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[Wan Quan] Although variola (smallpox) and exanthems originate from fetal toxins, they must wait for the abnormal qi of the seasons to transmit among people before erupting. Generally, spring qi is mild, summer qi is hot and humid, autumn qi is cool and dry, and winter qi is cold and biting; this is the normal sequence of the four seasons' righteous qi. If spring should be warm but turns cold, summer should be hot but turns clear and cool, autumn should be cool but turns hot, and winter should be cold but turns warm, this is having the qi out of season, which constitutes an abnormal seasonal command. When humans are affected by this, some manifest as alternating chills and fever, some as malaria or dysentery, some as throat obstruction (Hou Bi), some as swelling, and some as macules and papules (Zhen). This is called "Heavenly Epidemic Righteous Disease." It is also said: Epidemic diseases (Yi Li) involve mutual transmission within a year, with symptoms similar in severity across all ages. Furthermore, if winter warmth causes a sudden leakage of yang qi, it will inevitably lead to the eruption of variola/exanthems in the following year. Why? Because after the Solar Term of Light Snow, it is the final phase of the year, governed by Taiyang Cold Water. If the virtue of water fails to manifest, allowing Jueyin and Shaoyin Wood-Fire qi to counter-attack, yang qi emerges prematurely, resulting in insufficient nourishment for growth. Thus, the people will fall ill frequently in the coming spring. Moreover, the toxin of variola/exanthems hides beneath the extreme yin and erupts via the Taiyang meridian. When the appropriate time arrives and stirs its qi, the toxin erupts. This explains why variola/exanthems inevitably follow winter warmth. For diseases caused by such abnormal qi, treatment should employ sweating (Fa Han), purging (Xie), resolving (Jie), and balancing methods, without violating the annual qi. This is termed the work of a skilled physician. Therefore, in treating epidemic diseases, detoxification is the priority.

[Qian Yi] In Shanghan (Cold Damage), boys present with heavy body weight and sallow complexion; girls present with red face and rapid breathing. Both groups exhibit aversion to cold, hot breath, yawning with sudden chest oppression, and neck stiffness. In contrast, exanthems present with red and restless cheeks, frequent sneezing, palpitations, drowsiness, lethargy, and cold limbs. Shanghan should be treated with dispersing methods. Exanthems should be treated with warming and balancing methods; if there is intense heat, detoxification is indicated. Drowsiness, preference for sneezing, and palpitations are signs that exanthems are about to erupt.

[Liu Wansu/Danxi School context - Note: Yuan Hao is Li Gao's contemporary/student, often grouped here] Differentiation of Symptoms: Yawning, sneezing, acute convulsions during sleep, cold ear tips, and dry eyes. Differentiating Shanghan: Hot mouth, sour odor in the mouth, undigested milk curds, and abdominal pain.

[Cai Songting] The condition may stem from contagion, wind-cold/wind-heat injury, food stagnation, or variola/exanthems, presenting variously. Pain in the head and joints occurring at irregular intervals indicates febrile disease from epidemic contagion. Red face with sweating and clear nasal discharge indicates wind-heat injury. Fever in the afternoon, heat in the head and abdomen, and lines on the upper forehead indicate food-stagnation heat. Alternating chills and fever, yawning with chest oppression, palpitations, coughing, sneezing, bright red cheeks, and cold ears/hands/feet indicate variola/exanthem heat. Generalized high fever, delirium seeing spirits, epistaxis, unceasing convulsions, near-death experience followed by revival, indicates excess heat of variola/exanthems trapped internally.

[Qian Yi] Prodromal signs of exanthems: Dry face with red cheeks, red eyelids, yawning with chest oppression, alternating chills and fever, coughing and sneezing, slightly cold feet, nighttime startle/palpitations, and excessive sleep. These are signs of exanthems as a heavenly epidemic disease. At the initial eruption of exanthems, signs of the five zang organs appear, except for the Kidney, which shows only peaceful signs, specifically coolness of the buttocks and ears. The buttocks and ears belong to the Kidney, located in the North, governing cold.

[Zhang Yan] The onset of variola may result from wind-cold/shanghan, epidemic contagion, food stagnation/vomiting, or trauma/fright/blood stasis. Manifestations may include eye involvement, convulsions resembling wind-stroke, pain in the mouth, tongue, throat, or abdomen, restlessness, mania, deep sleep, spontaneous sweating, diarrhea, fever, or absence of fever. The patterns are diverse and difficult to distinguish hastily. Verification must rely on coldness of the ears, buttocks, feet, and nose tip. Additionally, observing red veins or threads behind the ears confirms true variola. Furthermore, a pulse that is surging, large, wiry, and rapid, accompanied by slight tremors of the body during pulse diagnosis, indicates this condition.
Song says: Cold fingertips indicate unsettled fright and epilepsy; warmth in the middle finger indicates definite Shanghan. Isolated coldness in the middle finger relates directly to measles or smallpox; distinguish between males (left) and females (right) carefully.
Secret method: When initially examining for variola, if uncertain, look for redness under the skin of the heart pit, cold ear tips, and red ear veins. Seeing these indicates variola signs. Regarding ear veins: purple veins before eruption are untreatable; treat preemptively with blood-cooling and detoxifying formulas, though some may recover. If constipation occurs, first promote bowel movement. Bright red cases are treatable and curable; pale red cases heal without medicine; peach-red cases require treatment based on severity. Observe left for males and right for females.

[Verifying Heat Timing]
[Qian Yi] If tidal fever lasts more than three days upon onset, and the heat晕 (yun/miasma) enters the skin, exanthems will erupt but not excessively. This indicates heat remaining in the skin and interstices, emerging with the tidal fever according to the affected zang organ. If tidal fever persists after early meals, it indicates vesicles.
[Zhang Yan] Variola always erupts due to fever. By observing the timing of the fever, one can determine the originating zang organ. Tidal fever during Yin-Mao-Chen hours belongs to the Liver, indicating vesicle eruption. Tidal fever during Si-Wu-Wei hours belongs to the Heart, indicating pustule/ulcer eruption. Tidal fever during Shen-You-Xu hours belongs to the Lungs, indicating pus-filled blisters. Tidal fever during Hai-Zi-Chou hours belongs to the Spleen, indicating rash eruption.

[Using Medication to Verify]
[Wang Kentang] To verify variola (referred to here as Zhen, meaning smallpox): If no visible traces appear after three days, apply raw wine to the body and observe frequently. If the marks resemble flea bites, it is variola. Some argue that Shanghan, food stagnation, and tidal fever cannot be distinguished from variola/rash. In such cases, use acrid-cool formulas to regulate. If eruption occurs with sweating within five days, it is confirmed; if not after five days, it is not variola. Treat according to the specific manifestations.

[Verification and Treatment]
[Yan Xiaozhong] Treating pediatric high fever and drowsiness: Wind-cold, wind-heat, exanthems, and food stagnation present similarly. During the period of uncertainty, administering Shengma Gegen Tang (Cimicifugae and Puerariae Decoction), Xingxing San (Awakening Powder), or Xiao Chaihu Tang (Minor Bupleurum Decoction) is highly effective, as these formulas broadly address these conditions without error. However, food stagnation presents with sour-smelling, undigested stool, anorexia, or vomiting, requiring purgative treatment. Haizang (Zhang Yuansu) stated: When using purgatives, one must identify the ingested substance, as foods vary in nature (raw, hard, cold, hot). Do not hastily use highly toxic purgatives like Radix Crotonis (Badou). Shengma Gegen Tang addresses Taiyang and Yangming channels. Xingxing San treats wind-heat causing throat obstruction, spleen dysfunction, Shaoyang thirst, and dysuria. Xiao Chaihu Tang treats alternating chills and fever and slight hypochondriac pain, addressing the Shaoyang channel. To identify the channel, differentiate by pulse. Pediatric signs of impending exanthems include cold ears/buttocks, fluctuating hand/foot temperature, red face, intermittent cough/sneezing, and palpitations. While differentiation is unclear, Shengma Tang and Xiaodu San are suitable regardless of eruption status. Also apply Hu Su Jiu (Coriander Wine) and Huang Bo Gao (Phellodendron Ointment). For irritability in summer months, administer Baihu Tang (White Tiger Decoction) or Yulu San (Jade Dew Powder) after meals. For intense heat, administer Zixue (Purple Frost). For throat ulcers, administer Ganjie Tang (Licorice and Platycodon Decoction) or Ganlu San (Sweet Dew Powder). Other treatments follow previous descriptions; adult and pediatric therapies are identical, differing only in dosage. Haizang stated: Xiaodu San is a Taiyang channel formula. Baihu Tang treats body heat, eye pain, nasal dryness, and insomnia; it is a Yangming channel formula. Ganlu San targets Lung and Kidney. Ganjie Tang targets Shaoyang. Zixue, Tian Dong (Asparagi Radix), Mai Dong (Ophiopogonis Radix), Huang Qin (Scutellariae Radix), and Sheng Di Huang (Rehmanniae Radix) are blood-level agents. Yulu San targets Lung and Kidney; Shi Gao (Gypsum Fibrosum) and Hanshui Shi (Lapis Aquamarina) are qi-level agents. The above five formulas are all used to drain summer-heat.