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When the smallpox rash gradually appears completely after three days, the toxic qi remains within the body. It is contraindicated to use formulas that are excessively cold or excessively hot. Cold medicines cause the toxin to stagnate and fail to disperse, making it difficult to erupt; hot medicines intensify the fire pathogen. Therefore, in cases where heat-toxin is abundant, detoxification should be performed first; after the toxin is resolved, a slight warming and tonifying treatment should be given. Otherwise, it may transform into a deficiency-cold syndrome. In cases of severe deficiency-cold, warming and tonifying should be done first; after tonification, slight detoxification should be administered. Otherwise, it may generate heat-toxin syndromes. A skilled practitioner merely adjusts the body to achieve a state of harmony (Zhonghe).

Those whose fever lasts only one day before the eruption of smallpox have a very severe condition; those with eruption on the second day also have a severe condition. Those with mild fever who show eruptions after three days have a mild condition; those whose body temperature returns to normal after four or five days before the appearance of pustules have an especially mild condition. If the eruptions appear evenly between the first and third days, varying in size, with a ruddy color, round tops, and a lustrous, clear appearance like pearls, this is auspicious, and no medicine is required. If other symptoms are present, adjust the treatment according to the discussions below.

If a child has a fever for one day and red spots appear all over the body, resembling mosquito or flea bites, this is definitely not smallpox. It is caused by heat-toxin being constrained by wind-cold, preventing its release. One should refer to the "Fever" chapter and decoct Baidu San (Toxin-Resolving Powder) to relieve the exterior and dissipate heat. After sweating, when the body cools down, the red spots will naturally recede. Two days later, the actual smallpox will emerge sparsely.

If there is a fever for one day and the body is covered with dense eruptions resembling silkworm eggs, with ruddy roots but white, flat, soft tops that do not offer resistance upon palpation, containing clear fluid inside, this is miliaria (heat rash) generated by heat-toxin steaming the skin, also known as zhenzi (rash), commonly called mazizi (chickenpox/measles-like rash). The initial fever resembles typhoid fever (Shanghan). However, measles/miliaria can be treated with diaphoresis from start to finish. One should refer to the "Fever" chapter and decoct Baidu San to release the exterior and dissipate cutaneous heat, causing the rash to disappear. The "Fever" chapter states: "Once red spots are seen, strictly avoid further diaphoresis," referring specifically to true smallpox. Here, "relieving via diaphoresis" refers to measles or miliaria, not true smallpox. Caution must be exercised in differentiation. Although early smallpox and measles/miliaria may look slightly similar, if the base is red, the top is round and protruding, and firm/hard to the touch, it is smallpox; if the base is not red, the top is flaccid/soft, contains some clear fluid, and feels smooth/non-resistant to the touch, it is measles or miliaria. Between these suspected conditions, differentiation can clarify the diagnosis, ensuring correct medication.

If red spots appear on the first day of fever, with red bases, round tops, and firmness against the finger, it is true smallpox. This results from excessive toxic qi, leading to rapid eruption. Baidu San (Toxin-Resolving Powder) or Huadu Tang (Toxin-Transforming Decoction) added with Zicao (Arnebiae Radix seu Rhizoma), Honghua (Carthami Flos), and Chantui (Cicadae Periostracum) should be used to cool the blood and resolve toxicity. If the eruption becomes complete in one day, dense, red, and forming patches, the toxin is excessively abundant. Without intervention, the patient will soon develop purple-black macules and die.

For high fever accompanied by convulsions, irritability, thirst, delirium, and hallucinations (seeing spirits), Chen Sha Liuyi San (Cinnabar Six-One Powder) is indicated. For excessive phlegm, Baolong Wan (Dragon-Holding Pill) is indicated.

For slow or delayed eruption of smallpox, Jiawei Sisheng San (Modified Four-Saints Powder), Zicao Yin (Arnebia Decoction), or Sigua Tang (Luffa Decoction) may be used.

If the pustules are grayish-white, non-erupted, or grayish-black with sunken tops, accompanied by exterior cold and deficiency, clear urine and stool, cool body, cold breath, lack of thirst, anorexia, indigestion, interior cold and deficiency, this indicates exterior-interior deficiency-cold. Urgent warming of the spleen and stomach and tonification of blood and qi are required to assist in suppuration and scabbing. Baoyuan Tang (Preserve-Yuan Decoction) added with Baizhu (Atractylodis Macrocephalae Rhizoma), Chuanxiong (Chuanxiong Rhizoma), Danggui (Angelicae Sinensis Radix), and Muxiang (Aucklandiae Radix) should be used. Once the spleen-earth is warmed, stomach qi flows smoothly, avoiding internal collapse and sinking. Once blood and qi are formed, toxins are expelled outward, preventing itching and collapsing. Failure to treat at this stage will result in failure to suppurate and scab; after eleven or twelve days, death will occur due to scratching and breaking the lesions. If, after warming and tonifying, the pustules become plump, ruddy, the patient eats well, and excretion is normal, the exterior and interior are balanced. Do not continue warming and tonifying, lest heat-toxin arise. If the pustules are red-purple, detoxification and blood regulation are needed; otherwise, black sinking may occur. Smallpox transformations are unpredictable, unlike miscellaneous diseases which respond more directly.

If the pustule color is red-purple, the base is patchy and near-black, looking like crow feathers but moist/lustrous, the blood is active, and the condition is treatable. If black like charcoal, the blood is dead, and the condition is untreatable. Observe colors based on this principle. "Jiao xian" (scorched sinking) indicates exterior heat-excess. Constipation, dark/scanty urine, fever, hot breath, dry mouth with desire to drink indicate interior heat-excess. This represents excess heat in both exterior and interior. Urgently cool the blood and resolve toxicity using Quchu Huadu Tang (Remove-Toxin Transform-Decoction) added with Honghua (Carthami Flos), Huangqin (Scutellariae Radix), and Digupi (Lycii Cortex); or use Zicao Tang (Arnebia Decoction) to mix with Sisheng San (Four-Saints Powder). Cooling blood prevents red-purple discoloration; resolving toxicity prevents black sinking. Neglect leads to death after six days as the abundant toxin attacks the zang-fu organs, turning black and returning to the kidney. Regret will be useless! If, after detoxification, the pustule tops are not red, the bases are ruddy, urination is clear/profuse, defecation is normal, and the patient eats without thirst, the exterior and interior are clear. Do not continue detoxification. If the color turns white and the syndrome becomes deficiency-cold, warm and tonify blood and qi to aid suppuration and scabbing; otherwise, itching and collapsing will occur. This is akin to Yang syndromes transforming into Yin syndromes due to excessive cooling medicines in Shanghan. In such cases, Baoyuan Tang added with Ganjiang (Zingiberis Rhizoma) and Baizhu (Atractylodis Macrocephalae Rhizoma) should be taken. Do not adhere rigidly to protocols.

At the initial eruption of smallpox, inspect the chest. If dense, urgently decoct Xiaodu Yin (Detoxifying Decoction) added with Shanzha (Crataegi Fructus), Huangqin (Scutellariae Radix - wine-fried), and Zicao (Arnebiae Radix seu Rhizoma). Reduce food intake and add Renshen (Ginseng Radix et Rhizoma).

If the pustule color is pale white, the top is not firm, and it does not resist the finger, this indicates Qi deficiency. If the base is not red, or slightly red, and turns white upon rubbing, this indicates Blood deficiency. Profoundly tonify Qi and Blood using Baoyuan Tang (Preserve-Yuan Decoction) added with Chuanxiong (Chuanxiong Rhizoma) and Danggui (Angelicae Sinensis Radix).

If smallpox heat is abundant, causing red macules resembling brocade patterns on the skin and flesh, use Huadu Tang (Toxin-Transforming Decoction) added with Honghua (Carthami Flos), Huangqin (Scutellariae Radix), and Shengma (Cimicifugae Rhizoma). For sore throat, add Xuanshen (Scrophulariae Radix) and ground Xijiao (Rhinocerotis Cornu) for oral administration. This follows the method of modifying Xuanshen Shengma Tang (Scrophularia and Cimicifuga Decoction) for Yang-toxin macules in Shanghan. If black macules appear, death will occur within half a day.

During smallpox eruption, if red dan (erythema) appears, protruding like cloud heads, use Baidu San (Toxin-Resolving Powder) added with Zicao (Arnebiae Radix seu Rhizoma), Honghua (Carthami Flos), and Huangqin (Scutellariae Radix) to resolve it.

After smallpox eruption, if measles appear densely like silkworm eggs, use Huadu Tang (Toxin-Transforming Decoction) added with Chaihu (Bupleuri Radix) and Honghua (Carthami Flos). If the color is good, avoid excessive use of cold medicines to prevent spleen injury and toxin sinking.

During smallpox eruption, if diarrhea occurs with yellow stool, red urine, hot breath, and thirst, this is heat-diarrhea. Use Wu Ling San (Five-Ingredient Powder with Poria) minus Guizhi (Cinnamon Twig), added with Mutong (Akebiae Caulis), Cheqian (Plantaginis Semen), and Dengcao (Junci Medulla). If loose/watery stool is clear, breath is cold, and there is no thirst, this is cold-diarrhea. Use Wu Ling San (Five-Ingredient Powder with Poria) added with Roudoukou (Myristicae Semen). For severe cases, use Baoyuan Tang (Preserve-Yuan Decoction) added with Baizhu (Atractylodis Macrocephalae Rhizoma) and Ganjiang (Zingiberis Rhizoma).

If smallpox is erupting but collapses due to vomiting/diarrhea, use Weiling Tang (Stomach-Linus Decoction). For severe cold with incessant vomiting/diarrhea, use Lizhong Tang (Regulate-the-Middle Decoction) added with Dingxiang (Caryophylli Flos), Roudoukou (Myristicae Semen), and Fuzi (Aconiti Lateralis Radix Praeparata).

For abdominal distension and pain due to food stagnation from raw/cold foods, use Pingwei San (Peace-the-Stomach Powder) added with Shanzha (Crataegi Fructus), Maiya (Hordei Fructus Germinatus), Xiangfu (Cyperi Rhizoma), and Sharen (Amomi Fructus).

During the initial onset of smallpox, spontaneous sweating is acceptable due to damp-heat steaming. For severe cases, use Baoyuan Tang (Preserve-Yuan Decoction) to consolidate the exterior and prevent difficulty in scabbing.

If smallpox is red and hot, but the skin is soft and does not resist the finger upon touching, this is "Thief Smallpox" (Zeidou). After three days, it transforms into blisters, which is a critical condition. Urgently administer a small dose of Baoyuan Tang (Preserve-Yuan Decoction) with large amounts of Zicao (Arnebiae Radix seu Rhizoma), Chantui (Cicadae Periostracum), and Honghua (Carthami Flos) to resolve it. Alternatively, decoct Dengcao Mutong Tang (Juncus and Akebia Decoction) to mix with Liuyi San (Six-One Powder) to drain heart-heat, causing redness to subside. If blisters have already formed, double the amount of Siling San (Four-Poria Powder) in Baoyuan Tang to promote diuresis. This is a thousand-gold secret recipe. Otherwise, the body will be scratched until raw and bloody, leading to death. (My opinion: Thief smallpox refers to pustules maturing prematurely before others have turned to pus, also called false deficiency. When appearing on Taiyang pulse gates, throat closures, or heart areas: if seen on day 3, death on day 6; day 4, death on day 7; day 5-6, death on day 11-12.)

If smallpox turns black immediately upon eruption, it is a Kidney syndrome, a malignant sign. If there is any sign of recovery, use a small amount of Baoyuan Tang (Preserve-Yuan Decoction) with large doses of Zicao (Arnebiae Radix seu Rhizoma) and Honghua (Carthami Flos) orally, and apply Sisheng San (Four-Saints Powder) externally. Early cooling of blood and detoxification would have prevented this. This often occurs due to spleen-stomach weakness, where Earth fails to control Water. The Classics state: "Red turning to white, white turning to yellow indicates life; red turning to purple, purple turning to black indicates death."

Within the first three days of eruption, the toxin is half in the exterior and half in the interior. Reckless diaphoresis causes maceration and ulceration; reckless purgation causes sinking and collapse. Harsh obstructive medicines damage the stomach; harsh hot medicines assist fire. Deficiency-cold untonified leads to sinking, itching, and collapsing; abundant heat unresoved leads to black sinking into the kidney. Thus, how can physicians fail to examine the syndrome carefully?