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At the onset, the body experiences a lingering fever with alternating hot and cold sensations. The muscles are relaxed, and the spirit is fatigued. The complexion is cyanotic and pale. Food intake decreases. The hands and feet alternate between cold and hot. The smallpox spots have just appeared, faint and unenergetic, light red in color with thin skin.

Within three to four days, the spots appear successively but irregularly, making it difficult for them to grow properly. By five to six days, they fail to fill with pus. Reduced food intake leads to Qi deficiency; food stagnation easily causes diarrhea. By seven to eight days, the pustules collapse, turning grayish-white and failing to rise. There is spontaneous sweating and slight thirst. Alternatively, there may be abdominal distension, asthma (wheezing), thirst, diarrhea, pruritus of the lesions, chest tightness, and mental confusion. Teeth chattering and shivering occur. The head feels warm while the feet are cold. These outcomes are inevitable due to Qi deficiency. Therefore, when treating deficient-type smallpox, one should not lightly administer exterior-releasing agents at the onset. Even formulas such as Shensu Yin (Ginseng and Perilla Decoction) and Renshen Baidu San (Ginseng Detoxification Powder) are unsuitable. How much more so are pure ascending and dispersing formulas like Shengma Tang (Cimicifuga Decoction)? As for Huanglian (Coptidis Rhizoma) and Zicao (Arnebiae Radix seu Lithospermi Radix), they are strictly contraindicated. One should primarily rely on Baoyuan Tang (Protect the Origin Decoction). However, if the patient has coarse breathing and dry skin lacking luster, Baoyuan Tang should also be avoided. Instead, use Sijunzi Tang (Four Gentlemen Decoction) with minor additions of Jiegeng (Platycodonis Radix) and Chuanxiong (Ligustici Chuanxiong Rhizoma), employing a slight lifting method within the tonification strategy. Once the spots have fully emerged, heavily use Ren Shen (Ginseng Radix et Rhizoma) and Huang Qi (Astragali Radix) to vigorously tonify Qi and assist in filling the pustules. If no other ominous signs appear by the eighth or ninth day, use Shiquan Dabu Tang (Comprehensive Great Tonifying Decoction) with doubled Gui Zhi (Cinnamomi Ramulus). For collapsed, grayish-white lesions accompanied by abdominal distension and diarrhea, use Muxiang San (Costus Powder). For pruritic lesions, chest tightness, mental confusion, abdominal distension, thirst, diarrhea, wheezing, cough, warm head, cold feet, shivering, and teeth chattering, urgently administer Yigong San (Extraordinary Skill Powder); delay will result in untreatable conditions.

For Qi-deficient smallpox, if managed appropriately, allowing the Yuan Qi (Primary Qi) to become substantial, the Cou Li (interstices/skin texture) to become firm, the Spleen and Stomach to become strong, and the bowel and bladder movements to be regulated, disaster can still turn into auspiciousness. However, excessive tonification, particularly the heavy use of Ren Shen (Ginseng Radix et Rhizoma) and Huang Qi (Astragali Radix) after the pustules are full, often leads to abdominal distension and urgent wheezing. In such cases, Zhike Tang (Immature Bitter Orange Decoction) should be used. Misuse of Wuling San (Five-Ingredient Powder with Poria) or Muxiang San (Costus Powder) often leads to constipation. In such cases, Kuanzhong San (Broaden the Middle Powder) should be used. If the stool is solid but thirst persists, use Maidong Tang (Ophiopogon Decoction). Overuse of acrid-warm agents such as Ding Xiang (Caryophylli Flos) and Rou Gui (Cinnamomi Cortex) leads to sore throat, swelling, restlessness, and closed-off thirst. In such cases, Rundao Tang (Moisten Dryness Decoction) should be used. Generally, urgent wheezing, abdominal distension, hard constipation, vexing thirst, and sore throat resemble excess patterns. However, this transformation from Qi deficiency to "excess" is false excess, not true excess. It is an error of using overly deep-acting drugs for a superficial disease. One should only exercise discretion and avoid purgative or draining methods. If mistaken purgatives or draining methods are applied, the newly generated Qi will become deficient again, and the syndrome of collapse (Tuo Zheng) will approach.