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The four limbs belong to the Spleen and serve as the root of all Yang channels. Initially, when fever begins, if the hands are warm and the feet are cool, this is a normal sign. This is because the Kidney governs the feet; since the Kidney has not been invaded by pathogenic factors, the feet remain cool. The Spleen governs the hands; as Spleen Qi is vigorous and flows along its meridians, the hands become warm. If during the initial fever, the patient reaches for clothing collars or randomly fiddles with objects, this indicates Liver Heat. If the hands touch the eyebrows, eyes, mouth, or nose, this indicates Lung Heat. Twitching and spasms of the four limbs indicate that Heart Fire and Liver Wind are transmitting to each other; coldness in the hands and feet indicates Spleen and Stomach deficiency and timidity. This is because the four limbs receive their Qi from the Stomach, but they are slightly distant from the chest and abdomen where the Zang organs reside. If Spleen deficiency fails to transport fluids for the Stomach, these fluids cannot reach the meridians, resulting in coldness. If vesicles appear on the hands and feet after the eruption of smallpox lesions, this signifies Liver excess and Spleen decline, with pathogenic factors overcoming healthy Qi. Urgent treatment is required, employing methods to drain the Liver and tonify the Spleen, to prevent lesion collapse and death. However, at the stage of initial spotting (Bao Dian), it is auspicious if the eruptions on both arms appear slightly later than those on the head. One must fear that if early eruptions are loose, the head's eruptions will emerge even more slowly. If eruptions fail to appear when they should, this is due to Spleen and Stomach Qi deficiency, preventing the distribution of Qi and Blood to the limbs. Furthermore, if eruptions cover the whole body but do not appear on the hands and feet, or if they are empty shells, these are all signs of Spleen and Stomach weakness, exhaustion of body fluids, and stagnation of Ying and Wei Qi, which cannot circulate and nourish the limbs. Consequently, the toxin remains郁结 (stagnant) and cannot erupt. Inability to eat indicates death. Ability to eat suggests a likely complication of carbuncles and sores. Additionally, if pustulation has begun elsewhere but scabbing has not occurred, yet the palms and soles scab first, strange diseases will likely follow. If joint swelling and pain occur in the hands and feet after the scabbing phase, it indicates unresolved toxins, requiring vigilance for abscess formation. If skin desquamation occurs on the hands and feet before the lesions form pus, it indicates death. Severe eruption accompanied by cold hands and feet is incurable. Itching with restless scratching of the hands and feet is ominous. Lesions that appear and disappear repeatedly, collapse again, and turn purple-black indicate Kidney overacting on the Spleen, which is incurable.

Smallpox lesions turning black may be treatable or untreatable. Why? This condition relates to adverse prognostic signs; early treatment is crucial. Delay leads to spread and transformation, with lesions appearing and disappearing suddenly, leading to gradual death. For lesions surrounded by fluid with a central black depression, only apply Rouge (Yanzhi) externally until the color turns red and the lesion rises and plumps up. For lesions that have risen with fluid, have a flat top, and are black, internal administration of blood-cooling and detoxifying formulas is appropriate, adding calcined human feces to the prescription. Externally, apply Rouge. For constipation, caused by internal heat steaming, administer internal cooling, detoxifying, and purgative formulas, and use external bile enema (Dan Dao). For diarrhea, indicating cold, administer strongly warming and Qi-tonifying formulas. If the base of the blackened lesion is hard, prick out toxic blood using a silver needle, then apply Si Sheng San (Four Sages Powder) mixed with oil into the wound. If the skin and flesh do not heal, the base does not swell, and the patient suffers from restlessness, oppression, confusion, and anorexia, there is absolutely no hope for survival.