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At the initial stage, when the body has a slight fever, it is most appropriate for the breath to be peaceful, diet to be sweet and palatable, urination and defecation to be normal, hands and feet to be warm, facial complexion to remain unchanged, accompanied by peaceful sleep. This indicates that the eruption of smallpox is proceeding smoothly. If the four limbs are cold, the facial complexion is pale, food intake is reduced, and spirit is listless, this syndrome should be viewed as deficiency; the erupted lesions will certainly fail to thrive. If loose stools and vomiting of milk occur, urgent supplementation of Qi is indicated. If the heat is severe and breathing is coarse, detoxification is absolutely necessary, leaving no room for doubt. Delirium, manic speech, and irritability all indicate internal heat. Wheezing, chest fullness, coarse breathing, and constipation indicate toxin stagnation. When toxins are abundant, the head and face become red and hot; when Qi is deficient, the hands and feet become cold and clear. Vomiting is due to fire qi ascending; loose stools are due to toxic vapors pressing downward. Abdominal distension, open mouth, rapid breathing, incessant crying with frequent hoarseness, require vigilance against hemorrhage. Cyanotic complexion, blinking, head shaking, sudden mania, and vomiting milk are precursors to convulsions. Therefore, in cases of excess heat, only cooling and dispersing methods should be used; harsh bitter-cold drugs must not be employed vigorously. Dispersing allows toxins to exit outward, resolving heat naturally; bitter-cold drugs cause toxins to retreat inward, making eruption more difficult. Thus, for mild cases, Shengma (Cimicifugae Rhizoma) and Gegen (Puerariae Lobatae Radix) are used to disperse heat; for irritable and robust patients, how else can the branch symptoms be settled? For severe cases, Mahuang (Ephedrae Herba) is used to open stagnation; for those with wheezing and abdominal distension, how else can the critical condition be saved? If diarrhea occurs before eruption, do not mistake heat syndromes for deficiency. If diarrhea has occurred with thirst, treat as deficiency if there is no heat syndrome. To stop heat-type diarrhea, use cooling methods combined with heavy dispersing; to treat deficiency-type loose stools, use warming and tonifying methods combined with lifting. Mistakenly using cold-cooling agents for internal deficiency promotes diarrhea; recklessly administering tonics for excess heat exacerbates irritability and severity. Patients who are calm and able to eat should not be assumed to have solid stool requiring purgation; patients with diarrhea and irritability/thirst should not be assumed to have heat syndromes suitable for cooling. Those with weak Qi and poor appetite cannot tolerate the toxin; those with strong spirit and good appetite retain their normal state.

I have said that when smallpox spots first appear, observe the luster or withering of the color. If they appear large and plump immediately, sparsity is certain; if they start fine and scattered, density is known. Lesions appearing with heat, emerging successively, can still be rescued; those erupting all at once with thin skin are unlikely to survive. Fine white heads like miliaria, becoming dry and withered, indicate internal attack. Dense red spots like cinnabar will inevitably become scorched and withered. Coarse, plump, mushroom-topped spots that are not red but eventually turn white and sunken, or those with pointed tops, thin skin, and "cornel" wrinkles, will result in empty pustules. White and tender skin implies thin, delicate redness; yellow and emaciated bodies result in brownish pustules. In individuals with dark skin and rough texture, lesion colors will inevitably be dull and dark. Infants have different muscle structures, so generalizations do not apply. Lesions should ideally protrude with spirit, avoiding delicate redness and flatness. Lustrous color and calm spirit, with spots like pearls or millet grains, are good signs. Dry hair and skin, with lesions turning purple or scorched while emerging with heat, are feared to be dense like needleheads. Even if subsequent eruptions occur, shapes resembling silkworm eggs, bran, or wheat chaff, rashes, or scabies, with no root base or foundation, are incurable. Clad spots resembling mosquito bites are extremely malignant; spiral-shell cloud patterns are slightly more treatable. A few spots appearing before fever, commonly called "reporting smallpox," are acceptable. If fever persists without eruption, treat as carbuncles. Blocks appearing before lesions indicate wind-toxin; lesions appearing before blocks, called "ghost swelling," are difficult to cure. Avoid secluded places for smallpox; the eyelids and inside of the lips are ominous sites. Muffled smallpox in vital areas (throat, tongue, chest, back) is dangerous. Smooth courses tolerate many lesions; adverse courses fear even one. Cold carbuncles appearing first prevent other lesions from showing; thief smallpox prevents other lesions from filling with fluid. If identification is accurate, puncture urgently. If interior syndromes are unbalanced, despite eruption, toxins remain interior; prioritize detoxification. If stool is regulated and the person is calm, despite fever, toxins have penetrated the exterior; prioritize stabilizing the exterior. If interior and exterior syndromes are balanced, avoid over-treatment. Assess spirit and courage, and examine interior/exterior conditions.

By the third and fourth days, eruptions should be uniform, reaching the soles of the feet, indicating stability. If eruptions are still uneven and hidden within the skin, it is either wind-cold stagnation or Qi deficiency. Before the fourth day, toxins are just emerging; the body surface should be kept cool. After the fourth day, toxins have emerged; the body surface should be kept warm. Cooling harmonizes Qi and blood, ensuring lustrous lesion color; warming opens the pores, facilitating pus formation. If, at this stage, there is no slight fever and the color is not fresh/lustrous, although not frozen, the lesions will certainly not grow. By the fifth and sixth days, blood sacs form; they should be large and coarse, with bright white tops. Red roots and white tops indicate readiness for pus formation. Excessive redness, though attractive, lasting six days, results in hollow, flower-like emptiness with thin, shiny skin containing water-like fluid. Pointed tops with non-red bases indicate incomplete pus formation. Unresolved intense heat/toxins lead to purple/black colors; stagnation without rising leads to sinking/collapse; stagnation without nourishment leads to dryness/grey-blue; weakness without vigor leads to slow/retarded pus formation. Flesh swelling without lesion elevation indicates stagnant pus; facial edema with receding lesions indicates blocked toxins. No fever with non-elevating lesions indicates ice-hard forms; if redness remains unchanged, warming may revive them. Weak Qi and blood causing non-thriving lesions, yet remaining rosy, can be revived with tonification. Purple/dry lesions contraindicate warming-tonifying; activate blood and loosen muscles instead. Stagnant toxins may require potent herbs to erupt, but penetrating the muscle is superior. Loose stools require warming-tonifying; severe diarrhea requires lifting agents.

On the sixth and seventh days, during Qi and blood transformation, smooth courses show half-filled pus, while deficient lesions emit faint light. Heavy toxins with stagnation show dry/red tops; abundant Qi shows full/glossy lesions. Head/face pus formation with non-raised limbs requires no panic; leg blistering with scorched face/forehead requires no joy. Fear choking and wheezing. Poor food intake risks organ deficiency and internal collapse; frequent fluids risk diarrhea and danger. Severe heat/irritability/thirst should not be treated as excess here; combined with loose stools, treat as deficiency. Black/purple/dry lesions require urgent heat-dispelling; Qi-deficient/sunken lesions require warming-tonifying. Choking fears voice loss; wheezing fears abdominal distension. White lesions lacking spirit, even with red roots, are hard to treat; tips not rising from roots, even with red bases, are futile. Pale/white/sunken/broad lesions lack pus; thin/shiny/delicate-red lesions have thin pus. These four conditions indicate Qi deficiency.

By the eighth and ninth days, itching is inevitable. High fever without itching leads to dryness. Purple/dry lesions need no attention; clotted blood traces may rarely succeed. Half-filled pus is not yet time for scabbing. Sudden all-purple/black should not be mistaken for scabbing. Proper dispersing generates blood points and further pus. Rapid breathing/abdominal distension predicts imminent death by voice loss.

After eight/nine days, dry red scabs form. If growth is irregular, pus formation occurs now. Heavy fever with body heaviness hinders scabbing, indicating Yang excess/Yin deficiency; use cooling/astringents. Full pus with shortness of breath suggests phlegm surge. Sudden convulsions suggest constipation of both bowels/bladder. Qi deficiency/sinking leads to black/scorched lesions; warming-tonifying revives them, dispersing saves them. Stable diarrhea indicates major deficiency/minor toxin. Spleen cold causes white pus; organ toxicity causes bloody stool. Hoarseness with full pus is tolerable; collapsing/itching/grinding teeth with solid stool/clear voice is livable. Hard scabs indicate no further changes; beware residual toxins. Over-evaporation causes ulceration. Burning fever causes blister rupture, leaving empty shells due to excessive heat clearing. Abdominal distension/wheezing/collapse indicates internal toxin attack. Lack of yellow pus results in blood-red scabs. Prior detoxification yields excellent prognosis. Stomach Qi exhaustion causes lip/mouth swelling; Liver heat causes upward-gazing white eyes. Wheezing after diarrhea indicates Qi deficiency; diarrhea followed by thirst is not excess heat. Persistent diarrhea/thirst requires lifting; excessive drinking worsening thirst is hopeless. Qi deficiency/chills with intact lesions require warming meridians; full pus/hard recovery with solid stool/heat requires draining. Cooling aids scabbing; avoid over-tonifying.

Scabs complete by the eighth/ninth day. Residual toxin variations are never auspicious. Closed eyes/abdominal distension indicate crisis; persistent edema indicates disaster. Voice loss despite scabs indicates black lesions. Swelling persisting with early eye-opening fears internal toxin attack. Extreme Yang causes manic screaming/wheezing; intestinal damage causes pus/blood in urine/stool. Lingering heat/toxins cause high fever/chills despite scabs; residual meridian toxins cause alternating chills/fever at dusk. Morning fever/red cheeks indicate excess; afternoon fever indicates Yin deficiency. Thin body with regulated stool. Lip-smacking/tongue-playing indicates Heart heat; belly-grabbing/chest-lifting indicates Lung/Stomach toxin. Fever/constipation risks acute convulsions; tidal fever/loose stools risks slow spleen wind spasms. Blindness with light-aversion; mouth ulcers with burnt lips/black gums. Excess heat in Large Intestine causes constipation; deficiency-cold in Stomach causes diarrhea. Distinguish excess/deficiency in wheezing/thirst; distinguish cold/heat in diarrhea. Observe post-scab fall and scar color. Peach-red/lustrous indicates safe Ying/Wei; grey-purple/dry indicates residual wind-heat; pink-white indicates Qi/Blood deficiency; sticky skin indicates Spleen/Stomach disease. Whole-body red spots indicate failed drainage; whole-body cyanosis indicates wind-cold invasion. Residual toxins cause carbuncles/furuncles. Early wind exposure risks new sores. Do not spread falsely; this is the true secret of sages.