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The appearance and color of smallpox (Xiaozhen) at the initial stage determine good or bad prognosis, while the patterns of cold-heat and deficiency-excess can also be identified. At this time, the power of regulation and rescue is particularly crucial. Moreover, within three days after the eruption, the pathogenic toxin lies between the exterior and interior, which is of utmost importance. Therefore, improper sweating will lead to ulceration; improper purgation will cause the lesions to sink and hide; excessive use of cold-cooling herbs will inevitably damage healthy Qi; excessive use of dry-hot herbs will assist pathogenic factors. If deficiency-cold is not supplemented, the lesions will sink and itch/ulcerate; if excess-heat is not resolved, the lesions will turn black and relate to the Kidney (a critical condition). If there is even one mishandling, life and death are decided immediately. Physicians must be extremely cautious in this regard.

1. After the red spots of smallpox appear, if body heat slightly subsides without other internal heat symptoms, or if the color is not very red and the apex is not very prominent, it indicates a deficiency pattern. Even within three to five days after eruption, cold-cooling herbs must absolutely not be used, as they may damage the Spleen and Stomach, causing significant harm. The Baoyuan Tang (Preserve the Origin Decoction) or Liuwu Jian (Six-Material Decoction) should be used as the main formula, modified according to the syndrome, to nourish and support the body.

2. Smallpox erupts and rises due to heat. If heat is excessive, it causes blood agitation and blood depletion, making eruption difficult. Therefore, before the appearance of spots, one must observe cold-heat conditions and regulate in advance. If heat signs are present, do not overuse acrid-warm, qi-moving herbs, lest they aggravate fire pathogens and cause variable complications.

3. Diarrhea is most feared at this stage and should be treated urgently according to the relevant section.

4. Early appearance of spots has distinctions of good/bad and deficiency/excess. If fever lasts only one day, or spots appear as soon as fever starts, it is caused by blood heat and abundant toxin, usually indicating a ominous prognosis. However, if the spots are sparse and appetite remains normal without other symptoms, it is harmless. If the patient's constitution is originally weak but spots appear rapidly, this is Ying-heat with Wei-deficiency, unable to constrain pathogens externally, leading to sudden eruption. It requires simultaneous exterior-strengthening to avoid itching and ulceration. Shibiao Jiedu Tang (Exterior-Solidifying and Toxin-Resolving Decoction) is indicated. If spots appear densely after one day of fever, the prognosis is worst and toxin is severe. This pattern strictly forbids warm-tonification. Sousong Decoction (Search-toxin Decoction) plus Chaihu (Bupleuri Radix) is indicated, or Qianghuo San (Notopterygii Rhizoma et Radix Powder) plus Niubangzi (Arctii Fructus), Zicao (Arnebiae Radix seu Rubra), and Chantui (Cicadae Periostracum), or Bao Ying Dan (Infant-Preserving Pill). For severe heat, Tuihuo Dan (Fire-Removing Pill) or Shuangjie San (Double-Resolving Powder) should be used urgently for a slight chance of survival. If spots appear early but are not red-purple and heat is mild, it belongs entirely to exterior deficiency. Baoyuan Tang or Liuwu Jian are appropriate.

5. Slow eruption has several patterns; one must examine for exterior invasion or internal injury to treat accordingly. In winter severe cold, or non-seasonal Yin-cold pathogens closing the exterior, causing slow eruption due to excess cold, Wuwu Jian (Five-Material Decoction) plus Shengjiang (Zingiberis Rhizoma Recens), Mahuang (Ephedrae Herba), and Xixin (Asari Radix) is indicated, or Wuji San (Five-accumulations Powder) is also good. In summer, heat steaming causes blood heat and Qi deficiency, restlessness, thirst, and agitation with slow eruption; Renshen Baihu Tang (Ginseng White Tiger Decoction) plus Mutong (Akebiae Caulis) and Gange (Puerariae Radix) is indicated. If affected by abnormal seasonal Qi, invaded by Wind-Cold exterior pathogens, causing closed pores, fever, no sweat, and slow eruption, accompanied by headache, nasal congestion, and limb stiffness/pain, Shuxie Yin (Dispersing Pathogens Infusion), Shen Su Yin (Ginseng and Perilla Infusion), or Xingxing San (Awakening Powder) are indicated. If there are no such pathogens but eruption is slow, it is due to internal Qi and Blood deficiency failing to drive out toxin, leaving it stagnant internally. Shixuan San (Ten-Accumulations Powder) or Tuoli Xiaodu San (Interior-Supporting and Toxin-Resolving Powder) are indicated. For severe Qi deficiency slowing eruption, Baoyuan Tang or Liuqi Jian (Six-Qi Decoction) are used. For severe Blood deficiency, Wuwu Jian or Liuwu Jian are used. For internal injury causing Qi stagnation and slow eruption, Yunqi San (Harmonizing Qi Powder) or Jupi Tang (Tangerine Peel Decoction) are used. For slow eruption on the head and face, Chuanxiong (Ligustici Chuanxiong Rhizoma), Jingjie (Schizonepetae Herba), Qianghuo (Notopterygii Rhizoma et Radix), Fangfeng (Saposhnikoviae Radix), and Tianma (Gastrodiae Rhizoma) are used as guiding herbs. For chest and abdomen, Gaoben (Ligustici Wallichii Rhizoma), Shengma (Cimicifugae Rhizoma), Zisu (Perillae Folium), and Zicao Mutong Tang (Arnebia and Akebia Decoction) are used. For limbs, Guizhi (Cinnamomi Ramulus), Gange, Gancao (Glycyrrhizae Radix et Rhizoma), Lianxu (Gancao with roots), Zicao, and Congbai (Allii Fistulosi Bulbus) plus Shengjiang as assistants are used; two doses will ensure rapid eruption.

6. Failure of eruption varies but is mostly due to internal Qi and Blood deficiency failing to push outward. Some require simultaneous dispersal, others require tonifying Yuan Qi exclusively. After full eruption, if blocked by Wind-Cold with fever, headache, and sinking lesions, Qianghuo San or Shen Su Yin plus interior-supporting herbs are used. If red spots are dark, dry, and fail to rise, it is ominous; Siwu Tang (Four-Substance Decoction) plus Zicao, Honghua (Carthami Flos), Dingxiang (Syzygii Flos), Chantui, and Guanzi Gui (Cinnamomi Cortex) or Wu Jia San (Priceless Powder) adjusted for age is used. If constipation and internal heat cause hidden failure to rise, Zicao Yin (Arnebia Infusion) is used. For slight Blood heat preventing toxin release, Tuoli Xiaodu San is used. For Qi deficiency and sinking, Baoyuan Tang or Chantui Gao (Cicada Paste) plus Huangqi (Astragali Radix) is used. For Blood deficiency, Xionggui Tang (Angelica and Ligusticum Decoction) or Siwu Tang is used. For Blood deficiency-cold, Wuwu Jian is used. For Qi deficiency-cold, Baoyuan Tang or Liuqi Jian is used. For both Qi and Blood deficiency, Liuwu Jian or Tuoli San is used. These Qi-Blood tonics work best with good wine, human milk, and glutinous rice. Eruptive herbs differ: some attack toxin with toxin (Shanjia [Manis Squama], Renya [Hominis Dentium Os], Chansu [Toad Venom], Chantui); some clear toxin (Cheqiancao [Plantaginis Herba], Honghua, Niubangzi, Xijiao [Rhinocerotis Cornu - note: substitute with Buffalo Horn in modern practice], Mutong, Lianqiao (Schizonepetae Herba? No, Forsythiae Fructus), Jinyinhua (Lonicerae Japonicae Flos)); some lift Qi and Blood (Chuanxiong, Baizhi (Angelicae Dahuricae Radix), Jingjie, Shengma, Manjingzi (Viticis Semen)); some disperse Cold (Mahuang, Guizhi, Chaihu (Bupleuri Radix), Gange, Fangfeng, Zisu, Congbai); some move Qi to unblock obstruction (Dingxiang, Muxiang (Aucklandiae Radix), Chenpi (Citri Reticulatae Pericarpium), Houpo (Magnoliae Officinalis Cortex), Shanzha (Crataegi Fructus), Dahuang (Rhei Radix et Rhizoma)); some warm Fire and restore Yang to stop diarrhea (Fuzi [Aconiti Lateralis Radix Praeparata], Rougui [Cinnamomi Cortex], Ganjiang (Zingiberis Rhizoma), Roudoukou (Myristicae Semen)). All these support the interior to promote eruption, but must be auxiliaries to the main treatment of Qi and Blood via Sijunzi Tang (Four-Gentlemen Decoction), Siwu Tang, or Shiquan Dabu Tang (Comprehensive Great Tonifying Decoction) for success.

7. Deficiency patterns during the reporting phase require immediate tonification; otherwise, pustule formation and scabbing will fail, leading to death after ten days. Excess-heat smallpox fears abundant toxin; deficiency-cold fears internal collapse. Excess-heat is obvious; deficiency-cold is hidden, often misdiagnosed, causing greater harm. Smallpox relies on diet and Qi/Blood. Diet root is Spleen/Stomach; Qi/Blood root is Liver/Kidney. Strong Spleen/Stomach Qi ensures nourishment without internal sinking; sufficient Qi/Blood transforms toxin without exterior itching. Differentiate early. Gray-white non-red spots, gray-black sunken tops, no high fever, tender shiny skin like dampness, no thirst, poor appetite, distended abdomen, loose stools, cool urine/stool indicate exterior-interior deficiency-cold. For Qi deficiency, Diaoyuan Tang (Regulate Origin Decoction) or Sijunzi Tang. For Qi deficiency with slight stagnation, Wuwei Yigong San (Five-Ingredient Extra-Effort Powder). For Qi deficiency needing warmth, Baoyuan Tang or Liuqi Jian. For Spleen Qi deficiency-cold, Yangzhong Jian (Nourish Middle Decoction), Wenwei Yin (Warm Stomach Infusion), or Lizhong Tang (Regulate Middle Decoction). For Blood deficiency, Siwu Tang; for Blood deficiency needing warmth, Wuwu Jian. For both Qi/Blood deficiency, Liuwu Jian, Wufu Yin (Five-Fortune Infusion), or Bazhen Tang (Eight-Treasure Decoction). For both deficient and cold, Shiquan Dabu Tang. For severe Spleen/Kidney Qi/Blood deficiency-cold, Jiwei Yigong Jian (Nine-Ingredient Extra-Effort Decoction) or Liuwei Huiyang Yin (Six-Ingredient Restore-Yang Infusion). For Spleen/Stomach deficiency-cold with Qi stagnation, Chen's Twelve-Ingredient Extra-Effort Powder. For gray-white non-rising spots (Qi deficiency), after full eruption, Baoyuan Tang with Mutong and Chuanxiong is safest.

8. Fire-pattern toxin after spot appearance requires rapid clearing. Delay leads to worsening and death. Very red spots with red base skin indicate Blood heat/Qi excess failing to constrain, leading to rapid, fragile eruption prone to fatal itching. Urgently clear Blood heat using Liangxue Yangying Jian (Cool Blood Nourish Ying Decoction), Shi Niu Zi Tang (Arctii Decoction), or Liuwei Xiaodu Yin (Six-Ingredient Toxin-Resolving Infusion) plus Shaoyao (Paeoniae Radix); or Siwei Xiaodu Yin (Four-Ingredient Toxin-Resolving Infusion), Yi Yuan San (Benefit-Origin Powder). If toxin clears but fever persists, toxin is trapped internally with dense spots; resolve toxin with Chaige Jian (Bupleuri and Pueraria Decoction) or Shi Niu Zi Tang. Persistent high fever, connected red-purple spots, scorched bases, red-purple patches, dry hot lips, thirst for cold, tongue coating, dry stool/urine indicate severe interior-exterior heat/toxin. Clear heat/toxin urgently. Severe exterior heat: Chaige Jian. Severe interior heat: Sousong Decoction plus Chaihu, or Liuwei Xiaodu Yin plus Jiuhuangqin (Wine-fried Scutellariae Radix), Mutong, Zhizi (Gardeniae Fructus), Huanglian (Coptidis Rhizoma), Shanzha, Chantui, Danggui (Angelicae Sinensis Radix), Shaoyao, Honghua; or Tuihuo Dan. If heat-toxin causes惊狂 (startled madness) and delirium, Zicao Jian (Arnebia Decoction) ground with Xijiao (Rhinocerotis Cornu) juice, mixed with Zhusha Yi Yuan San (Cinnabar Benefit-Origin Powder) or Tuihuo Dan. After detoxification, if redness fades, bowels normalize, appetite returns, stop detoxification. Immediately tonify Qi/Blood with Baoyuan Tang, Siwu Tang, Liuwu Jian to aid pustulation/scabbing, lest itching occur. If severe internal heat causes hard constipation, extreme thirst, irritability, abdominal fullness, surging-rapid pulse, and slow eruption, heat-toxin is trapped internally. Promote urination to remove heat-toxin using Chaihu Yinzi (Bupleuri Infusion) or Sanhuang Wan (Three-Yellow Pill); severely, Chengqi Tang (Chengqi Decoction) or Pig Gallbladder enema. This is only for internal heat-toxin before visible spots, used mildly if necessary. If spots are faintly visible on skin, they are emerging externally; do not use purgatives. For dense red spots initially, burn Chandouteng (Entadae Phaseoloides Caulis) to charcoal, add processed Zhusha (Cinnabar), take 2-3 doses; or Bohe (Menthae Haplocalycis Herba), Niuxiangzi (Arctii Fructus) decoction with Tuihuo Dan. Apply Wuzhuyu (Evodiae Fructus) powder mixed with water to soles to guide heat down.

9. Black smallpox is critical. Healthy blood/Qi makes spots red/vibrant; heat-toxin scorching makes them black; insufficient Yang makes them gray-black. Black relates to Water/Kidney, Yin attacking Yang, a dire sign. Differentiate and treat. If heat-toxin aggregates with constipation, irritability, thirst, turning black/depressed, unblock bowels first with Chaihu Yinzi or Danggui Wan (Angelica Pill). After evacuation, use Zicao Yin or Jiawei Sisheng San (Modified Four-Sages Powder) to resolve exterior toxin, apply Yanzhi Zhi (Red Lac Juice). If no constipation/heavy heat but dark/black spots, it is Spleen deficiency failing to control Water. Use Wuwu Jian or Baoyuan Tang plus Zicao, Honghua orally; apply Sisheng Dan, Yanzhi Zhi externally. Red/vibrant return is good; dry/black is bad. *Xinjian* states: Treat black spots with Baoyuan Tang plus Chuanxiong, Rougui to boost Qi; strong Qi disperses toxins, black turns yellow.

10. Smallpox with rash/macules is not auspicious but has severity levels. Between 2-3 days of fever, if red spots appear suddenly all over like mosquito bites before smallpox shape, it is macules/rash, not smallpox, caused by Wind-Cold blocking eruption. Use Shuxie Yin, Chaige Jian, or Baidu San (Resolve-Toxin Powder) to gently disperse. Once cool, macules fade, and subsequent smallpox will be mild. For simultaneous smallpox and macules/rash, differentiate cold/heat. Interior-exterior heat with unresolved pathogen: Chaige Jian modified. Mild heat, severe exterior pathogen: Shuxie Yin or Chai Gui Yin (Bupleuri and Angelica Infusion) plus Qianghuo, Fangfeng, Gange; or Baidu San. Red macules like brocade: Liangxue Huadu Tang (Cool Blood Transform-Toxin Decoction) plus Chaihu, Huangqin (Scutellariae Radix), Xuanshen (Scrophulariae Radix), Xijiao. Eye redness/lip cracking indicates exterior heat; irritability/thirst/delusions indicate interior heat. Both are dire; treat both with Shuangjie San. Dyspnea/confusion is untreatable.

11. "Thief Smallpox" appears after full eruption: single red/huge spots, soft to touch. After 3 days, they become blisters, even purple-black, critical. Urgently use Baoyuan Tang or Liuqi Jian plus Zicao, Honghua, Chantui; or Dengcao (Junci Medulla), Mubian decoction with Yi Yuan San to drain Heart heat, fading redness. If blisters form, Baoyuan Tang plus Sibing San (Four-Drain Powder) to diurese; this is a secret method, else whole body breaks down and rots.

12. Before eruption, if wet sores with pus flow, apply Fusshi Mo (Adhering Stone Powder) to prevent Qi leakage, or true Mouton Fen (Mung Bean Starch) works too.