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1. Qi and Blood each have their respective dominions. Throughout the entire process of smallpox (Dochuang), there is no reliance other than on Qi and Blood. If Qi and Blood are abundant and unobstructed, the eruption will be easy to emerge and easy to resolve; if Qi and Blood are deficient, myriad complications will arise. Therefore, those treating smallpox must first attend to Qi and Blood. However, Qi belongs to Yang and is formless; Blood belongs to Yin and is formed. Thus, formless entities are primarily governed by Qi; formed entities are primarily governed by Blood. Hence, Qi governs the superficial aspects, while Blood governs the root; Qi governs the initiation, while Blood governs the fullness; Qi governs the shape, while Blood governs the color; Qi governs the inflation, while Blood governs the foundation. Therefore, Qi enables the pustules to swell, forming the milky elevation; Blood enables the pustules to fill with pus, achieving fullness. Regarding pathological manifestations: symptoms such as white color, depression, grayish hue, failure to erupt, perforated tops, oozing fluid, pain, itching, edema, crust formation, failure to scab and fall off, unstable exterior, and blocked interstices are all diseases caused by Qi. Conversely, symptoms such as purple-black discoloration, dryness and withering, lack of blood, absence of pus, black depression and black scabs, shoulder/back pain and cancrum oris, ding carbuncles and maculopapular rashes, inability of body fluids to reach, and residual toxins after smallpox are all diseases caused by Blood. Although the distinction between Qi and Blood is indeed as described, Blood cannot circulate without Qi, and Qi cannot stabilize without Blood. If Qi arrives but Blood does not follow, although eruption may occur, filling will inevitably be incomplete; if Blood arrives but Qi does not, although moistening and floating may occur, the toxin will ultimately fail to be vented. Therefore, in treating these conditions, one must not neglect attending to both.

2. The key to observing smallpox lies solely in the concepts of Deficiency (Xu) and Excess (Shi). "Excess" refers to the excessiveness of pathogenic factors; when pathogens are excessive, clearing and purging are indicated. "Deficiency" refers to the deficiency of Qi and Blood; when Qi and Blood are deficient, warming and tonifying are indicated. Moreover, smallpox originates from fetal toxins; without Yuan Qi (Primal Qi), it cannot be vented outward, and without Yuan Qi, it cannot be resolved inward. Thus, even when seeking to detoxify and clear heat, one must rely on Yuan Qi. If Yuan Qi is weak, clearing will not work, and resolving will not work. If the body is already unable to withstand the condition, how could it endure further clearing and resolving? The entire course of smallpox should be evaluated with Yuan Qi as the primary consideration.

3. In cases where the Exterior is Excess and the Interior is Deficient, eruption will be easy but resolution difficult; where the Exterior is Deficient and the Interior is Excess, eruption will be difficult but resolution easy; if both Exterior and Interior Qi are substantial, eruption and resolution will both be easy. Thus, from the initial emergence of the rash until beyond ten days, if the exterior presents with high fever throughout the body, and the interior shows normal diet and bowel/bladder functions, this indicates Excess in both Exterior and Interior. The lesions will be lustrous and erupt easily, and will resolve and scab easily.

4. Both Exterior and Interior have states of Deficiency and Excess. Exterior Deficiency manifests as aversion to cold, or low-grade fever, alternating chills and fever, cold limbs, cyanotic or pale complexion, profuse sweating and wind-aversion, lethargy and desire to sleep, grayish-white lesions that are depressed and dull, tender skin with itching, vesicle-like appearance that feels soft to touch, non-red bases, inverted scabbing failing to form crusts, and a pulse that is floating, fine, and weak. These are all signs of Exterior Deficiency, treated by warming and tonifying the Yang aspect. Interior Deficiency occurs during the phase before or after eruption, manifesting as vomiting, diarrhea, nausea, preference for hot drinks, anorexia, indigestion, clear urine and loose stools, non-thirst, shortness of breath with faint voice, mental confusion and somnolence, abdominal distension and belching, acid regurgitation, and a weak, powerless pulse. These are signs of Interior Deficiency, treated by warming and tonifying the Yin aspect. Exterior Excess manifests as high fever without sweat, red face and purple lips, headache and body ache, red eyes and nasal congestion, scorched red skin, very hot hands and feet, red-purple lesions with swelling and pain, thick and hard skin, carbuncles and rashes, and a floating, surging, slippery, and large pulse. These are signs of Exterior Excess, treated by clearing and resolving Exterior pathogens. Interior Excess manifests as constipation of both stool and urine, chest and diaphragm fullness, dry lips and throat, mouth sores and black tongue, extreme thirst with cough and phlegm-wheezing, restlessness, mania, loud voice with delirium, and a deep, rapid, surging, and slippery pulse. These are signs of Interior Excess, treated by clearing and resolving Interior pathogens.

Zhang Yizhi stated: Vomiting, diarrhea, and poor appetite indicate Interior Deficiency; depression, inversion, and grayish-white lesions indicate Exterior Deficiency. When both are present, it is Deficiency in both Exterior and Interior, treated with Yigong San (Extra Efficacy Powder); even Guizhi Tang (Cinnamon Twig Decoction), Fuzi (Prepared Aconite Root), and Lingsha (Cinnabar) may be used. Ability to eat with constipation and inverted lesions indicates Interior Excess; mild cases use Shegan Nu Bazhen Zi Tang (Belamcanda and Burdock Seed Decoction), severe cases use Qianhu Zhiqiao Tang (Peucedanum and Aurantium Decoction). Dysentery with much blood and ability to eat indicates Interior Excess; tonifying the Interior here would lead to carbuncle-toxin formation. Red, vibrant, and protruding lesions indicate Exterior Excess; tonifying the Exterior here would lead to ulceration and failure to scab.

5. Smallpox can present with Cold or Heat in both Exterior and Interior. Heat indicates Yang syndromes; Cold indicates Yin syndromes. Cold causes Qi and Blood to become stagnant and obscure; Heat causes Qi and Blood to become too moist and fail to consolidate. Heat syndromes are mostly Excess, strictly contraindicating Cangzhu (Atractylodes Rhizome), Baizhu (White Atractylodes Rhizome), Guizhi (Cinnamon Twig), Fuzi (Prepared Aconite Root), and other hot/dry substances. If Yuan Qi is weak, even if Heat signs appear, one must not rigidly diagnose them as Excess-Heat. Cold syndromes are mostly Deficiency, strictly contraindicating Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), Zhizi (Gardenia Fruit), Huangbai (Phellodendron Bark), and other bitter-cold substances. Even if the physique is robust, if Deficient pulses and signs are seen, one must not mistake them for Excess.

Exterior Cold manifests as failure to erupt, lack of redness/vitality, pale bases, cool body with itching, inverted/depressed/withered lesions; these are signs of Yang deficiency in the muscle-surface, treated by tonifying Yang and warming the Exterior.
Interior Cold manifests as vomiting/diarrhea, nausea, abdominal distension/pain, acid regurgitation, anorexia, chattering teeth, aversion to cold/love for warmth, clear urine and undigested food in stool; these are signs of Yang deficiency in the Zang-Fu organs, treated by warming the Middle and tonifying Yang.
Exterior Heat manifests as intense skin heat, red-purple bases, red tops with macules, swollen/red head and face, purple-black scorched/withered areas, severe carbuncles and ding toxins; these are signs of Fire in the muscle-surface, treated by dispersing pathogens and resolving toxicity.
Interior Heat manifests as restlessness, mania, dry mouth with extreme thirst, swollen throat/sore throat, internal heat with spontaneous sweating, dark/scanty urine, constipation, epistaxis, hematuria; these are signs of Fire in the Zang-Fu organs, treated by clearing Heat and resolving toxicity.
Although Deficiency/Excess and Cold/Heat differ by Exterior/Interior, the Deficiency/Excess and Cold/Heat of the Exterior are all driven by the Middle Qi. Therefore, only by skillfully regulating the Middle Qi can the Exterior be harmonized; this is the way of seeking the root cause.

6. In pure Yin without Yang syndromes, although smallpox fever is present, the hands and feet should be warm. If the hands and feet are cold, it indicates prior vomiting/diarrhea and Spleen Qi deficiency. Since the Spleen governs the four limbs, coldness is a bad omen. Even if exterior symptoms exist, one must not use dispersing methods alone, as this damages Spleen and Stomach Qi. Instead, one should warm the Interior while addressing the Exterior, using Huangqi Jianzhong Tang (Astragalus Decoction for Building the Middle), Liuqi Jian (Six Qi Decoction), or Wuwu Jian (Five Substance Decoction) added with Fangfeng (Saposhnikovia Root), Qianghuo (Notopterygium Rhizome), Shengjiang (Fresh Ginger), and Jingjie (Schizonepeta Spike), to nourish Spleen and Stomach Qi and Blood, thereby assisting the maturation of the smallpox eruption.