: [Mortal sign].
Any cyanotic and blackened lips with retraction, swollen and closed throat, and black-white sores appearing in the mouth, tongue, and throat: [Mortal sign].
Any sudden invasion by external wind causing convulsions and spasms of hands and feet, foaming at the mouth, fixed gaze without consciousness, or even bluish-black discoloration of muscles and a crow-like sound from the mouth: [Mortal sign].
Any abdominal distension like a drum, asthma, irritability, high fever with thirst, and bleeding from the mouth and nose: [Mortal sign].
Any lesions that are purple-black: [Mortal sign].
Any general swelling like a melon after eruption, with rapid and urgent breathing: [Mortal sign].
Any blackening of the face, ears, mouth, and nose; cold reversal in the four limbs; sudden profuse sweating with a flaccid neck: [Mortal sign].
Any coldness of hands, feet, and body like ice; blackening and shrinking of the scrotum; foul-smelling breath: [Mortal sign].
Any sudden invasion by external wind, saw-like phlegm sounds in the throat, eyes closed with excessive sleepiness, and bead-like sweat on the head: [Mortal sign].
Any high fever, dryness, irritability, asthma, and urgency unrelieved by medication, especially when the face turns black: All are incurable.
For severe variola cases where immediate efficacy is seen after administering medicine, one must beware of sudden changes. While lack of response to medication is indeed incurable, sudden dramatic improvement often indicates that the root vitality has been exhausted, making the weak vital qi easily stirred by the drug's force. If the drug's effect wanes, or if the true Qi of the Zang-Fu cannot regenerate, the initial temporary improvement will not sustain further treatment. Moreover, things that emerge early wither early, and those that develop quickly perish quickly. It is like a cup of water, which fills and dries easily, versus a long river, which is hard to drain or fill. Therefore, treatments that yield gradual results indicate deep roots and stability, ensuring safety forever. This applies not only to variola but to all diseases. These observations are based on my (Zhang's) repeated clinical verification, and I dare to append this explanation hereafter.