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Whenever the smallpox rash first appears, the pustules are distinct and separate, then later enlarge and suppurate, beginning to connect in chains. Although they appear connected externally, beneath the skin each remains clearly distinct. When scabs form, swelling subsides, and pus dries up to reveal the scabs again, restoring a complete number of firm and thick scabs, this is the best outcome. Even if the bases are connected and the skin and flesh are entirely fused, as long as at the time of scabbing it remains clean without excessive exudation or rupture, it is second best. If no scab has formed and ulceration occurs, or if only tender skin remains where a scab should be, this is also considered "Dao Ye" (inverted smallpox/reverse progression). However, if inverted smallpox presents like a facial carbuncle with swelling and ongoing suppuration, and although half the body has scabbed, abscesses remain, this indicates the disease toxins have matured, making it a treatable condition. Conversely, if the smallpox lesions are still in the eruptive stage without forming pus, yet prematurely scab over, accompanied by symptoms such as open eyes but dry flesh, loss of voice, panting, rapid breathing, and restlessness, this is absolutely incurable.

Regarding the healing phase (scabbing) of smallpox: if the color is pale waxy, round and clean, firm and thick, raised like snail-shell scars or beads, this is "Zheng Ye" (normal/smallpox progressing smoothly). If the pus is full but the color is grayish-black, accompanied by dryness and collapse, lying flat on the skin, or if the head bursts with pus oozing out and piling up into scabs resembling chicken droppings, this is second best. If the skin breaks and pus flows out, with scabs thin as paper, this is even worse. If the skin rots and pus溃散 (discharges), failing to form scabs, with foul-smelling pus, this is called "Wai Ye" (external inversion), which is the worst grade. If this state occurs after the expected period, it is akin to fruits rotting after being ripe for too long; this follows natural laws and can still be viewed as a favorable course. If it occurs before the expected period, it is termed "Ban Lan" (mottled decay), an adverse sign that will inevitably turn into inverted smallpox leading to death. However, some cases result from excessive use of tonifying agents like Ginseng to push toxins outward; although internal pathogens have been expelled, external toxins cannot resolve spontaneously, causing prolonged rotting and failure to heal. Treatment should focus on releasing the exterior to overcome dampness and clearing the interior to dissipate stagnant heat toxins, allowing natural scabbing. In cases of extreme internal and external heat with scattered toxic qi and lack of Yin to consolidate it, only cooling and detoxifying methods are appropriate.

When damaged smallpox lesions swell again and fill with fluid without drying up, or when a new layer erupts at the original sites and suppurates, this indicates sufficient internal Qi preventing toxin invasion, keeping it superficial without becoming inverted smallpox; this is a favorable pattern within an adverse context. If the lesions re-erupt and the patient can eat and has hard stools, with abundant Qi and blood sufficient to withstand the renewed toxin, this is particularly favorable. If appetite is poor and stools are loose, Ren Shen Bai Zhu San (Ginseng and Atractylodes Macrocephala Powder) or Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction) should be administered together. If spontaneous diarrhea occurs, Rou Dou Kou Wan (Nutmeg Pill) is the primary treatment, as chronic illness leads to Qi deficiency requiring warming and tonification, rather than pure detoxification or pushing-out therapies. However, if a patient who previously lacked appetite suddenly desires food and gradually increases intake, this indicates the recovery of Stomach Zheng Qi (Upright Qi) and is auspicious. If a patient who usually lacks appetite suddenly eats excessively abnormally, this indicates Stomach Qi failure, with evil fire attacking internally and consuming grain rapidly, known as "Chu Zhong" (Elimination of the Middle), which is a ominous sign.