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Three days after the appearance of spots (the initial eruption of smallpox), life and death are determined. A judgment made at this time can be called a high-level opening-orifice diagnosis. The face is particularly critical, as it is the convergence point of all Yang meridians. The Tianting (Forehead Center) and Yintang (Between the Eyebrows) are especially crucial areas on the face. The Master said: "Tianting is the handle for observing smallpox." Why? Because it is where the Yuan Shen (Primordial Spirit/Essence) resides. Yuan Shen is Yuan Qi (Primordial Qi). In children suffering from smallpox, it boils down to three characters: Qi, Blood, and Toxin. Qi and Blood are governed by Yuan Qi. If Yuan Qi overcomes the Toxin, the lesions will open and scab according to schedule. If the Toxin overcomes Yuan Qi, it will attack internally and cause external erosion. Once the Toxin has gained the upper hand, how can one expect Yuan Qi to regain dominance?

If the spots appear first and rise first in the Tianting area, filling with pus and scabbing early, these are good signs. However, if the spots are dense and itchy (indicating Excess Toxin and Deficient Qi), or pale and dull (indicating Excess Toxin and Deficient Blood), these are fatal conditions. It is indeed true that toxins emerge from weakness.

When spots are distinct and well-spaced, feel raised to the touch, have a lustrous color, appear first below the eyes, and body heat gradually subsides, these are auspicious signs. Such distinct, raised spots, though sparse, possess spirit; a lustrous color indicates vitality. If spots appear late in the Tianting area, it signifies that Yuan Qi is solidified internally; the opposite is an adverse sign.

Ye Xihou said: "When toxin is abundant, spots appear first from the upper part; when toxin is slight, they appear first from the lower part, just as a strong fire must first show flames above." If they appear on the head and forehead not led by blood or constrained by Qi, the nature of the toxin can be known, and thus life and death can be predicted.

When smallpox first emerges, spots appearing in clusters of three to five will likely become dense later; those appearing singly will remain sparse. The depth of the toxin can be predicted from this.

Form belongs to Qi, color belongs to Blood. Both can verify auspiciousness or inauspiciousness and determine life or death. Why do people only discuss Blood and neglect Qi? Qi is formless and hard to perceive, while Blood is有形 (has form) and easy to see. Therefore, three days after the appearance of spots, if the color resembles pig liver, it is fatal; if it resembles red rice grains, it is also fatal. If the toxin is scattered on the skin like washed bright red silk, the condition is severe. Nevertheless, if there are dozens of spots on the face with brilliant spirit, recovery is still possible. The Master said: "Do not worry about ugly form, worry about lack of spirit; do not worry about ugly color, worry about lack of luster." If the form is open and convex, and the color is moist and bright, even in critical malignant cases, seeing one or two red and lively spots means that although the prognosis is ominous, it will turn auspicious. Why? Because Yuan Qi still exists.

Cheng Zhanwu said: "Seeing one or two red and lively spots means that although ominous, it will turn auspicious." Fools always claim it is untreatable. Families who fail to recognize brilliance may sadly watch their crying infants without seeking help.

Generally, if spots appear above the eyebrows with spirit and are pleasing to the eye, not琐碎 (trivial/cluttered), nor crooked or evil, even if dense all over the body with various complications, death is unlikely. The term "pleasing to the eye" is hard to describe fully; it relies on the student's intuitive understanding.

If the scalp hair is scorched and the mind restless upon spotting, with a thick coating or purple tongue, this indicates blazing toxin in the Blood level, possibly due to internal heat.

If spots are white like water droplets, the condition is heavy. If sparse, and the person usually has a yellow complexion but the spots rise well, it indicates Qi has arrived but Blood has not. Fire should be dispersed. If the spirit is not calm internally and spots increase daily with pointed tops, toxin is extremely abundant, and medication may not cure it.

If two days after spotting, stool remains constipated with no tongue coating, it indicates Blood Heat, not toxin stagnation. Urgently clear and resolve using the base formula with Zhike (Fructus Aurantii) and Mingfen (Alumen). Otherwise, during the pus-filling stage, vomiting, pain, diarrhea, and failure to rise may occur. Use Xiong (Rhizoma Chuanxiong) and Gui (Radix Angelicae Sinensis) in double doses.

White spots that are not red should not immediately be treated as deficiency. White with no spirit, pale lips/tongue, vomiting/diarrhea indicate deficiency. White with rising color, red lips/tongue indicate non-deficiency. Turning deep purple after three days is a serious misdiagnosis. Cold feet upon spotting need not be worried about; Qi has not yet descended.

Initially, spots vary in size. Red spots like boiling water are called "Jia Zhen" (accompanied by rash). Treat with the base formula plus Jiuku Dan. Tiny red spots hidden in the flesh are called "Jia Sha" (accompanied by sand-rash); treatment is similar. Dan Du (erysipelas/toxic heat) is the same. However, for these to be considered accompanying rashes, the main smallpox must be pleasing. Otherwise, it is just smallpox and must be distinguished. Sometimes a few smallpox spots appear, followed by a full-body rash that is round, clean, sparse, red, and lively, disappearing completely in two days. Observers are amazed. This is a rash, not smallpox. Smallpox resolution causes restlessness; this case is calm, and main spots are obvious, confirming it is a rash. Treat with mild agents for self-healing. Recognition is difficult before resolution.

Fever upon spotting indicates toxin is not exhausted. Causes differ: external cold constraint or internal heat constraint; both require dispersion.

Spontaneous sweating upon spotting can mean life or death. Zhu Danxi said sweating is harmless, referring to good form and color. If sweating leads to worsening color, death is certain; careful distinction is needed.

For slow eruption, treat according to season: winter cold constraint, summer heat constraint. Differentiate deficiency/excess. Moist lips/tongue with no coating suggest deficiency treatment.

White spots, poor elevation, pale lips/tongue, vomiting/diarrhea, abdominal distension, spontaneous sweating, cold limbs, weak spirit require deficiency protocols.

Spots at the navel or anus, clustered around, are severe.

A few spots at Shan Gen (root of nose) are severe. Voice change upon emergence is also severe.

A few spots with face shining like a melon, foul breath rushing out, will lead to macules, hematemesis, and death.

Spots appearing first above eyebrows or temples, rising bright then vanishing quickly, are "Thief Pox," leading to death.

Appearing lovely initially, thin-skinned and bright, growing large in 1-2 days, arriving prematurely due to pestilential Qi, will end in itching and collapse death. New or healing sores with spotting indicate severe Yang Toxin. Non-red dry sores are severe but not fatal.

"Do what is possible, avoid what is impossible" refers to critical cases. Spots resembling snake skin, silkworm eggs, mosquito bites, scratch marks, soup blisters, fire thorns, blue-black patches, body like beaten flesh, macules with swollen lips/foul breath, locked neck, covered head, broken waist, rootless, powder-white like dead bones, chest qi with panting, bleeding from seven orifices, orange-peel facial texture, irregular form with convulsions, unceasing back/abdominal pain—are these treatable? Or not?

Books say vomiting purple-black blood upon spotting is untreatable. Previously, a six-year-old Pan girl vomited liters of purple blood on day two. Family panicked, old doctors left. I diagnosed it was not toxin, but cured by strongly tonifying Spleen/Stomach. Why? Moist lips/tongue, no internal toxin. Good form/color, no external toxin. Blood loss calmed spirit, indicating excess blood. Her father had a history of blood disorders; her vomiting was child inheriting father's residual Qi, agitated by heat, not toxin. Using Rhinoceros Horn (Xijiao) to detoxify would have killed her. As the saying goes: Better to have no books than to believe them entirely.

Saying "broken waist/rootless" applies only when form/color are bad. If round and lustrous, absence at waist/legs is harmless.

Shishen Jiedu Tang treats fever, scorched hair, dry skin, red cheeks/forehead/spots, thirst, restlessness, dark scanty urine.
Ingredients: Danggui (Radix Angelicae Sinensis), Chuanxiong (Rhizoma Chuanxiong), Shengdi (Radix Rehmanniae Preparata), Chi Shao (Radix Paeoniae Rubra), Danpi (Cortex Moutan), Honghua (Flos Carthami), Lianqiao (Fructus Forsythiae), Mutong (Caulis Akebiae), Gancao (Radix Glycyrrhizae), Jiegeng (Radix Platycodonis), Dengxin (Medulla Junci), Congbai (Bulbus Allii Cepae), Dafupi (Pericarpium Arecae), Danyezhu (Folium Phyllostachidis).
Add Gegen (Radix Puerariae), Qianhu (Radium Peucedani), Digupi (Cortex Lycii) for intense fever, tight skin/muscles.
Add Shanzha (Fructus Crataegi), Niu Bang Zi (Fructus Arctii), Chantui (Periostracum Cicadae) for slow eruption.
Add Guizhi (Ramulus Cinnamomi) for itching.
Add Fangfeng (Radix Saposhnikoviae), Huangqin (Radix Scutellariae) for pain.
Add Re Jian Chou for dry lips/coated tongue. (Backup Formula)
Use Jiuku Dan for accompanied rash. (Backup Formula)
Add Xuanshen (Radix Scrophulariae), Xijiao (Cornu Rhinocerotis), use Re Jian Chou for red macules.
Add Chaihu (Radix Bupleuri), Danshen (Radix Salviae Miltiorrhizae - *Note: Text says Danshen/Caosh likely Longdan Cao*), Re Jian Chou for red/swollen tearing eyes; apply external Hu Fa.
Add Xingren (Semen Armeniacae Amarum), Sangpi (Cortex Mori Radicis) for cough.
Add Xuanshen, Shegan (Rhizoma Belamcandae) for sore throat; apply external blow method.
Add Sai Chun Lei for black depression/boils; apply external Si Sheng Dan. (Backup Formula)
Add Xijiao, Re Jian Chou for blood loss/dry retching.
Add Chenpi (Pericarpium Citri Reticulatae), Huanglian (Rhizoma Coptidis), Zhuling (Polyporus), Zexie (Rhizoma Alismatis) for vomiting.
Add Xijiao, Shengdi for hematuria.
Add Cheqian (Semen Plantaginis), Difuzi (Herba Kochiae) for scanty/difficult urination.
Add Zhike, Xingren, Sugeng (Caulis Perillae), double Danggui for constipation.
Add Xijiao, Taoren (Semen Persicae), Huanglian for black stool.
Add Mahuang (Herba Ephedrae), use Jiuku Dan for abdominal distension/panting, staring/swollen eyes, straight hair/dry skin.
Add Qianli Ma for constipation with panting. (Backup Formula)
Add Huafen (Radix Trichosanthis), Maidong (Rhizoma Ophiopogonis) for restlessness/fever. Mix Mantian Qiu. (Backup Formula)
Add Zhuling, Zexie for diarrhea.
Add Shigao (Gypsum Fibrosum), Zhimu (Rhizoma Anemarrhenae), mix Mantian Qiu for delirium/manic confusion.
Add Qianghuo (Rhizoma Notopterygii), Duhuo (Radix Angelicae Pubescentis) for backache.
Add Shanzha, Houpo (Cortex Magnoliae Officinalis), Quya (Massa Medicata Fermentata) for food stagnation/distension.
Abdominal pain has three types: Food stagnation, take Hezhong Wan. Toxin attacking, take Jiuku Dan. Qi stagnation, add Qingpi (Pericarpium Citri Reticulatae Viride), Muxiang (Radix Aucklandiae).
All abdominal pains should be purged with Qianli Ma until relieved; do not overdo. Over-purging causes toxin to act internally, creating other symptoms.
On days 4-5, if toxin is strong, add Shanzha, Baizhi (Radix Angelicae Dahuricae), Sunjian (Shoots of Bamboo). On day 4, formula should theoretically change. But if toxin remains strong, do not change lightly.
Just add Renshen (Radix Ginseng) 4-5 fen. This is called the "Pus Method."
For heat coating, Re Jian Chou is essential. For downward symptoms, Qianli Ma is essential. For stagnation/blockage, Jiuku Dan is essential. For spots wanting to emerge but failing, dry/purple/scorched, black depression/boils, Sai Chun Lei is essential. For red lips/tongue, scanty urine, fever/thirst, dry red spots, Mantian Qiu is essential. Generally, for heat syndromes, Mantian Qiu is the primary herb.

Question: Re Jian Chou and Qianli Ma are bitter-cold herbs. You use Re Jian Chou for tongue coating, correct. What are "downward symptoms"?
Answer: Refers to excessive tongue coating.
Question: Can one have tongue coating and diarrhea?
Answer: Yes. This is "treating obstruction with unblocking methods" (Tong Yin Tong Yong).
Question: What is "stagnant heat"?
Answer: Abundant toxin blocked and constrained. How to verify? Abdominal distension/panting, staring/swollen face, straight hair/dry skin, spots wanting to emerge but failing, steaming heat/restlessness, flickering heat.