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Just as an echo responds in a valley and a shadow follows movement, the eruption of smallpox (Xiaochuang) reflects internal conditions externally. If the internal heat is mild, the external manifestation will be light; if constipation and irritability are present, the external signs will be severe. What exists internally manifests externally; this is the natural course of things.

Regarding color, glossiness is preferred over dullness; radiance is preferred withered dryness; pale red is preferred over black stagnation; round and clean shape is preferred over damage; high elevation is preferred over flatness; firm texture is preferred over emptiness and thinness. Tight roots help distinguish Yin and Yang types. The appearance of spots should be lively, but facial edema must be feared. Eruption should be uneven, and blood should remain within the lesions. Fewer eruptions behind the ears, at the heart area, and in the throat are auspicious. The brow ridge, zygomatic arches, and forehead should be lustrous without leakage. Early eruption during fever indicates severity; eruptions mixed with measles indicate moderate severity. Mild redness inside and out indicates light disease; black outside and red inside indicates slightly severe; red outside and black inside indicates very severe. Black dots like needle holes inside the lesions indicate extreme heat. Cyanosis, drying, purple depression, lethargy, sweating, irritability, thirst, abdominal distension, crying and wheezing, and closure of bowels and urine indicate critical distress. A skilled practitioner distinguishes severity by observing form and color; light cases recover, and severe cases can be treated effectively.

Fetal toxin accumulates and erupts as smallpox; transmission occurs via external pathogens; severity depends on internal injury. Initially affecting the Taiyang channel, Ren Water (Kidney Water) controls Bing-Ding Fire (Heart Fire). Later it returns to the Yangming channel, where blood and water transform into pus and plasma. The situation is urgent like burning eyebrows, changing rapidly like flipping a hand. It is better to remove firewood before a fire starts than to scorch one's forehead after ignition; it is better to lift one's clothes when entering water than to save someone already drowning. To understand exterior-interior and deficiency-excess, one must clarify cold-heat-warm-cool patterns. Symptoms vary, and organ states change. Liver fire agitation causes blisters; the Lung governs mucus and generates pus; Heart macules are red-purple; Spleen rashes are red-yellow; the Kidney channel is lower and resists turbidity, so blackening can be prevented. Observing external symptoms allows inference of the five Zang organs. Yawning and stuffiness stem from Liver Wood pathology; coughing, runny nose, and sneezing are signs of Lung Metal involvement; red eyes indicate Heart Fire spreading to the chest and diaphragm; cold extremities and lethargy indicate Spleen Earth trapped in the center. The ears and sacrum belong to the Kidney; warmth there is normal, while heat indicates abnormal rash progression. First distinguish locations, then observe omens. Yangming issues descend from eyes to nose; Taiyang issues appear on the head. Intense Heart Heat causes dry tongue and red face; Lung Metal stagnation injures the chest and diaphragm first. Hands and feet belong to the Spleen and Stomach; Liver and Gallbladder govern the flanks; the neck is the intersection of three Yang channels; the waist and back are governed by the Bladder. External symptoms are clear; careful imagination aids diagnosis. Diarrhea indicates pathogenic excess below; vomiting indicates pathogenic excess above. Qi rebellion causes hidden abdominal pain; severe toxicity causes alarming lower back pain. Extreme Heart Heat causes convulsions; Stomach pathogenic excess causes mania. Dry mouth and throat indicate Lung fluid depletion due to Fire evil; constipation and dysuria indicate Kidney fluid loss due to hyperactive Fire. To identify severity, observe heat and morphology. Severe toxicity makes the mind restless like rising flame; mild toxicity leaves the interior and exterior cool. Alternating chills and fever with clear spirit predict auspicious eruption. Gradual emergence over several days is like spring returning to the Yang Valley; sudden simultaneous eruption is like fierce fire on Kun Gang. Mosquito-bite-like spots lead to death within a set time; snake-skin-like shedding leads to death after prolonged suffering. While red-purple is feared, gray-white is most detested. Pale red and moist is best; black depression and dry yellow must be avoided. Color should be bright and moist, yet too thin/tender risks rupture; lesions should be dry and firm, yet itching/collapse is hard to bear. Sparse cheeks ensure safety; dense chest lesions make prognosis uncertain. Peaks should be pointed/round, not flat/depressed; plasma should be full, not empty. Skin prefers toughness over tenderness; flesh prefers mobility over smoothness. Firm and elevated lesions cause no worry; floating Dan (erythema) on skin predicts trauma/swelling. Swelling of lips, face, and head is often fatal; lower back pain and stomach rot guarantee disaster. Lesions on tongue/lips and neck entanglement, pharyngitis, and throat swelling make eating difficult. Dysentery with pus/blood and toxic collapse without plasma mean human effort is futile and life is short. Scabbing distinguishes Yin/Yang. Crusting first in the upper/lower philtrum is good; black crusting first on feet/waist indicates bad omens.